Hello and welcome. I'm Shereen Khan, Vice President of Operations and Strategy at Thresholds, Illinois' oldest and largest provider of community mental health services, and I also serve as social work expert for SMI Advisor. I am pleased that you are joining us for today's SMI Advisor webinar, Ethical Practice and Boundary Setting for Mental Health Professionals. Next slide. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Next slide. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians, one Continuing Education Credit for Psychologists, one Continuing Education Credit for Social Workers, and one Nursing Continuing Professional Development Contact Hour. Credit for participating in today's webinar will be available until May 30, 2023. Slides from the presentation today are available in the handouts area, which is found in the lower portion of your control panel. You can select the link to download the PDF. Next slide. And please do submit your questions throughout the presentation by typing them into the question area, which is also found in that lower portion of your control panel. We do reserve about 10 to 15 minutes at the end of the presentation for Q&A. Next slide. Now I'd like to introduce you to the faculty for today's webinar, Andrew Hannigan. Andrew Hannigan, LCPC, has over 15 years of experience in the mental health field. He has practiced in a variety of settings, including inpatient, residential, and community-based care. Andrew develops trainings for Thresholds, as I already mentioned, we work together, a community mental health agency that provides services addressing serious mental health needs in and around Chicago. Thank you so much for leading today's webinar, Andrew, and I'll turn it over to you. Thank you very much, Shireen. Okay, I have no relationships or conflicts of interest related to the subject matter of this presentation. Okay, so let's talk about ethics. Upon completion of this activity, participants will be able to identify some common ethical considerations related to mental health, analyze warning signs that an ethical dilemma may exist, utilize an ethical decision-making model to address ethical concerns. So ethics and values. One of the foundations of being able to think ethically is to put our values into practice. So this could be personal values. This is what you're bringing with you as you arrive. This is based on how you were raised, how you were brought up. If you have a religious background, then the religion will help dictate those values to you. And then we've got our professional values. So these are established by the professional governing bodies, whether that's the American Psychiatric Association for psychiatrists, the American Psychological Association, could be the National Association of Social Workers for social workers or the American Counseling Association. All of these agencies develop codes of ethics. So guidelines that professionals in those fields are expected to abide by. And then we have community or legal values. So this would be reflected in the laws that are established. We vote together to come up with the laws. However, this can also include unjust laws. So that's something to consider when we're thinking ethically. Ideally, all three of these value systems are aligned. Our personal values, our professional values, and the legal values. When they're not aligned, then we have difficult decisions to make. Here's an example of putting values into practice. So I based this idea off of the National Association of Social Worker Code of Ethics. But I related it to the work that we do at Thresholds where I work. So the values for human rights. If we value human rights, then the way that we carry that into action is we advocate as an agency on behalf of people with mental illness, both in the community and at the state capitol. If we value cultural humility, then we have to be actively inclusive and remain open to learning and respecting cultural differences. If we value independence of individuals and promoting and supporting self-determination and self-efficacy while practicing informed consent. For collaboration, then we believe that we have to collaborate with people with mental health conditions on their care teams and as their care practitioners. For privacy, we protect the rights of individuals, their right to privacy. And we also respect the negative impact of stigma while we're protecting privacy. And then, of course, competence. We continually strive to improve our professional efforts, our experience, and knowledge. And when we recognize that we are not prepared for something or that we don't have the competence in a certain area, then we would defer to a specialist when needed. So now some ethical principles. Respect for persons. This is regard for an individual's worth and dignity. So they're all ethical guidelines have to be founded on a basic respect for persons, basic respect for humanity, humanitarianism. We also have to respect autonomy. So this is the self-governance, the independence, supporting people in their own decision making, developing their own vision of recovery, what their recovery looks like. Beneficence. This is the responsibility to act in a way that seeks to provide the most benefit to the individual. So basically trying to do good by the individual. Fidelity. So this is faithfulness to the interests of the patient or the client, the person with mental health conditions. So whatever actions we take, whatever ethical decisions we make, how faithful are they to the best interest of that person? Non-maleficence. It's just a long word to describe the commitment to doing no harm. There are times when we may have to consider actions or make decisions where there isn't a best answer, where there isn't the possibility to do no harm, but we still have the commitment to deciding on what does the least amount of harm. So one example of that might be working with a person with serious mental illness and deciding on an involuntary hospitalization. So in that situation, the hospitalization would obviously cause stress to the individual, but we would be making the decision based on the idea that the person is a danger to themselves or others, or is unable to care for themselves. We also have to consider veracity. So this is the duty of truth and honesty. We are expected to be honest and truthful when working with people. Justice. So this is the act of fair treatment without prejudice. Upholding the individual rights of the people that we work with. And privacy. So protecting the patient's personal information. And like I had mentioned before, also respecting not just the legal expectations of protecting personal information, but also appreciating the stigma surrounding mental illness and how protecting people's personal information also helps protect them from that stigma. And integrity. Honorable conduct within the profession. So basically living by our values and working by our values, putting those into play as we work and with people. This is our integrity. Here's an example of ethical principles. A professional helper is working with a person experiencing delusions. The delusions involve the belief that nanobytes are poisoning the food at the care facility. The professional helper goes along with the delusion and tells the person that a nanobyte removal tool has been used to clean the food. This solution goes against the ethical principle of veracity. So a better response would be to show empathy for the feelings, build rapport, and remain truthful, noting that the facility takes the safety of the food very seriously. I wonder if we can hear in the chat, what are some of the ways that the person might be feeling who's concerned about nanobytes? I would want to put myself in their shoes and take into consideration what sort of feelings might they be having? So people are responding in the question. A lot of people I'm seeing anxious, fear, scared, yeah, a lot of fear-based feelings, anxiety. Great. So yeah, our ability to show empathy for that is going to build rapport and help build that trust between us. That would help relieve some of the anxiety and the fear that's related to the delusion, even though we're not likely to be able to dissuade the person from believing in the delusion. Okay, let's discuss some ethical dilemmas. So slippery slopes, gray areas, and red flags. And for each of these areas, I'll discuss what the meaning is, and then we'll go over a small vignette to give an example. So slippery slopes, if you've ever read the children's book, if you give a mouse a cookie, you've seen an example of a slippery slope. So this is where any sort of smaller issue escalates to become a big issue. Here's the example here of loaning money to a client for a bus, assuming that you're working with a client who's on extremely limited income, for example, a social security disability check. At first, this is an unintentional misstep, and then it moves into rationalization and secrecy. I might decide, you know what, it's not a large amount of money, it's just a couple bucks for the bus, so I don't necessarily need to consult with anybody or worry about this. Then what was unintentional has now become intentional. So now the expectation for money and how much, when I might give money to this person has been blurred. So for example, a person living on extremely limited income, if they find that they can get some bus money from me, they might use any cash on hand or reserve that for, for example, purchasing food or some other necessary expense, hoping that they can again utilize the bus money from me as a resource. What happens if one day I just don't happen to have any cash on me? This is going to have a very serious impact for this other person that I'm working with. So here's an example. You've been working with a client on improving her budgeting skills. She's developed a budget that includes less money for cigarettes. She's asked you to drive her to the suburbs to buy cigarettes because they are cheaper there. You're a smoker too, so it would be a win-win situation. Now in this example, this is reflecting community support work where it's not unusual for the mental health professional to be driving somebody to appointments, for example, with a doctor to go see their psychiatrist, something like that. But in this situation, you're being asked to drive out to the suburbs, which is less common to buy cigarettes. How does this relate to the slippery slope? Let's hear in the chat. People are saying that if you do it once, it will be expected again, right? So it's kind of the early sign of a boundary crossing. Yeah, creating an expectation that this is going to be routine. So that's a lot of comments I'm trying to get from, but yeah, a lot around expectations. Okay, right. So those expectations have changed then. You've shifted that. Is this something that I would do every time? What are the limitations? I would have to clarify that with the person. Another big concern about this is that it really gets me off track from what the actual clinical purpose of our work is together. So does anyone know what is it that we were actually working on? People are saying budgeting, right, building autonomy, yeah. Right, the budgeting skills, building that autonomy. Yeah, I just want to add something that somebody said to the first question is that it's about expectations, but are you then, would you do this for everybody, right? So are you setting the expectation that you'll take everybody? So I just know that comes up a lot, but yeah, a lot of people talking about budgeting, managing resources. It's great when making those ethical decisions, that's a great question to be asking yourself. So is this something that I would be doing for everybody? If not, then there's probably a reason why there's a, that's a red flag as to why there's an issue there. Great. Okay. So now let's look at gray areas. It's important to appreciate the distinction between black and white situations where the right answer is abundantly clear or gray areas. So a gray, a black and white situation, for example, would be something taking money from a client that would be clearly wrong, right? Also having an intimate relationship with a client that you're working with, that would be black and white, very clearly wrong. Gray areas, however, are these ethical dilemmas where two reasonable mental health professionals could reach different conclusions, even when they're examining the same circumstances. So whenever the correct answer, the right ethical dilemma, or the right ethical answer is not clear. Here's another vignette. You've hired a client from your agency as a recovery specialist. Now a recovery specialist would be an individual with lived mental health experience. They've had their own mental illness that they have worked through and are now in a position where they're supporting others through their mental health recovery. It comes to your attention that she has been in a relationship for three years with another client who receives services at your agency. You know that it's an ethical violation for staff and clients to date. So we already have a clear policy on the books that staff and clients are not allowed to date. However, this is a gray area. What makes this different? What makes this situation gray when it comes to considering the relationship between staff and client? Go ahead and put your answers in the chat. People are saying because it is a pre-existing relationship. And then people are also saying maybe because they're a peer. So but yeah, it's mainly about pre-existing. And then if the peer, I actually don't know the answer to that, if the peer would make a difference. Yeah, I think it does make a difference. I think that part of the special training that peers receive includes the boundary cross of the differences in their relationship. Because by definition, we'll talk about dual relationships later on. It is a sort of dual relationship where they have both an expectation to manage their own mental health care as well as supporting others. So that is part of the training that the peer receives. I think that one of the things that we would consider then is, yeah, I think that was right that it was a pre-existing relationship. It's not unusual for two people to have got into a relationship or entered into a relationship. And then one of them later on gets employed. That wasn't taking advantage of the power differential there. So what we do need to consider, though, is how do we manage this? How do we monitor this afterwards? So supervision would have to be provided to this person about how to keep them separate, how to manage the relationship, and how to not let the work relationship interfere with the personal relationship. So they definitely wouldn't be allowed to provide services to their partner. That would be one thing that would be clear. But if there were social events, other things like that, supervision should help the person understand how to behave and conduct themselves professionally. Okay, are there any other comments about that one? Yeah, so a lot of people are just saying that there is kind of ethics and boundaries specific to the peer specialist role, and it is pretty similar that they wouldn't be, as you said, they wouldn't be able to work together. People are also saying, you know, that your agency would have, I mean, I guess this kind of brings up a good question, right? Your agency has probably a set of rules, right, an ethical policy, and then you, but you also have your rules as, you know, a professional in the field. So you just have to, I think, take into account both of these, your agency policy, as well as your, whatever your profession is, your policy, those ethical guidelines. Right, and find a balance between the two. Yeah, thank you. Okay, let's talk about red flags now. So red flags signal the risk of unethical behavior. So whether that's poor self-awareness, am I aware of my own feelings, emotions, am I feeling stressed today? Any kind of strong feelings that are positive or negative. So it might seem clear that negative feelings would lead to a red flag or ethical considerations, but also when we have especially positive feelings, we might be more likely, for example, to cut corners or something for someone we want. So we have to take special consideration of strong positive feelings as well, and make sure that we're still making rational ethical decisions. Poor boundaries, burnout or impairment. One thing to consider is that going through the pandemic for several years and now moving into this next stage, whatever it is for the pandemic, that everybody has been somewhat impaired based on the changes we've been asked to take on in life. Any kind of burnout that might be happening in our employment, misunderstanding our role. So for example, what is it to advocate for somebody? Does that lead me to having poor boundaries, for example, trying to make myself available 24 hours a day aside from some sort of crisis line or something like that, thinking that this would be the best way to advocate for someone? Then any kind of secrecy is a red flag, so being careful. If I'm not comfortable consulting with a peer in the field, someone, a co-worker or something, assuming that I'm following the HIPAA and privacy laws, if I'm not comfortable consulting with someone else, then that's a big red flag that there's an issue. So red flags, here's an example here. A co-worker decides to vent on social media about a stressful interaction with a client. The co-worker says it's okay because she didn't include any names, diagnoses or information about the treatment plan, so there's no protected health information present. What was the first red flag in this situation? See, people are saying, yeah, posting on social media and venting in a public forum. I also saw somebody say the first sign was just the frustration, the feelings of frustration and responding to those strong feelings of frustration. Right. So absolutely, we're going to have frustration at times. It's not like you're supposed to be some master who never feels frustrated, some Zen master who never feels that frustration, but we have to be conscious of that and how that's going to affect the decisions we make. So especially then going to make the decision of posting on social media is a big red flag that's way too public of a forum to be appropriate for venting. It mentions that there was no protected health information, but HIPAA doesn't just talk about this not sharing protected health information. Technically, any identifying information, if someone else were to identify who they were talking about just based on the description, that would be considered a violation of their privacy. Also, we want to consider what does this do for the perception, that stigma that we talked about for mental illness, right? How does this impact people's perception about the work that we do as mental health professionals? It would definitely have some sort of negative impact. Let's talk about boundaries now. So boundaries are the emotional and physical space between the helper and the other person with mental health conditions. So proper boundaries create safety. This could be emotional safety or physical safety. They create, enable growth and promote healing. If we're working with somebody who is very disorganized due to symptoms related to schizophrenia, for example, respecting the appropriate physical space, maybe giving extra space so that the person feels more comfortable would be appropriate. Being considerate of emotional safety for somebody with a history of trauma. Want to consider small steps like asking permission before asking certain questions, checking in with them frequently to maintain that feeling of a safe space. There's two types of boundaries here. There's fixed boundaries that should always be followed regardless of the circumstances. These would be expectations like legal requirements for mandated reporting, any kind of policies that the agency has. And then there's some variable boundaries where we have to use our judgment to sort of choose what's most appropriate for the circumstance. This is going to be based on our personal limits, any kind of clinical issues, and then also the client preferences. For boundaries, we run the risk of being under-involved or over-involved. So ideally, the most helpful behaviors are somewhere in the middle between those two. If we're under-involved and neglectful, maybe we're saying that we're using the excuse that the person needs to be more independent, so I'm not going to provide the assistance with that, or my boundaries are too rigid. That can be harmful to the relationship. At the same time, if I'm too available, if I'm over-involved, then I'm getting in the way of the person developing their own independence. The way to set boundaries are through role clarity, safety concerns, and preferences, both the helping professional and the client. So role clarity, we're talking about making it clear, you know, what is my role depending on, am I working for a community support agency? Am I working in a residential setting, in an inpatient or outpatient basis? Each of those is going to have different expectations for what the role, what kind of services are provided and are not provided. That needs to be especially clear to the client, to the person that we're working with. Any kind of safety concerns, again, whether that's emotional safety concerns, in support of people with a history of trauma, or whether those are physical safety concerns. If you're working in the community, does the client, for example, due to paranoid thoughts or some sort of delusion, prefer not to meet out in their apartment? Do they prefer to meet in the community somewhere, or vice versa? Dual relationships. So dual relationships are first holding more than one role in a relationship, each with its own set of expectations and responsibilities. This is where it makes dual relationships especially tricky, is that when we have two different sets of expectations, how can we follow both of them when they conflict? That automatically creates a conflict of interest. Some examples of dual relationships could be a friend, a spiritual advisor, a business partner, a peer advocate. I like to say that we can be friendly with the people that we work with, with clients. However, if we're friends, then we're robbing the person of the opportunity to develop supportive relationships. That should be one of the things that we would work on with anybody, is making sure that they have supportive relationships and not be dependent on mental health professionals for friendships. Same thing with a spiritual advisor. Even if I were to have the same religious beliefs, maybe even go to the same church as the client, I would want to support them in finding some sort of spiritual advisor outside of our relationship instead of trying to provide that for them. In relation to multiculturalism, there's an ethical responsibility towards delivering culturally responsive care to clients. There's a term broaching, broaching the subjects of race, ethnicity, and culture. A broaching behavior refers to a consistent and ongoing attitude with a genuine commitment by the counselor to continually addressing or seeking to explore issues of diversity. It's important. Many counselors and mental health professionals are often feeling hesitant or shy about bringing up or introducing topics such as race when working with someone. We may disregard or unfortunately think that a person who's disorganized or something that it may not be as relevant an issue. However, it's important that we give the opportunity to all of the people that we work with the chance to discuss those topics in case it is relevant to them. Let's talk about actually making the ethical decisions, this ethical decision-making model. First, we identify the problem or dilemma. Then we identify potential issues involved. We review relevant ethics codes. We have to know the applicable laws and regulations. We have to obtain consultation. We want to consider possible and probable courses of action. We numerate the consequences of various decisions and decide the best course of action. When we identify the problem or dilemma, we want to gather information, clarify the nature of the problem. This is the information gathering stage. What kind of problem are we dealing with? Is this an ethical issue? Is this a legal issue? Is this some sort of professional issue? Those are going to help determine where to guide our search for information, to collect information. We want to consider it from many perspectives, consider it from our perspective, consider it from the client's perspective, but also from a legal perspective. How would this look in a court of law? How would this be perceived by others? How would this be perceived by peers in the field, other mental health professionals? Also, in the spirit of informed consent and involving the clients that we work with, people with mental health conditions, we want to begin consulting with the client at that stage. We want to identify potential issues involved. Identifying critical issues, what are the most important issues? We want to narrow it down. Make sure that we have a focus for this ethical decision-making model. We want to evaluate the rights, responsibilities, and welfare of all involved. Who's responsible for what? Who's going to be affected by this decision? Does it impact family members as well? Does this impact more than one client? Is this a situation where I have to decide whether it's something that I would do for all clients or just one in particular? I want to consider the cultural context. Are there any relevant cultural considerations that would help shape a perspective on this? I want to look for competing values. Often, the most complicated and difficult ethical decisions to make involve a variety of factors. I want to look at the cultural context. Ethical decisions to make involve some sort of competing values. Like I had mentioned, the involuntary hospitalization is an example. We want to promote the value of independence in the individual. But then, of course, we also have to promote the ethical principle of doing no harm and supporting somebody to promote their safety if their safety is threatened. We want to review the relevant ethical codes. So consider whether your values are consistent with or conflict with the relevant ethical codes. These would be going to the organization, the American Psychiatric Association, National Association of Social Workers, American Counseling Association, any of those organizations that are relevant to your field. Consulting what they have to say about this. We have to know applicable laws and regulations. So these are going to vary state by state. There's going to be federal laws, but there's also going to be state laws that vary. Are there some sort of reporting requirements based on this ethical dilemma? There's certain key areas or certain areas that I really want to especially be aware of the laws related to this. So anything related to confidentiality, reporting of child or elder abuse, danger to self or others, parental or guardian rights, record keeping. This would be my own record keeping of notes, treatment plans, things like that. Testing and assessment, any kind of expectations around that. Diagnosis, licensing statutes. So any expectations related to my licensing, which again would vary state by state. And then any kind of grounds for malpractice. I'd want to be aware of laws and regulations related to grounds for malpractice. Okay. For ethical decision-making model, we have to obtain consultation from others. This helps create oversight, demonstrates efforts to abide by community standards, should be documented, and legal issues should be addressed. Abide by community standards should be documented and legal issues should involve legal counsel. So whenever we have any kind of legal issues, we need to be talking to a lawyer. Consultation would look good. It's important. It's the thing to do. It also shows that we're making efforts to communicate to other mental health professionals to find what's the norm for the profession. What would be the normal kind of response that the majority of mental health professionals might take? We're more likely to be able to see that when we obtain consultation. We want to consider possible and probable courses of action. So this would involve brainstorming and discussing with the client if appropriate. So at this stage, brainstorming and bringing the client back into the conversation. So what are the possibilities? We want to lay those out and start pursuing each of those possibilities. We want to talk through them. If I make this decision or that decision, what would that lead to? What kind of decisions would I have to make after that? How can we expect people to respond to that? We want to enumerate the consequences of various decisions. So we want to consider implications for the client and for you, often choosing from multiple outcomes and discuss consequences with client. Ideally, we've got multiple outcomes to choose from. That's going to be the best case scenario where we can make the best decision from those multiple outcomes. We want to understand what are the consequences of each of these cases. And remember earlier, we would have decided who is going to be impacted by this. What are the legal ramifications? We also have to consider what are the emotional implications of any of these decisions that we're making involving the client. We have to decide on the best course of action. Finally, we're making the decision, right? So after all of these steps, the brainstorming, the exploring multiple perspectives and possibilities, working through those plans, consulting with people, exploring the consequences, we're finally ready to make a decision on the best course of action. And we're still not done even after we've made the decision, though. We consider the information and perspectives collected. We weigh all the consequences, but we reflect. Taking the time to reflect is so important. Pausing, taking that time. We document the outcome. If you didn't document it, it didn't happen. I think we're all familiar with that phrase. And review the outcome for any necessary follow-up. After making a decision, we have to pay attention to how accurate were we in determining the potential consequences. Did we guess right? Were we aware? Were there any other consequences that we hadn't anticipated? This is one of the most valuable times for us to learn from, so that we can be more prepared for the next situation or scenario. Okay, so shared decision-making. Decision-making is a process of choosing between alternatives. This may include doing nothing as one of the decisions. Ideally, we're being proactive, and we're making active decisions. But even doing nothing counts as your decision. So, we're going to talk a little bit about how we're going to do that. People are more likely to choose an option they think is linked to valued outcomes, and to avoid undesirable outcomes. The optimal decision that we make is informed, it's consistent with personal values, and it's acted upon. If any decision that we make that's not acted upon, of course, isn't helpful. And this is where those personal values come into play. We're going to feel much better about any decision where our personal values are aligned with the decision that we make. So, shared decision-making is a process of choosing between alternatives. Okay, so shared decision-making is an interactive and collaborative process between individuals and their healthcare practitioners. So, it involves the treatment. We look at the treatment, what's the nature of the problem? Do we agree on this? Do we see eye-to-eye? This is something that we have to discuss with the clients that we work with to make sure that their understanding of the treatment matches what we see as the treatment, what we see as the nature of the problem. This can be especially tricky working with serious mental illness, if it involves delusions, paranoid thoughts, things like that. Oftentimes, we may have a clear idea of what we think is the problem, and the client might disagree with us. So, it's important to have those discussions and to clarify that. Services. What services are available, and how will they help? Have we informed people about the available services? Does the client have an understanding of what those services are, how they can be helpful? And personal recovery. What does recovery look like to the client, to the person with a mental health condition? It's important that we work with people to define this vision for their personal recovery. When we talk about recovery, we're talking about the movement as opposed to, in opposition to, the medical model, where we're looking for a cure for a mental illness. Instead, when we talk about recovery, we're talking about helping somebody find the best possible, what it looks like to that individual, how to regain control of their life from the mental illness. When we talk about ways to collaborate, so defining goals in the wellness vision. So, working on a treatment plan. We've probably seen treatment plans before that pretty much look like they did not involve the person with the mental health condition. It's written in a way that is pretty much just what the clinician, what the mental health professional wants to see. It's really important to involve people in the goals, defining what their goals are. Occasionally you even have a person tell you a goal that is what they think that you wanna hear. And it's important to challenge people to say, is that really what you're looking for? Is that really what you think is best for you? All of this is gonna bring better outcomes to the individual. Wanna assure accessibility of information regarding effective service options. So making sure they have access to information about the service options that are available. That way the individual can weigh the options about what is the best service for them? What's gonna be most useful to them? What do they feel most comfortable with? We wanna provide help with choosing service options. We can give our opinion and help the individual balance that out with their own thoughts. Wanna promote that participation in treatment plans. And we wanna provide ongoing assessment of progress and review of treatment decisions. So it's not just the initial treatment plan. We wanna check in with them. How is this working for you? Which treatment goals are working? Which ones aren't? How can we re-imagine or re-envision your wellness plan? The shared decision-making sweet spot would be somewhere in the middle between a paternalistic approach and an overly individualized approach. So we don't want to be there, the expert who's dictating all the answers, how to move forward, what you need, what's best for you. And at the same rate, we don't wanna completely leave it up to the individual. So we wanna balance the authority and expertise of a practitioner with empowerment of the individual. So we wanna be able to find that sweet spot in the middle to promote shared decision-making. Okay, and here are the references. Okay, thank you. Oh, let me come on camera to join you. So you're not by yourself for the Q&A. Give me one second. Okay, before we move into that Q&A, I just wanna take a moment and let you know that SMI Advisor is accessible from your mobile device. So you can use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. Download the app now at smiadvisor.org slash app. And I'll get started with a couple of questions. And if people do have more, you can go ahead and put that into that Q&A. So the first one I'll ask is actually the last one that was asked because it's the topic most fresh in our minds. So somebody was asking in the shared decision-making model, how do you balance what somebody actually wants and what their goals are with what has to be documented in their care plan or assessment that's based on diagnosis? Is there a way to balance that to make sure that you are actually working on what the person wants while still reflecting what the questions and what is needed for the treatment plan? Sure, so one thing that I would run into is that sometimes I would work with people with a serious mental illness who didn't want to, when we did, when I use a shared decision-making model and was helping them with coming up with goals, they didn't come up with a mental health goal. So it's okay for me to come in and say, you know what, to redirect back to, this is the main purpose of why we're working together and set a requirement that at least one of these goals has to be a mental health goal, for example. And being able to frame it in that way would often help people come back to establishing, well, I guess then this would be my mental health goal. We can often use quotes from people to make it clear that this is what they're stating is their goal. In our documentation, that can be helpful. Yeah, and I can just add to, what is stemming from the treatment plan needs to be then elaborated on in your conversation, right? So a need is indicated by the treatment plan, but then it's up to you to kind of figure out as the clinician with the person, like how do we translate this into their goals? So let's see. Oh yeah, people have some good open-ended questions that you could ask around this in the Q&A. So you mentioned at one point that people should pause, right, before we, if we're thinking that we might be in some type of ethical dilemma. So are there any good questions that you could ask yourself in that moment, you know, before you make that decision? And this is more of those gray areas, not like the clear black and white ones, but are there any good questions you can ask yourself when you're kind of in the middle of an ethical dilemma? Sure, that's a good question. So asking myself, well, thinking, it's helpful to have some sort of mentor or someone that you would, that you really trust in the field. If you don't have access to consulting them, thinking about what would they do, right? What would this other person do? We wanna think about, we could have some imaginative questions, like if this were in the media, how would it go over? How would it be received by others, right? Nine o'clock news or something like that, whether reporting on some incident that I was involved in. If everyone did the same thing, how would it impact the clients? If other mental health professionals also act in this way, that would be another question to ask myself. Yeah, I've definitely heard that news one, which I like. It's, you know, if the next day somebody was to report on what you did, then how would you feel about that, right? Would there be any type of, yeah, uncertainty. And then somebody, you know, brought up earlier too, would you do this for, would you do whatever you're doing for every client you've worked with? So I just wanna remind that of one that was brought up in the chat earlier. So, you know, we offer supervision, right? And know that that is one of the most effective ways to address ethical considerations. But what would you do, what do you do if your agency does not offer supervision or if your supervisor is just, you know, not available to consult with you as needed? If you don't have access to somebody. Yeah, if you don't have supervision, do you have any suggestions? Yeah, I think that's difficult. I think that that's where it would be helpful, especially consulting the ethical guidelines for each agency, right? So supportive agency. So if I'm a social worker looking for the National Association of Social Workers, would be reviewing those guidelines would be a great way to kind of get a better understanding. There's also a number of books available specifically about ethics to help, you know, give case examples and make decisions. I would review like the principles, ethical principles that were mentioned in the slides and try to see how can I apply these to this particular decision? Great, do you, if there are any, are there any books recommended in particular or somebody just asks us to follow up or maybe is there any in the bibliography that they could see? Let's see, I have one book right next to me. I happen to have Ethics in Psychotherapy and Counseling by Kenneth S. Pope and others. I'll put the name in there. Ethics in Psychotherapy and Counseling. I put the author. So yeah, people actually are saying, which I didn't know about even as a social worker, that there is, NASW has an ethics hotline that you can consult with. I would also say if you are delivering direct service and you're not receiving consultation or supervision, then that in itself could be kind of a great area. And I would encourage you to speak with somebody in the organization, you know, that has, yeah, either your supervisor who you're not getting that from or somebody, because my thought is that you should be receiving some type of oversight supervision. If you're working direct service. So somebody has a question about what if your personal values don't align with the, with, hold on, let me go back to it. Like if your personal values aren't in alignment with the values of the organization. So the person, they gave the example of like cigarettes, right, like this person does not believe in smoking cigarettes, but yet there's nothing in your agency rules that says that you can't take somebody when you're out shopping to pick up cigarettes. So any recommendations for when your personal values don't align with what the agency or your code of ethics allows? Right, so that is a difficult situation, right? I think that we have to, we have, the agency is allowed to set their expectations of, you know, how we conduct ourselves. I think that it's important to kind of question and weigh those out. Like what are my personal values? Where's that come from? And decide when it's appropriate to apply. You were using the example of like smoking or whatever. What was that example again? Yeah, basically somebody, you know, wants to go, like if your agency doesn't have any rules against you, when you run errands with people, you do community support, but you don't believe in smoking and you don't want the person to smoke. How would you make that decision? Do you go with your personal values or would you follow, like, is there maybe even just, is there an hierarchy of ethics, right, that you would follow? Right, well, I think that ideally or ultimately we're responsible to ourselves and we're gonna feel best when we're following our own values, right? When we make decisions that are in direct conflict with an agency's expectations, then, you know, we could face disciplinary actions of, if it was something that we truly believed in, then we would have to act on our personal values. Right, somebody brought up something more challenging, such as like working with somebody who is transgender. And I would say, you know, I think that part of our role, part of our responsibility in this profession is to continually learn and expand our values to be order to help everybody. So I would just, you know, kind of suggest that if there's things that you're regularly coming into play with that are against your personal values, that you do seek out supervision because it is kind of, it is a value of ours is to be continuous learners and to provide culturally competent and effective care. Okay, so the questions are now like flying in. So let me try to pick out a couple. So here's one. So what if your boundaries are different from your coworker? And it's not something there's a set rule on, but you just have a different boundary than your coworker does. How do you suggest addressing that? Right, it's really important to talk with the coworker about why you both have different boundaries and to come up with matching boundaries. You're gonna have to come up with some sort of agreement to work together because otherwise that provides these inconsistent expectations. It's confusing for the client and it can lead to splitting between the two. Yeah, so I would say you definitely have to consult about that with each other and try to match those boundaries. Yeah, exactly. I would say, you know, especially we worked in the team approach. And so it's important for boundaries, as mentioned are important, not only for you as the helping professional, but also for the person you're helping. And so to have clear, you need to have clear boundaries established as a group so they're not getting mixed messages. Okay, and then, yeah, we'll show, I'm gonna ask one more question and then somebody wants to see the book again. I thought I typed it in, but maybe I did not. So let's see, this is one about, I guess, yeah, actually, somebody kind of answered this themselves as they asked the question, but what would you do if there is a gray area or, you know, that you're seeing from a coworker or from a supervisor, what should you do? Ideally, you'd be able to discuss it with that individual, right? That kind of goes along with the idea that there shouldn't be secrecy. And so if it's not something that you could discuss with that individual, is it, do you have to follow the chain of command and discuss it with the person above? I think just the, how will you, you know, there's tactful ways of addressing that kind of thing. So I'm curious because I have a different way of working and I'm curious about what your reasoning is for working in this manner or following, you know, working with clients in the way that you do would be one way to phrase it. Yeah, I agree. If it's in, you know, if it's obviously a red flag or clear ethical violation, that would be addressed differently. But if there are those in that gray area or slippery slope, we do want to, you know, take it upon ourself to address first with them. Okay, so I think we're not going to be able to get to any more questions because we have a couple more slides to wrap up, but let's one more time just read the title and I'll put it into the name of the book. What was, let me see. Actually, if you can just say it because I can't, oh, I can put it in the chat. Okay, go ahead. What is the name of the book one more time? Ethics in Psychotherapy and Counseling. Okay. Oh, somebody found it. I see it. And Counseling, and this is Kenneth S. Pope is the main author, and then back, guys. Okay, cool. All right, thank you so much. Now, I'm just gonna, basically, I know we did not get to several questions, so if there are any topics that were covered in this webinar that you would like to discuss with colleagues in the mental health field, you can post a question or comment at the SMI Advisors webinar round table topics discussion board. This is an easy way to network and share ideas with other clinicians who participated in this webinar. And then also, if you would like your question about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of our SMI Advisors National Experts. So this service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI, and it's a completely free and confidential service. So SMI Advisor offers more evidence-based guidance on navigating client relationships, such as the duty to warn, duty to protect, and duty to control, the exceptions to mental health provider patient confidentiality. This issue brief defines the contours related to clinicians' roles with regard to the duty to protect third parties who might be at risk at the hands of a patient or client of a mental health professional. You can access this resource by clicking on the link in the chat or downloading this slide. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession, and verification of attendance may take up to five minutes. You'll then be able to select Next to advance and complete the program evaluation before you claim your credit. And please join us in two weeks on April 13th as Dr. Catania Brown presents Nutrition and Exercise for Wellness and Recovery, a Health Activation Intervention. Again, this free webinar will be on April 13th at 3 p.m. Eastern, that's a Thursday. So thank you so much for joining us and for your great comments and participation, and thank you so much to Andrew, and until next time, take care. Thank you for participating in today's free course from SMI Advisor. We know that you may have additional questions on this topic, and SMI Advisor is here to help. Education is only one of the free resources that SMI Advisor offers. Let's briefly review all SMI Advisor has to offer on this topic and many others. We'll start at the SMI Advisor website and show you how you can use our free and evidence-based resources. SMI Advisor's mission is to advance the use of a person-centered approach to care that ensures people who have serious mental illness find the treatment and support they need. We offer several services specifically for clinicians. This includes access to education, consultations, and more. These services help you make evidence-based treatment decisions. Click on consult request and submit questions to our national experts on bipolar disorder, major depression, and schizophrenia. Receive guidance within one business day. It only takes two minutes to submit a question and it is completely confidential and free to use. This service is available to all mental health clinicians, peer specialists, and mental health administrators. Ask us about psychopharmacology, recovery supports, patient and family engagement, comorbidities, and more. You can visit our online knowledge base to find hundreds of evidence-based answers and resources on serious mental illness. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Harvard, Emory, NAMI, University of Texas at Austin, and more. Browse by key topics or search for a specific keyword in the search bar. Access our free education catalog to find more than 100 free courses on topics related to serious mental illness. You can search the education catalog by topic, format, or credit type to find courses that fit your needs. SMI Advisor also offers live webinars each month that let you learn about evidence-based practices and participate in live Q&A with faculty. Check out our education catalog often to find new courses and earn continuing education credits. For individuals, families, friends, people who have questions, or people who care for someone with serious mental illness, SMI Advisor offers access to resources and answers from our national network of experts. The individuals and families section of our website contains an array of evidence-based resources on a variety of topics. This is a great place to refer individuals in your care for information about their conditions. They can choose from a list of important questions that individuals who have SMI typically ask. SMI Advisor worked with experts from the National Alliance on Mental Illness to develop these important questions and many of the resources in this section. Watch videos on important topics around SMI, such as what to know about a new diagnosis. They can also find dozens of fact sheets, infographics, and links to other important resources. To access even more evidence-based resources for individuals and families, visit our online knowledge base. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Mental Health America, National Alliance on Mental Illness, and more. Browse by key topics and select View All to uncover a list of resources on each topic. SMI Advisor offers a smartphone app that lets you access all of the same features on our website in an easy-to-use, mobile-friendly format. You can download the app for both Apple and Android devices. Submit questions. To submit questions, click on the link in the upper right-hand corner of the screen. This will take you directly to the SMI Advisor website. Browse courses and access clinical rating skills that you can use in your practice with individuals who have SMI. SMI Advisor also created My Mental Health Crisis Plan, a smartphone app that helps individuals in your care to create a crisis plan. The app is available on both Apple and Android devices. It helps people prepare in case of a mental health crisis. They can make their treatment preferences known and specify who should be contacted and who should make decisions on their behalf. The app even guides individuals through the process to turn their crisis plan into a psychiatric advance directive. Thank you for your interest in SMI Advisor. Access our free education, consultations, and more on smiadvisor.org at any time.

Ethical Practice

Boundary Setting

Mental Health Professionals

Webinar

Shireen Khan

SMI Advisor

Evidence-Based Care

Ethical Considerations

Shared Decision Making

Andrew Hannigan