Clinical PhD Program - ethicality of clients

[diceymice07]

I've changed the original message on this post because I was uncomfortable with how many people had viewed the post. Here's part of what I had posted:

The type of clients first year students work with in my program's in house training clinic (it is community mental health, not just students) are too complex and risky for first year students (one student in our program's SECOND client had active suicide ideation, a suicide plan, direct access to means, past suicide attempt history, and complex trauma). In my opinion, this is unacceptable for both the student and the client. Some risk is appropriate - and is the only way to learn - but having a client at that high risk as your second client is ethically wrong. For reference, clients are screened - asked questions related to their risk. We do not have any training in our program specifically on suicide risk and crisis management.

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[psych.meout]

The type of clients first year students work with in the clinic (it is community mental health) are too complex and risky for first year students (one student in our program's SECOND client had active suicide ideation, a suicide plan, direct access to means, past suicide attempt history, and complex trauma). In my opinion, this is unacceptable for both the student and the client. Some risk is appropriate - and is the only way to learn - but having a client at that high risk as your second client is ethically wrong.

As in this patient was assigned to the student knowing that they were suicidal and high risk or that this information came out as the student was working with the patient?

 

[smalltownpsych]

Anywhere I have worked and trained has had a spectrum of different staff from toxic to amazingly supportive. Odd that this one is so toxic if it is run by the university, our little captive clinic was pretty tame compared to some placements. Also, clinical complexity is something that is not always easily screened and I tend to side with imcreasing support for students who have complex cases that could be beyond their readiness. It can be hard to justify the risk of shifting an unstable client that already connected with the new student.

Sometimes I think,part of our training is learning how to deal with dysfunctional systems and still keep our sanity and maybe even help a few patients along the way.

 

[WisNeuro]

As in this patient was assigned to the student knowing that they were suicidal and high risk or that this information came out as the student was working with the patient?

Honestly, it's better to have this type of patient when you have close supervision than when you are on your own. It is not "ethically wrong." Some of the other details are problematic, but not this. Unfortunately, this has been popping up more and more with trainees shying away from anything perceived as hard or complex.

 

[PsyDr]

You're upset. I'm not saying that what is happening is right, just, or something that should happen. But it is going to continue to happen, and there is nothing you can do about it. You end up with two realistic choices:

1) Confront the problem and eventually get dismissed from the program. From their standpoint, it's MUCH easier to label you as the problem, take your money, make things hard on you until you quit, or find an error for which they can kick you out. That's a LOT easier than trying to fire someone, deal with employment lawsuits where poor business practices might be disclosed, find a totally new patient population that is almost impossible to find, retrain employees, and spend high amounts of money to do so.

2) Get through it, limit contact with difficult people, slap a smile on your face, say "yes", and try to do better when you're in the powerful position.

 

[diceymice07]

Honestly, it's better to have this type of patient when you have close supervision than when you are on your own. It is not "ethically wrong." Some of the other details are problematic, but not this. Unfortunately, this has been popping up more and more with trainees shying away from anything perceived as hard or complex.

I get where you're coming from. Trust me, I agree; I think students need complex and hard cases in training to learn. But you have to consider, this student was assigned this client as their second client ever. The factors I listed are extremely high risk for suicide - and, yes, whoever assigned the case knew the factors I had mentioned previously (this individual had disclosed their risk factors during the phone screening). Assigning this case actually went against the clinic's screen out procedures (i.e., this client should have been screened out for the first year cohort). This is absolutely ethically wrong (in my opinion); it is doing an extreme disservice to the client to be getting a new therapist who has never had any experience, while they are at such high risk for suicide. The therapist did not have experience or training to adequately care for this client. Any other complex case, I would agree is fine, but when it is our responsibility to care for the client above all else, this client should have gotten an advanced therapist to take the case. This is not "shying away" from complex and hard cases, this is knowing your limits and what you can and cannot treat based on experience.

 

[WisNeuro]

I get where you're coming from. Trust me, I agree; I think students need complex and hard cases in training to learn. But you have to consider, this student was assigned this client as their second client ever. The factors I listed are extremely high risk for suicide - and, yes, whoever assigned the case knew the factors I had mentioned previously (this individual had disclosed their risk factors during the phone screening). Assigning this case actually went against the clinic's screen out procedures (i.e., this client should have been screened out for the first year cohort). This is absolutely ethically wrong (in my opinion); it is doing an extreme disservice to the client to be getting a new therapist who has never had any experience, while they are at such high risk for suicide. The therapist did not have experience or training to adequately care for this client. Any other complex case, I would agree is fine, but when it is our responsibility to care for the client above all else, this client should have gotten an advanced therapist to take the case. This is not "shying away" from complex and hard cases, this is knowing your limits and what you can and cannot treat based on experience.

I disagree about the ethical issue here. As long as someone is adequately supervised, complex patients are actually usually in better hands than a solo therapist. If this is against a set clinic policy, that's one things, but the mere issue of it is not an ethical lapse in and of itself.

 

[smalltownpsych]

I get where you're coming from. Trust me, I agree; I think students need complex and hard cases in training to learn. But you have to consider, this student was assigned this client as their second client ever. The factors I listed are extremely high risk for suicide - and, yes, whoever assigned the case knew the factors I had mentioned previously (this individual had disclosed their risk factors during the phone screening). Assigning this case actually went against the clinic's screen out procedures (i.e., this client should have been screened out for the first year cohort). This is absolutely ethically wrong (in my opinion); it is doing an extreme disservice to the client to be getting a new therapist who has never had any experience, while they are at such high risk for suicide. The therapist did not have experience or training to adequately care for this client. Any other complex case, I would agree is fine, but when it is our responsibility to care for the client above all else, this client should have gotten an advanced therapist to take the case. This is not "shying away" from complex and hard cases, this is knowing your limits and what you can and cannot treat based on experience.

Our university’s training clinic had a screen out policy for more severe cases, but they came through regardless in a lot of different ways. We would have discussions during our group supervision class about how to deal with these types of dilemmas. It was common for us newbies to focus on what was wrong and someone needs to fix it, but over time we all realize that there are no easy answers. I have two suicidal clients right now working with my trainees who are brand new counseling students. I could do a better job theoretically than them but for a number of reasons they are getting the cases. They will probably help these clients and learn a lot in the process or I could be wrong. I have been wrong before in a situation with a supervisee and the client did commit suicide. Part of the job is making life or death decisions and balancing the ethical dilemmas and eventually these decisions will be yours. At this point your job is to learn and seeing things occur that you clearly disagree with and may or may not be able to “fix” is part of the learning process.

 

[cara susanna]

I actually had the opposite experience: I really wanted to work with patients who were high risk for suicidality and had trouble finding supervisors for them in grad school.

Either way, I'm sorry to hear that you are having a difficult time in your program, OP.

 

[texanpsychdoc]

I can see how this would appear to be "unethical" to some, but I think you will find others may view it differently. As mentioned by others, as long as this student is receiving good 1:1 supervision on this case, then it's fair game. It really does come down to a decisional balance between the training needs of the student and the safety and wellbeing of the client. There's no perfection here. The university-based clinic I worked at as a 1st year was very clear to prospective patients about the nature of our facility, that it was a training clinic. They set the expectations with the clients from the very beginning to give them options as well if they felt that clinic would not be sufficient to meet their needs. If I were the supervisor, I'd be making sure this student was adequately receiving training and filling gaps in their training in this area as needed. Heck, even after getting my license I see a lot of folks that I frankly have had little to no experience working with as a trainee. Part of professional development is seeking out colleagues who are well-versed in this and regularly consult with them (and document); in addition to other aspects like CEUs, and other didactics one could take to acquire knowledge and skills in an unfamiliar area of practice.

I think some of us have a little more tolerance for risk vs. others, and that's okay too. I'd like to think most of my colleagues practice competently and ethically, but I also know we are not perfect. I wonder if the frustration and/or angst coming up here is something to reflect on? I've learned not to view everything through dichotomous lenses, meaning, that if I see something "off" or different in another's practice, I don't jump to conclusion of unethical practice and file a board complaint. Ethics code also mentions "Psychologists do not file or encourage the filing of ethics complaints that are made with reckless disregard for or willful ignorance of facts that would disprove the allegation." How would a board view such a complaint if it came their way? It likely wouldn't even rise to the level of preponderance of the evidence (e.g., 51%).

I realize you didn't mention anything about filing complaints, nor do I think that's what you were going after, but I figured I would draw our attention into that direction as a frame of reference.

 

[smalltownpsych]

We do not have any training in our program specifically on suicide risk and crisis management.

This part here is probably the most concerning to me. My program had this training before we saw our first patients. It was started in the second week and in at least two of our classes. We started classes in September and earliest anyone got started with practicums was in October so we had a chance to get some of that training. Our practicum placements included some high risk situations so some students got those right away. Lots of supervision was available and encouraged throughout and it was second week of October when I got my first suicidal patient.

As a clinical supervisor, I talk about risk assessment in our first meeting and tell supervisees to let me know immediately when som has any risk factors. Funny thing is that they do exactly what I did my first time and try to handle it on their own initially. Just happened again last week. My suggestion is to use your supervisors and other psychologists as resources as much as possible. We learned that walking with them was one good way to get a little extra direction as they were always pretty busy. Good luck working through this.

 

[Sanman]

I think the issue here lies in the phrasing of the question more than anything. Should a high risk suicidal patient be given to a new student compared to what? Being immediately seen by a supervisor? Perhaps not. Rather than waiting weeks for a more seasoned clinician or not being seen at all? Perhaps. In these times, clinicians routinely have weeks to months long waiting lists. What is ethical is based on the available alternatives.

What is ethical for me as a rural psychologist is very different from my colleagues in the metro hospital. What was ethical in 2019 may be less ethical in an era of telehealth consults in 2022. This is constantly evolving issue.

 

[diceymice07]

I think the issue here lies in the phrasing of the question more than anything. Should a high risk suicidal patient be given to a new student compared to what? Being immediately seen by a supervisor? Perhaps not. Rather than waiting weeks for a more seasoned clinician or not being seen at all? Perhaps. In these times, clinicians routinely have weeks to months long waiting lists. What is ethical is based on the available alternatives.

What is ethical for me as a rural psychologist is very different from my colleagues in the metro hospital. What was ethical in 2019 may be less ethical in an era of telehealth consults in 2022. This is constantly evolving issue.

In this situation, it actually took longer for this client to be seen by the first year student than an advanced therapist (2nd-3rd year student) due to the difference in time the first year students get assigned their clients (e.g., the first year students are assigned clients starting in late September, whereas advanced therapists are assigned clients on a rolling basis from August - January).

 

[PsychJustice]

I'm not sure what geographical area you're working in, but from my experience in a rural town, our in-house clinic ends up being a highly sought out resource for community clients that ends up getting them in quicker than other practitioners in town. A high suicide risk client may be seen quicker at an in-house clinic than waiting months on a private practitioner's waitlist; so although they are receiving services from a training clinic that may not have all advanced therapists, their needs are being met rather than not receiving services for months.

As long as the supervisor for that clinician was aware of the suicide risk and provided appropriate supervision, I think that clinician did the best thing they could for that client which was provide services. They may not have felt comfortable or competent doing so, but those are also very familiar and normal feelings for a first year student. Suicide risk is an intimidating clinical factor in treatment. But we also have an ethical duty to provide care. I understand the ethical dilemma here is "do no harm," but I guess I view this is as: would the client be in more harm being provided services by a first-year student feeling incompetent to provide services while being actively supervised, or by telling them they have to seek out services elsewhere? Because I would assume if the first-year student truly couldn't provide the service, the client would be transferred to another clinician in your clinic.

 

[Sanman]

In this situation, it actually took longer for this client to be seen by the first year student than an advanced therapist (2nd-3rd year student) due to the difference in time the first year students get assigned their clients (e.g., the first year students are assigned clients starting in late September, whereas advanced therapists are assigned clients on a rolling basis from August - January).

In that case, the ethical issue is why would you delay care of an acutely suicidal patient, not who saw them.

 

[Therapist4Chnge]

As someone who trained almost exclusively with high acuity chronic mental illness, it can be really helpful training, as long as there is sufficient supervision. As others have mentioned, while some places try to screen out people, it's pretty common and expected in a community health setting to see acute cases with active SI. For a time, I remember college counseling centers were viewed as "worried well" type cases, but in the past 10-15+ years, the average college counseling referral has become a lot more complex. It can be scary to be confronted with actively suicidal patients, but we need to be able to handle those situations, and I hope you can stick it out and learn from the experiences.

 

[psycho1391]

This part here is probably the most concerning to me. My program had this training before we saw our first patients.

There is actually some data out there that only 40-50% clinical and counseling training programs have suicide risk assessment training. Of those programs that provide training, the average time spent is 2 hours. That truly is not sufficient.