PhD/PsyD professional dillema?

[calimich]

A colleague reached out to me for consultation and I thought I'd pose the question here...

Scenario: you are the owner and only clinician of a private practice. Your office is in a large (30+ floors) multiuse office building in a main thoroughfare of a major metropolitan area. In order to enter the building all patients/clients/customers must check in with the security desk and sign in with their name and the purpose of their visit/who they're seeing. For health-related visits (there are many clinicians of various sorts in the building), clients are asked for their initials only and which office suite they're visiting.

The issue: the building manager alerted my colleague (a licensed psychologist) via email that one client, for two weeks in a row, has "been disrespectful" toward the security personnel. The building manager asked the psychologist to "address this with the client before the next appointment" and if the behavior continues the client "is not welcome back in the building."

my colleague feels triangulated and is unsure how to proceed. They are concerned about client confidentiality, whether/how to address this in treatment, and what might happen if the client is banned from the building. I suggested they call their insurance company to consult.

any thoughts here? anyone been in similar situation?

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[erg923]

A colleague reached out to me for consultation and I thought I'd pose the question here...

Scenario: you are the owner and only clinician of a private practice. Your office is in a large (30+ floors) multiuse office building in a main thoroughfare of a major metropolitan area. In order to enter the building all patients/clients/customers must check in with the security desk and sign in with their name and the purpose of their visit/who they're seeing. For health-related visits (there are many clinicians of various sorts in the building), clients are asked for their initials only and which office suite they're visiting.

The issue: the building manager alerted my colleague (a licensed psychologist) via email that one client, for two weeks in a row, has "been disrespectful" toward the security personnel. The building manager asked the psychologist to "address this with the client before the next appointment" and if the behavior continues the client "is not welcome back in the building."

my colleague feels triangulated and is unsure how to proceed. They are concerned about client confidentiality, whether/how to address this in treatment, and what might happen if the client is banned from the building. I suggested they call their insurance company to consult.

any thoughts here? anyone been in similar situation?

Why does the psychologist have anything to do with any of this? This an issue between 2 adults. Or 3, maybe (owner, security guard, patient)?

I would tell the building manager I am not the patient's mom and have no desire to get involved in whatever drama they gots goin on.

 

[calimich]

Why does the psychologist have anything to do with any of this? This an issue between 2 adults. Or 3, maybe (owner, security guard, patient)?
I would tell the building manager I am not the patient's mom and have no desire to get involved in whatever drama they gots goin on.

Agreed. Would communicating with the building manager, and thus confirming this person is a current patient, constitute a breach of confidentiality? Does it matter that the patient signs in with their initials and suite #?

 

[Sanman]

Why does the psychologist have anything to do with any of this? This an issue between 2 adults. Or 3, maybe (owner, security guard, patient)?

I would tell the building manager I am not the patient's mom and have no desire to get involved in whatever drama they gots goin on.

Yeah, but if the patient is banned from the building then psychologist loses money.

This really depends on what the client is seeing the psychologist for as well. Is it for related social/anger issues or is it because their dog died or for an ADHD eval. If it has nothing to do with therapy, I would likely not address it as part of therapy. I may say that the security guard lodged a general complaint I was I asked to tell all of my clients to be respectful to the security guard by building management. If it is part of what the person is addressing that is more complicated.

 

[cara susanna]

Agreed. Would communicating with the building manager, and thus confirming this person is a current patient, constitute a breach of confidentiality? Does it matter that the patient signs in with their initials and suite #?

That would be my concern. I would want the building manager to speak to the patient directly without the therapist having to get involved.

 

[Fan_of_Meehl]

A colleague reached out to me for consultation and I thought I'd pose the question here...

Scenario: you are the owner and only clinician of a private practice. Your office is in a large (30+ floors) multiuse office building in a main thoroughfare of a major metropolitan area. In order to enter the building all patients/clients/customers must check in with the security desk and sign in with their name and the purpose of their visit/who they're seeing. For health-related visits (there are many clinicians of various sorts in the building), clients are asked for their initials only and which office suite they're visiting.

The issue: the building manager alerted my colleague (a licensed psychologist) via email that one client, for two weeks in a row, has "been disrespectful" toward the security personnel. The building manager asked the psychologist to "address this with the client before the next appointment" and if the behavior continues the client "is not welcome back in the building."

my colleague feels triangulated and is unsure how to proceed. They are concerned about client confidentiality, whether/how to address this in treatment, and what might happen if the client is banned from the building. I suggested they call their insurance company to consult.

any thoughts here? anyone been in similar situation?

How does the building manager even know that the person in question is a client of the psychologist? Did the client inform the business manager of that themselves? In that case--since they hold the privilege--have they waived it?

If confidentiality is no longer an issue, what about straightforwardly discussing roles/boundaries with the manager? Basically, it's not the therapist's role to 'take orders' on what the agenda items will be at the client's next session from third parties. The client is ultimately responsible for his own behavior (and consequences) emitted outside of session, even if driven by psychopathology.

 

[erg923]

Agreed. Would communicating with the building manager, and thus confirming this person is a current patient, constitute a breach of confidentiality? Does it matter that the patient signs in with their initials and suite #?

I just meant that I would tell them, perhaps in a less sarcastic way, “I find it best not to get involved in other peoples affairs or disputes.” I’m not “confirming” anything with a generic statement like that.

That said, the building manager already knows, quite obviously, so I don’t know what confidentiality the psychologist would to be breaking.

 

[psychRA]

Setting aside the question of confidentiality for a moment. I'd want to talk with the patient to get their perspective on what's happening during these interactions. We often don't have the opportunity to gather data on how patients interact with the world outside of therapy. If this patient's behavior is eliciting a reaction this strong from building security, it may also be popping up in other areas of the patient's life. If the patient is at risk of being banned from the building, this seems like a therapy-interfering behavior that might need to be addressed. At a minimum, it would be helpful for the patient to be aware that they're on the edge of being banned from the building so they have an opportunity to change their behavior.

With that being said, I would not get in the middle in terms of communications between the patient and the building manager, nor would I communicate any information back to the building manager. I'd consider talking this over with the patient and helping them work out some steps for communicating with the building manager if they chose to do so, and for changing his/her behavior if needed.

 

[erg923]

Yeah, but if the patient is banned from the building then psychologist loses money.

This really depends on what the client is seeing the psychologist for as well. Is it for related social/anger issues or is it because their dog died or for an ADHD eval. If it has nothing to do with therapy, I would likely not address it as part of therapy. I may say that the security guard lodged a general complaint I was I asked to tell all of my clients to be respectful to the security guard by building management. If it is part of what the person is addressing that is more complicated.

Just because someone accuses another of being "disrespectful" (which could mean any number of pretty benign things) doesn't mean I need to get involved...or even be all that curious about it unless it was directly related to a pattern of problematic behavior. The psychologist has no idea what actually occurred (I dont think?), and getting involved likely opens up more worms and complications than it is worth. The person could just be depressed and grumpy for all we know? In other words, I think you don't get involved because it infantalizes your patient.

In this instance, I would be a more concerned that someone might be banned from attending treatment because they were once "disrespectful" to someone. Belligerent, threatening, violent, profane...and I could understand.

 

[Sanman]

Just because some person accuses another person of being "disrespectful" (which could mean any number of pretty benign things) one time, doesn't mean I need to get involved..or even be all that curious about it unless it was directly related to a pattern of behavior. In other words, I think you don't get involved because it infantlizes your patient.

I would be a little more concerned that someone might be banned from a attending treatment because they were once "disrespectful" to someone. Belligerent, threatening, violent, profane...and I could understand.

Oh, I agree. I'm not really sure if this is a two time thing, ongoing issue, or what happened( disrespectful verbally, threw a piece of paper, refused to listen to instructions, etc). If anything, That's why I said address it as a general issue. For example, when I was in PP one of the buildings had a shared restroom for the building that was getting messy. I used to let patients know with a posted notice aan a quick chat to make sure that the bathroom was locked and where to take and return the key as well as to keeping it clean as building management had requested this due to instances of past problems. It was not directed at any one patient. If the psychologist were to address it more generally as a business matter it would not infantilize of accuse the patient. Now, if the patient has a history of punching people in the face and this is court mandated therapy...

 

[AbnormalPsych]

I would tell security thanks for their concern, but I cannot confirm or deny blah blah blah. Perhaps it may be most effective if they consider addressing any issues they have with people, directly, since they have first hand knowledge and particular concerns.

The psych would be free to have this discussion with the patient, if they feel it is clinically appropriate. Also, not to. I honestly could see it going either way in a variety of scenarios, but would err on not because I wasn't there, and who knows what went down and what the patient's clinical, legal, etc. reaction would be.

 

[Fan_of_Meehl]

I would tell security thanks for their concern, but I cannot confirm or deny blah blah blah. Perhaps it may be most effective if they consider addressing any issues they have with people, directly, since they have first hand knowledge and particular concerns.

The psych would be free to have this discussion with the patient, if they feel it is clinically appropriate. Also, not to. I honestly could see it going either way in a variety of scenarios, but would err on not because I wasn't there, and who knows what went down and what the patient's clinical, legal, etc. reaction would be.

I sometimes think of these situations as having two components: (a) a set of ethical, clinical, professional principles that may be in conflict--and the varying ways that these conflicts can be managed; and (b) a set of affirmative legal duties that must be discharged.

We could write a book about (a) and many very fine clinicians could disagree entirely and have fascinating back-and-forth discussions.

Regarding, (b), aren't there only two that would possibly apply here?

(1) a duty to protect (the client and members of the public from serious, imminent, and foreseeable risk of bodily harm--e.g., threats of suicide or imminent violence), which doesn't appear to apply here

(2) a duty to protect confidentiality (if the client hasn't already waived that privilege)

I'm not a forensic specialist so I'm probably fuzzy about the legal aspects, but aren't these more what the colleague is concerned about?

 

[PsyDr]

The psychologist should call their malpractice carrier. And they should figure out if the building was built prior to ADA

It’s incredibly complicated. The patient being banned could be an ADA violation if the building is applicable, and/or could lead to a patient abandonment suit/complaint. Acknowledging that the person is a patient could be a HIPPA violation. Then there are whatever state laws that may apply. Not to mention the clinical stuff.

 

[foreverbull]

Tricky situation given the banning risk.

I would also agree that the clinician needs to go the CCOD route (can’t confirm or deny) with the manager to protect confidentiality as step one.

Then, if there is a real risk of the person being banned from the site, I’d agree with PsyDr that this necessitates a call to insurance consultants to see what to do if it’s a possibility and the clinician needs to somehow be involved to address it (i.e. whether it’s okay to warn the client directly about the feedback and possibilities moving forward and that’s considered enough due diligence, or if it would ever be appropriate to talk to the manager with client permission, etc.).

My initial thought was this isn’t the clinician’s domain at all to intervene as a mediator in this, but the client being banned could raise the issue of client abandonment if the client decided to take it that far (very extreme for the client to retaliate against the therapist rather than the building manager, but is a possibility), as @PsyDr mentioned. But more practically speaking, having to end a therapy relationship suddenly when it’s preventable is a tricky situation. And clinicians are sometimes encouraged to advocate for clients; I know clinicians who speak to social services staff in skilled care facilities in behalf of clients at times, with client permission to do so, although this is a different setting. So this scenario could go either way with regard to either warning the client and creating a termination/referral “backup” plan, or actually speaking to the manager on the client’s behalf with client permission....or some variation of both, or neither, and some other action instead.

I wouldn’t do anything without consulting with the insurance consultant/ethics expert in this particular case. Given my own curiosity, I would be interested to hear the recommendation from the consultant.

 

[GradStudent2020]

The psychologist should call their malpractice carrier. And they should figure out if the building was built prior to ADA

It’s incredibly complicated. The patient being banned could be an ADA violation if the building is applicable, and/or could lead to a patient abandonment suit/complaint. Acknowledging that the person is a patient could be a HIPPA violation. Then there are whatever state laws that may apply. Not to mention the clinical stuff.

I don’t believe that ADA would be applicable here. Possibly if they are in Texas or California, but not based on federal language of ADA.

 

[GradStudent2020]

Your colleague may consider checking their lease to see if what the building manager is threatening is even legal. I’d be very surprised if it were but would depend on the individual language of the lease. Without any actual physical aggression/threat of harm what grounds do they have to ban a client of someone leasing space?

People with some “power” may overstep because they don’t anticipate being called out on it. Checking the lease carefully would be my first step. If it’s not explicitly outlined that the building manager can bar clients, I’d let them (manager) know directly that it isn’t an option.

I’d also speak to all clients about any potential concerns with the building/check-in process. Just a “let me know if you ever have a concern” to open that door for them if they need it.

 

[PsyDr]

I don’t believe that ADA would be applicable here. Possibly if they are in Texas or California, but not based on federal language of ADA.

I was thinking something along the lines of building access. If there’s arguments about how to access a building for X “disability” then I don’t see why psychiatric diagnoses wouldn’t have something in there. But I’m not an attorney.

Everyone should be aware that any office that provides healthcare has been designated as having federal rules applicable. It’s a weird section of the CFRs. I looked into this years ago because there is a debate about if forensic services are covered under HIPPA and other federal healthcare laws. And there was something in there that basically stated that healthcare offices are federal properties for the purposes of who can enforce laws. I do not think this has ever been tried.

 

[GradStudent2020]

I was thinking something along the lines of building access. If there’s arguments about how to access a building for X “disability” then I don’t see why psychiatric diagnoses wouldn’t have something in there. But I’m not an attorney.

Everyone should be aware that any office that provides healthcare has been designated as having federal rules applicable. It’s a weird section of the CFRs. I looked into this years ago because there is a debate about if forensic services are covered under HIPPA and other federal healthcare laws. And there was something in there that basically stated that healthcare offices are federal properties for the purposes of who can enforce laws. I do not think this has ever been tried.

That would fall into the public accommodations section of ADA, but there’s not much specific language there about mental illness so I think it would be a stretch to apply it. Most of the protections for mental health concerns/accommodations are related to employer/employee relationships.
It’s definitely worth considering if there are any applicable federal/state level guidelines that would allow or prevent the building manager from blocking access to care.

 

[calimich]

Update: Colleague consulted with their insurance risk management folks and reported the following:

1. as expected, the psychologist can not confirm or deny to the building manager whether or not the person is in treatment, even through the person signs in with their initials to enter the building.

2. The psychologist is strongly recommended to bring this up with the patient as it relates to "threat to treatment" The psychologist needs to communicate to the patient that the decision to allow entry into the building is out of the psychologist's control. Document this clearly in the chart in case patient makes a complaint against the psychologist for "abandonment"

3. Inform patient that psychologist will not / has not disclosed any PHI to the building manager, including whether the patient is in treatment . Again, clearly document this in chart.

4. Psychologist encouraged to form contingency plan (phone termination) should patient in-fact be denied entry to the building. Document in chart.

5. Continue to provide vague, professional responses to building manager. "Thanks for the information and as you know I can not comment about individual clients without their written permission."