Integrated care settings are treatment settings in which a psychologist is embedded on an interdisciplinary and/or medical team. Examples include primary care, intensive care units and specialty medical clinics (e.g., oncology, chronic pain). Psychologists increasingly work in integrated care settings (APA Council of Representatives, 2016).
Interdisciplinary settings present unique ethical dilemmas for psychologists (e.g., Kerkhoff & Hanson, 2015, Taylor, 2001, Darnall, Carr, & Schatman, 2016). One example of an ethical challenge in an integrated setting is mandated care consults (e.g., “The doctor said I have to come see you so I can keep getting my medication”). In addition, differences in scopes of practice across different disciplines can present other ethical challenges (e.g., “The occupational therapist diagnosed my patient with Alzheimer’s?”). Capacity concerns present frequently in integrated settings (e.g., “Why is my patient declining to undergo dialysis when it could save her life?”), and psychologists often assist their teams in decision-making when such issues arise.
A major ethical dilemma that can arise in interdisciplinary settings is management of privacy and confidentiality concerns. Patient privacy and confidentiality are fundamentally different in integrated settings as compared to traditional mental-health clinics due to electronic record sharing and interdisciplinary consultation.
In many interdisciplinary settings, all clinic staff have full access to the psychologist’s notes, and communication with other disciplines about patient care, including mental-health care, is standard on integrated teams.
One example of this type of dilemma occurs frequently in pain management clinics: Your patient, Pat, is prescribed opioids at your clinic. Pat has a significant alcohol abuse history. Pat disclosed to you that she currently drinks alcohol four times a week and has been borrowing opioids from a friend. She has asked you not to disclose this to the team, citing fear that her opioid prescription will be discontinued and her pain will then become debilitating.
This dilemma can be anxiety-provoking — it involves patient safety, disclosure of sensitive material, legal and clinical liability to multiple providers and several conflicting ethical principles.
Fortunately, an ethical decision-making model for psychologists working in integrated settings (Kerkhoff & Hanson, 2013) is available. This model, which was developed by rehabilitation psychologists, consists of six steps:
1. Identifying the critical incident and ethical challenge; 2. Identifying conflicting ethical principles; 3. Understanding the social context and key stakeholders; 4. Addressing organizational and legal concepts; 5. Generating and anticipating alternative solutions; 6. Evaluating disposition.
This model provides a means of reconciling opposing ethical principles in integrated settings and includes the patient and team as stakeholders in decision-making.
In Pat’s case, and in other situations involving sensitive disclosures, it is critical that the psychologist works to maintain the therapeutic relationship. Discovery of opioid misuse is not a “gotcha” moment — it is an opportunity to discuss patient safety and revisit the patient’s care plan with the team.
It is recommended that psychologists discuss their documentation and consultation requirements during informed consent, taking care to review psychologists’ ethical duty to document and consult truthfully while maintaining patient privacy to the greatest possible extent.
Of note, it is possible to document information and consult sensitively and truthfully, and to include the patient in this process. For example, the psychologist and the patient could make the disclosure to a prescribing provider together.
Alternatively, the psychologist could send the provider a secure message with the patient in the room to allow the patient to have some input about the language used within the disclosure.
In situations involving prescription medication misuse, it can be very helpful for psychologists to emphasize the importance of patient care and safety — not punishment — and to offer additional mental health follow-up and support as needed.
For more complex disclosure situations, the psychologist should consider professional/peer consultation (e.g., contacting an ethics committee) to improve decision-making, limit risk, and increase the probability of a positive outcome.
Interdisciplinary settings offer a unique opportunity to provide mental-healthcare to hard-to-reach populations with complex treatment needs.
Although integrated care settings present many ethical challenges, psychologists can successfully manage these by using an ethical decision-making model that incorporates the complex contexts and multiple stakeholders involved in these settings.
Efrat Hedges Eichenbaum, Ph.D., is a fellowship-trained rehabilitation psychologist in Minnesota. She serves as APA Division 22’s (Rehabilitation Psychology) Practice Committee Chair and is a member of the Minnesota Psychological Association’s Ethics Committee. She can be reached by email at Efrat@DrEichenbaumCBTsheets.com.