Dr. Allan Tepper, back by popular request, put on another great performance in the second of two workshops held Wednesday, 12/5: “Ethics Boundaries Potpourri: Records, Minors, Email, Cell Phones, Texting, and Telehealth.”

As in the past, Dr. Tepper presented a reality check, including risks for noncompliance for record keeping, release of records and other issues related to ethics.  Dr. Tepper again told it like it is for licensed Mental Health Professionals.

Regardless of the profession, few people enjoy hearing what they might be doing wrong and what they could be doing better.  Dr. Tepper asked some pointed questions of the audience on ethical issues regarding their practice. He did a nice job of pointing out legal and ethical issues to their responses without embarrassing anyone (much). Again, his sense of humor often saved the day, or at least the moment.

Dr. Tepper is an attorney, and a psychologist. He was able to switch hats as needed during his workshop. He reminded the audience that his topic was limited to “Ethics Boundaries Potpourri” for Pennsylvania licensed mental health professionals (LMHP). Many of us have previously heard Dr. Tepper speak on ethical and legal topics in Mental Health. Apparently, some of the audience also appreciated his broad expertise, as some questions were beyond the scope of this workshop. He briefly answered the question, and adroitly steered his response back to the topic.

Dr. Tepper’s goals for this Workshop included:

At the end of the workshop, participants will be able to:

1. Cite examples of how nonsexual boundary issues can negatively affect good clinical practice,
2. Briefly describe rules associated with records, minors, email, and telehealth.
3. Name some methods to effectively balance treatment goals with treatment realities..

Within his unique style, and gentle sense of humor, Dr. Tepper met these goals. Sometimes he appeared to veer of topic, but he always got back to the point. No complaints from me! His workshops are always fun, and there never seems to be enough time.

As usual, Dr. Tepper provided a handout with many pages of regulations, laws, court case summaries, examples of letters and forms and a few brief articles related to the topic. He discussed the ethical and legal rules for Psychologists, Social Workers, Licensed Professional counselors and Marriage and Family Counselors.

For example, the regulations for psychologists require that records, at a minimum, contain:

1. The name and address of the client and parents if a minor, and consent(s) for treatment.
2. The presenting problem or purpose or diagnosis.
3. The fee arrangement.
4. The date and substance of each service contact.
5. The results of evaluations obtained and basic test data.
6. Notations and results of formal consults with other providers.
7. A copy of all test or other evaluative reports prepared.
8. Authorizations, if any for release of records.

The record keeping regulations are similar for the other Licensed mental health professionals but differ slightly specific to each profession.

We were reminded that treatment records come in all forms, shapes and sizes including paper, electronic, audio and video tapes etc. Regulations regarding records and record keeping must be followed regardless of the format. Electronic records require a back-up copy, but paper records do not.

In his discussion of record keeping and communication with the client, Dr. Tepper talked about boundaries. Two nonsexual areas where LMHP’s can get into trouble with boundaries include: Confusion about the professional role, and with LMHP-Client communication. In one example where the LMHP chose to avoid content in notes due to concerns that the client may lose insurance funding, Dr. Tepper advised that the LMHP should be focused on treatment, not advocacy with insurance companies. Dr. Tepper also said that social media communication with clients is another boundary trap. For example, when allowing clients to use your cell-phone, text or email when communicating, you may be signaling that you are available 24/7. He said that communication boundaries must be discussed and made clear during the first session with the client.

Regarding release of records, Dr. Tepper said that clients have access to their own records for all licensed mental health professions. Social Workers, Licensed Professional Counselors and Marriage and Family therapists have some leeway under exceptional conditions to restrict this access, but psychologists do not. While the mental health professional is the custodian of the records, the content belongs to the client. Written authorization from the client (or clients in some cases, such as marriage counseling), is always required to release records, except when there is a court order from a judge.

Dr. Tepper acknowledged that we all censor our records to include some content but, also, leave out some information. Mental Health Professionals should avoid wring defensively.  That is, being worried that the notes would be read someday and get the client or LMHP in trouble.

In an interesting discussion regarding the purpose of record keeping, and some record keeping techniques, Dr. Tepper made up a hypothetical world where record keeping was not required. After a few minutes of questions and answers with the participants it became clear that record keeping has therapeutic value, aside from the regulations. Record keeping should be driven by the need for good continuity of care, not just regulation. Dr. Tepper suggests that “more is more” in record keeping. To benefit the client over time, each provider should carefully “tell the story” of reasons for and progress in treatment in as much detail as possible. Vague or cryptic notes, sometimes written to protect the provider, often do harm to the client by presenting a barrier for continuity of care. He said that vague and cryptic notes are also unsuccessful in protecting the provider, should a complaint be made.

Dr. Tepper reminded the audience that rules regarding consent for treatment, confidentiality and release of records differs according to the age of the client in Pennsylvania. He referred to the regulations showing that a parent/guardian must provide treatment consent for children under 14. If the parents are divorced with shared custody, then consent is required from both parents. For children 14 to 17, either a parent/guardian or the minor child can provide consent. Dr. Tepper said that either parent or the child should sign the consent for this age range, but not both. Once treatment starts, the 14-17-year-old minor has the right to record release.

In a brief discussion of treatment goals, Dr. Tepper mentioned that the LMHP should be careful to balance treatment goals with treatment reality. Is the client motivated and able to work toward the treatment goals in the plan? Are the family or other participants in the client’s life able to participate to the extent desired? He cautioned that unless the treatment goals are designed with treatment reality in mind, resulting frustration can interfere with or cause precipitous treatment termination.

Dr. Tepper provided an overview of the current regulations regarding electronic treatment and telehealth He referred to his handouts showing that Pennsylvania as well as most states have specific licensing regulations regarding distance treatment in mental health. Pennsylvania and most states require that the LMHP be licensed in the state where the service is being provided. Some states, including Pennsylvania, may require that the LMHP also be licensed in the state where the LMHP is, at the time of the service. Dr. Tepper warned that it is the obligation of the LMHP to be familiar with and adhere to the licensing regulations for this topic in any state before providing the service.

If both the LMFP are in the same state, Dr. Tepper cautioned that the purpose of the distance treatment, versus face to face treatment be clinically justified, and confidentiality issues satisfied. He also said that the consents for this type of service must be complete. Dr. Tepper referred to the regulations that may require training before providing electronic treatment including telehealth.

Dr. Tepper’s Workshop met his objectives. His presentation was not “high tech” Thank goodness!  As usual, he did not allow Power Point to get between him and his audience. Dr. Tepper called himself “Power Pointless.” The three hours went by very quickly.  As in the past, Dr. Tepper advised all licensed MHP’s to frequently check their Board’s Websites for updates on new statutes and regulations.

Another informative, fun and very satisfying workshop with Dr. Tepper!

Any comments?