Mala praxis en Psicología Clínica y Forense a la luz de los tribunales de justicia españoles: un análisis exploratorio / Malpractice in Clinical and Forensic Psychology in Spanish courts: an exploratory analysis

En este artículo se analizan los problemas más significativos en la práctica de la Psicología Clínica y Forense que han llegado a los tribunales de justicia españoles en los últimos años. Entre estos problemas de mala praxis se incluyen: a) ausencia de consentimiento informado en relación con el diagnóstico y el tratamiento psicológico, b) errores en el diagnóstico debidos a una negligencia profesional, c) transgresión del secreto profesional y revelación de información confidencial del paciente en determinadas circunstancias, d) negligencia para prevenir el daño para el propio paciente u otras personas (suicidio u homicidio), e) conflictos relacionados con la protección o conservación de la historia clínica, f) problemas relacionados con la hospitalización psiquiátrica involuntaria y con el manejo del riesgo en pacientes suicidas o violentos y g) peritajes contradictorios en los tribunales. Se comentan asimismo algunas sugerencias para las investigaciones futuras en este campo

This paper reviews the most relevant ethical and malpractice issues in Clinical and Forensic Psychology arising in Spanish courts of justice. The main issues related to malpractice include: a) lack of informed consent regarding diagnosis and psychological treatment, b) mistakes in diagnosis because of professional negligence, c) violation of the professional secrecy and disclosure of confidential information without the consent of the individual in various circumstances, d) clinical negligence in preventing harm to patients or other people (suicide or homicide), e) negligence in protecting clinical records regarding the ownership of psychological records and data, f) involuntary psychiatric hospitalization and risk management with suicidal or violent patients and g) contradictory expert reports in courts. Suggestions for good practice in this field are considered

Implications of Healthcare Payment Reform for Clinical Psychologists in Medical Settings.

Health reform, post the passing of the Patient Protection and Affordable Care Act, has highlighted the need to better address critical issues such as primary care, behavioral health, and payment reform. Much of this need is subsequent to robust data showing the seemingly uncontrollable growth of healthcare costs, and the exacerbation of these costs for patients with comorbid behavioral health and medical conditions. There is increasing recognition that incorporating behavioral health in primary care leads to improved outcomes and better care. To address these problems, primary care will play critical roles across the healthcare system, especially in the delivery of behavioral health services. Psychologists are uniquely positioned to take advantage of this propitious moment and can help facilitate the integration of behavioral and primary care by developing competencies in integrated care, training a capable workforce, and advocating for integrated care as the status quo.

Clinical supervision: the state of the art.

Since the recognition of clinical supervision as a distinct professional competence and a core competence, attention has turned to ensuring supervisor competence and effective supervision practice. In this article, we highlight recent developments and the state of the art in supervision, with particular emphasis on the competency-based approach. We present effective clinical supervision strategies, providing an integrated snapshot of the current status. We close with consideration of current training practices in supervision and challenges.

Disciplinary supervision following ethics complaints: goals, tasks, and ethical dimensions.

Clinical supervision is considered an integral component of the training of psychologists, and most of the professional literature is focused on this type of supervision. But psychologists also may supervise fully credentialed colleagues in other circumstances. One such context occurs when licensing boards mandate supervision as part of a disciplinary order. When supervision is provided in disciplinary cases, there are significant implications for the ethical dimensions of the supervisory relationship and concomitant ethical challenges for supervisors. Not only are the goals, objectives, and supervisory tasks of disciplinary supervision distinct from other types of supervision, but the supervisor's ethical responsibilities also encompass unique dimensions. Competence, informed consent, boundaries, confidentiality, and documentation are examined. Recommendations for reports to licensing boards include a statement of the clinical or ethical problems instigating discipline, description of how these problems have been addressed, and an assessment of the supervisee's current practices and ability to perform competently.

Clara Harrison Town and the origins of the first institutional commitment law for the "feebleminded": psychologists as expert diagnosticians.

The first law providing for the commitment of "feeble-minded" individuals in the United States was passed in 1915, in the state of Illinois. House Bill 655 not only allowed for the permanent, involuntary institutionalization of feeble-minded individuals, but it shifted the commitment and discharge authority from the institution superintendents to the courts. Clara Harrison Town, a student of Lightner Witmer, and the state psychologist at the second largest institution for feeble-minded individuals in the country, was instrumental in this law passing and in ensuring that psychologists, for the first time, be viewed as court "experts" when testifying as to the feeble mindedness of individuals.

Practice guidelines regarding psychologists' involvement in pharmacological issues.

The guidelines presented in this document are intended to provide a resource to psychologists interested in the issue of what represents optimal practice in relation to pharmacotherapy. They are not intended to apply to those psychologists who choose not to become directly or indirectly involved in medication management regardless of their level of competency. Some of the guidelines presented in this document are targeted specifically to the population of psychologists with prescriptive authority. Others are considered relevant in any case where the psychologist is actively involved in decision making, whether as a prescriber or collaborator. Still others are considered applicable any time a psychologist is involved in the practice of pharmacotherapy, whether as a prescriber, collaborator, or information provider. Given the unique elements of the population of psychologists who can prescribe on the one hand, and the frequency with which psychologists participate in collaborative and information-providing activities on the other, it was considered important to provide guidelines appropriate to each set of activities. However, it is also important to recognize that a principle of optimal practice may have different implications in the context of active participation versus providing information. In particular, the distinction between active participation and providing information can often be blurred in the practice setting, with a psychologist often playing different roles at different points in the treatment. Given the ambiguity that surrounds these activities, it is urged that these guidelines be read with the understanding that the clearest practice delineation occurs between those psychologists who possess prescriptive authority and those who do not, and that psychologists who do not possess prescriptive authority use critical judgment in determining which guidelines best inform their practice.

Prescriptive authority for psychologists.

The proposal that psychologists should pursue prescriptive authority was first put forth 25 years ago, and it has been an official goal of the American Psychological Association for 15 years. Since then some form of prescriptive authority has been approved by three states, the Territory of Guam, and three branches of the military. Psychologists are also eligible to prescribe in the Public Health Service and the Indian Health Service. The movement has generated strong opinions both in favor and in opposition. Supporters focus particularly on increasing access to appropriate care and changing the role of psychologists within the healthcare system, while opponents raise concerns about how prescriptive authority will change professional psychology and whether psychologists will prescribe safely. This review provides a summary of milestones in the movement to date, as well as the arguments that have been raised for and against prescriptive authority.

Teaching psychology to jurists: initiatives and reactions prior to World War I.

This article deals with the kind of psychology suggested for jurists that was thought to be necessary training for their work. An analysis of the content of two textbooks by Otto Lipmann and Karl Marbe reveals that such teaching activity involves two different levels of historical analysis. On the one hand, it relates to experimental research done by psychologists on law-related issues; on the other, it concerns the professional experience psychologists accumulated by acting as expert witnesses in court. The paper investigates how psychologists presented psychology to jurists, which methods and theories they suggested as being essential for juristic training and professional performance, and whether jurists appreciated these materials and efforts. These inquiries are embedded in the debate on the history of criminal psychology, taking into account the European, particularly the German, context. The author shows how specific historical developments led to an increased exchange between experimental psychology and criminal law during the first decades of the 20th century.

Consent and confidentiality in clinical work with young people.

Consent and confidentiality are increasingly important in clinical practice. However, the dilemmas faced by mental health practitioners can be highly complex and difficult to resolve. This difficulty is compounded by the fact that consent and confidentiality are subject to several different types of legislation based on different principles, and many of the policies which are formulated for general medical practice may not fit well with the mental healthcare context. The ethical principles, evidence base, legal context, developmental considerations and clinical context relevant to each situation must all be integrated, in consultation with children and adolescents and their parents, in order to arrive at a treatment plan which is sensitive to the views of all, developmentally appropriate for the children and adolescents, and responsive to changes in the situation or attitudes. We offer some practical approaches, including clinical practice algorithms, to consider the issues of consent and confidentiality in the child and adolescent mental healthcare setting.

Prescribing non-psychopharmacological agents: a new potential role for psychologists in primary care settings and specialty clinics.

At least 10 years have passed since the Department of Defense Psychopharmacology Demonstration Project graduated its first class of psychologists. All graduates of that program were credentialed to prescribe and the program received promising external reviews and audits. The profession has since moved well beyond the initial question, "Can and should psychologists prescribe?" posed over two decades ago. A number of professional schools and training institutions have implemented postdoctoral psychopharmacology training programs and over 20 states are actively pursuing legislative agendas. Given recent initiatives to provide health psychology services within the primary care arena, the authors introduce a new role in the scope of psychology's prescribing activities. They propose that psychopharmacological agents are not the only medications psychologists should be trained to prescribe and psychopharmacology training should include course work and supervision related to treatment within a primary care patient setting in addition to a traditional psychiatric one. The authors provide the rationale for primary care clinical health psychology training as the appropriate mechanism for psychopharmacology education and practice. Public health needs and epidemiological data provide the rationale for health psychologists additionally prescribing non-psychopharmacological agents.

Prescription privileges for psychologists: a comprehensive review and critical analysis of current issues and controversies.

The debate over whether clinical psychologists should be granted the right to prescribe psychoactive medications has received considerable attention over the past 2 decades in North America and, more recently, in the UK. Proponents of granting prescription privileges to clinical psychologists argue that mental healthcare services are in crisis and that the mental health needs of society are not being met. They attribute this crisis primarily to the inappropriate prescribing practices of general practitioners and a persistent shortage of psychiatrists. It is believed that, as they would increase the scope of the practice of psychology, prescription privileges for psychologists would enhance mental health services by increasing public access to qualified professionals who are able to prescribe. The profession of psychology remains divided on the issue, and opponents have been equally outspoken in their arguments. The purpose of the present article is to place the pursuit of prescription privileges for psychologists in context by discussing the historical antecedents and major forces driving the debate. The major arguments put forth for and against prescription privileges for psychologists are presented, followed by a critical analysis of the validity and coherence of those arguments. Through this analysis, the following question is addressed. Is there currently sufficient empirical support for the desirability, feasibility, safety and cost effectiveness of granting prescription privileges to psychologists? Although proponents of granting prescription privileges to psychologists present several compelling arguments in favour of this practice, there remains a consistent lack of empirical evidence for the desirability, feasibility, safety and cost effectiveness of this proposal. More research is needed before we can conclude that prescription privileges for psychologists are a safe and logical solution to the problems facing the mental healthcare system.

Risk management with suicidal patients.

The patient who is at-risk for suicide is complex and is difficult to evaluate and treat effectively. Should suicidal behavior occur, the clinician faces the potential wrath of bereaved survivors and their externalized blame exercised through a malpractice suit. The clinician's duty of care to a patient is to act affirmatively to protect a patient from violent acts against self. A finding of malpractice is established if the court finds that this duty was breached, through an act of omission or commission relative to the standard of care, and that this breach was proximately related to the patient's suicidal behavior. This article discusses the standard of care and factors that determine liability in a suicide death of a patient. An extensive list of recommendations for competent caregiving for the at-risk patient and risk management guidelines are then presented.

Informed consent and clinical research involving children and adolescents: implications of the revised APA ethics code and HIPAA.

In 2003, 2 new sets of rules and regulations affecting the conduct of clinical research involving children and adolescents went into effect: the revised American Psychological Association's (APA) Ethical Principles of Psychologists and Code of Conduct (APA, 2002; effective June 1, 2003) and the Privacy Rule (45 CFR Part 160 and A and E of Part 164; effective April; 14, 2003) of the Health Insurance Portability and Accountability Act (HIPAA: Public Law 104-191). This article highlights those APA ethical standards and HIPAA regulations relevant to clinical research involving children and adolescents and discusses how psychologists can apply these rules in ways that will ensure ethical and legal compliance.