Brian Fingerson, RPh NOAP Conference

18 March 2015

President/Owner of Kentucky Professionals Recovery Network (KYPRN)

Administer addictions recovery programs for accounting, chiropractic, optometry, pharmacy, dentistry, veterinary medicine, respiratory care, social work, and physical therapy

>30 years pharmacy practice with >28 years working primarily with HCP with addictions

Brian Fingerson, RPh declares no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria

Goal: To gain a deeper understanding of the advantages and disadvantages of the disclosure of one’s own addiction to colleagues and patients.

Objectives: 1. The participant will identify ethical

dilemmas as relates to disclosure. 2. The participant will explore possible

consequences of disclosure. 3. The participant will learn what differences

there may be among the various professions in disclosing to colleagues and patients.

4. The participant will learn appropriate resolutions for legal, moral, and ethical dilemmas encountered with disclosure.

Exposure – the disclosing of something secret

Divulge – disclose something secret or private

Revelation – a dramatic disclosure of something not previously known

I am a pharmacist, a minister, and a professor, a husband, a father….

That being said, in this setting, I will also disclose that I am….

AA: “Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio, and films.”

And from the Tradition Eleven of Al-Anon: “We need guard with special care the anonymity of all AA members.”

Craig Ferguson “Speaks from the heart”

Elton John – NBC Today Show

Joe Walsh – song “One Day at a Time”

www.facesandvoicesofrecovery.org/

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The February 2010 issue of Counselor contained an article by William A. Rule titled “Self-Disclosure in Addictions Counseling: To Tell or Not to Tell.” We are grateful to Rule for addressing the therapeutic advantages and disadvantages of counselor self-disclosure and for his contribution to the continued discussion of counselor boundaries. However, we disagree with Rule’s statement in the final paragraph of his article, “Therapists and counselors who are also recovering addicts and alcoholics and who wish to be considered professional and effective should not, under any circumstances, self-disclose to his or her client that they are in recovery.”

“We believe that a recovering counselor’s selective self-disclosure of their recovery can be an effective tool in promoting client recovery. We share our observations with the goal of promoting much-needed dialogue of this important subject.”

They have concluded that it is an over-simplification to merely flatly assert, “no-self-disclosure,” and states that “decisions about the therapeutic use of self-disclosure need to be made on a case-by-case basis in the content of the type of therapy offered.”

The decision by a recovering counselor “not to tell under any circumstances” when asked if they are in recovery ignores the nature of what often prompts the client to ask the question. The question behind the question is the issue of counselor competency. When a client asks a counselor if they are in recovery, the inquiry is often an attempt by the client to establish trust in the relationship, and confirm that his counselor is able to help. If the counselor responds appropriately, the ensuing dialogue can encourage the client to explore the nature of the therapeutic client/counselor relationship, fundamental boundaries and counseling expectations.

If the counselor responds to the question, “Are you in recovery?” with “That’s a very good question. Thanks for asking. I wonder what prompted you to ask that?” the client could perceive the counselor response as an invitation to explore deeper their motivation for asking the question. This could be an occasion for the client to clarify their assumptions and expectations about the counseling process. Then, based on the work done by the client in the session, the counselor can decide “to tell or not tell” based on an informed judgment as to what’s best for the client.

Decisions about the therapeutic use of self-disclosure are appropriate and need to be made on a situation-by-situation basis, based on what’s best for the client. It is beneficial for clients to explore the “question behind the question.” Here are suggested guidelines for therapeutic self-disclosure (Gutheil & Brodsky, 2008):

Limit your self-disclosure to information that you believe will be helpful to the client by sharing the “mountain tops” of your experience, not the “valleys.” You do not want to shift the focus to yourself for too long, but rather, keep the focus on the client.

Decide for yourself what information you will not share with the client. This information might include your financial condition, sexual preference, past legal problems, conflict with employers, etc. Firm boundaries will create safety in the relationship for the client.

If you are in recovery and thereby are subject to a “dual relationship,” always be aware of which relationship you are in. For instance if you see a client at a 12 Step meeting, remember that you are not acting as a professional counselor in that setting.

Remember, there are different levels of self-disclosure which are often associated with differing results. For instance, sharing you once received a traffic ticket for speeding might have a far lesser impact upon your relationship with a client than sharing you were once incarcerated for DUI.

Which person benefits from this disclosure. Is disclosure serving the needs of the counselor or the client? Is it being done for the sake of the client, to build the therapeutic alliance, to enhance the therapy process? Does it work?

By: Jim Jensen from www.RenewEveryDay.com

Recovery mentoring is about using wisdom — the process of tempering knowledge plus experience. Jim Jensen has seen three variations.

Self-Disclosure: The Good, Bad & Ugly on Aug 11, 2011

The type that is used judiciously, at the “right” time, and for the benefit of the client. If the self-disclosure doesn’t benefit the client or a particular situation, it isn’t used.

Used pretty much anytime, for the unconscious purpose of trying to heal the counselor’s own wounds and not tied to a legitimate client issue but rather injected at any opportune time for the counselor.

This is where “professional” self-disclosure has bonded personal opinion to professional judgment, hardening into a rigid, “I know what’s right” dogma.

Gwen Adshead is a consultant psychotherapist for West London Mental Health Trust (Psychotherapy Department, Broadmoor Hospital, Crowthorne, Berkshire RG45 7EG, UK. E-mail: gwen.adshead@wlmht.nhs.uk).

She is also a member of the Fitness to Practice Panel at the General Medical Council and Chair of the Ethics Committee of the Royal College of Psychiatrists.

I think these next slides can be applied to any healthcare professional field.

Assessment indicated

Diagnosis made

Peer or allied health field = must be no bias

Questionable as to ability to safely practice a profession with reasonable care and competence

Ethical dilemmas that arise when psychiatrists are involved in the assessment and treatment of medical colleagues. Special attention needs to be paid to the context of the relationship between the psychiatrist and the doctor-patient, and to the extent to which the patient is seeking help voluntarily or at the request of a third party.

Psychiatrists may find themselves uncertain about how to meet the ethical demands of their duties to the patient and their duties to the public, when these conflict.

The ethical duties to a ‘medical’ patient (a doctor) are the same as those to a ‘non-medical’ patient (a member of the general public), but the therapeutic alliance that gives rise to those duties may be more difficult to achieve, resulting in particular ethical tensions

A psychiatrist asked to assess a sick doctor must act impartially and be unbiased by personal responses to a doctor’s problems

The decision of an assessing psychiatrist may remove a fellow doctor’s livelihood

Assessing and treating psychiatrists cannot guarantee a sick doctor absolute confidentiality

A treating psychiatrist has a duty to report a poorly performing doctor, with or without that doctor’s permission

Should doctor-patients, particularly psychiatrists, be treated out-of-area or privately, to protect their identity?

The first ethical dilemma faced by psychiatrists relates to the identification of problems and the need for action in situations where a fellow doctor (especially a psychiatrist) appears not to be aware of their own problems, or is reluctant to accept the reality or severity of their mental difficulties.

DENIAL?

Let me explain why I’ve changed my assessment decisions.

Doctor-patients or for that matter any HCP may be reluctant to admit the extent or severity of their difficulties.

Dilemmas for medical colleagues (and patients) usually center on the need to disclose their concerns, either in the face of the doctor-patient’s refusal or without their knowledge, both of which may result in conflict, anger, distress and deception.

Psychiatrists may be asked to assess doctors with mental health problems in a variety of settings and for a variety of purposes. The most common situation will be provision of an assessment at the request of a third party e.g. Board of Licensure, PHMP, Employer, and others.

Here the doctor being assessed cannot assume that the psychiatrist will provide a report that is helpful to him, nor that the interview is entirely confidential.

In this sense, these assessments are like any other reports prepared at the request of third parties, and psychiatrists will need to give the usual warnings about the limits of confidentiality and a duty to disclose risk.

Assessing psychiatrists need to be thoughtful about their own personal responses to the assessment process. It is easy to both over- and under-identify with the doctor being assessed, especially with a fellow psychiatrist.

Another ethical issue that arises during assessment relates to the pursuit of justice and equitable treatment. There is an absence of an evidence base addressing the relationship between mental disorder and work performance, which means that judging fitness to practice can have a potentially arbitrary quality.

The more common issue around disclosure relates to providing progress reports for third parties. If a doctor is in treatment for a problem that has impaired fitness to practice, then it is likely that employers or the Board of Licensure will seek feedback on progress (or lack of it). In such circumstances, if the patient gives consent to disclosure then there is no dilemma.

Depending on the situation, the treating psychiatrist may: speak directly to the third party, or pass on their views through another professional such as the general practitioner or supervisor/employer.

In practice, it is usually best (and fairest) if the evaluation and treatment roles are separated. However, this may not solve the ethical tension; if the doctor-patient refuses to give consent to any disclosure, then the treating psychiatrist will be faced with the same dilemma described above, namely whether any risk exists that justifies disclosure.

The chief professional concern is whether the sick doctor poses a risk to others as a result of the mental disorder. However, the assessment of risk in relation to mental disorder and decision-making based on that assessment are fraught with ethical dilemmas: again, these are mainly to do with justice and equitable treatment and the lack of evidence to justify decisions that have huge consequences.

For example, it seems plausible to argue that doctors addicted to alcohol will be a risk at work and unable to practice. However, anecdotally at least, it appears that it is all too possible to carry on being an adequate practitioner while being an addict. I make this point not to suggest that addiction is not harmful or should not be treated, but only to demonstrate that it may not be all that easy to quantify the risk to others posed by a mentally disordered doctor.

Another issue that is raised by treatment relates to its purpose. Is it to make the doctor safer or better?

Consider again the alcohol-misusing doctor who can be helped to abstinence with treatment. Employers and the Board of Licensure may be happy to employ someone who is abstinent, and the doctor herself may be keen to resume work. However, the psychiatrist may not be so convinced that all is well if it is obvious that underlying emotional problems remain that are powerful risk factors for relapse.

I have worked with Licensing and Regulatory Boards in Kentucky since 1986. I currently work with nine licensing boards in KY.

There are similarities within each as to how impaired practitioners are handled and a few differences.

Knowing or having reason to know that a pharmacist, pharmacist intern, pharmacy technician, or home medical equipment and services provider is incapable of engaging or assisting in the practice of pharmacy or providing home medical equipment and services with reasonable skill, competence, and safety to the public and failing to report any relevant information to the board

KRS 315.126(1) requires the Board of Pharmacy to establish a pharmacy recovery network committee (PRNC)

The PRNC shall be comprised of eleven (11) members.

There may be no more than four (4) members in successful recovery on the PRNC.

All new applicants for a Kentucky pharmacist license (by initial licensure or reciprocity) shall submit to a nation-wide criminal background investigation by means of a finger print check by the Kentucky State Police or the Federal Bureau of Investigation

filing reports with Kentucky Attorney General, Kentucky Office of Inspector General, and Kentucky State Police; commencing investigation and charging decision by Board

penalties including: life-time revocation of dispensing controlled substances if pharmacist has felony conviction of improper, inappropriate, or illegal dispensing of controlled substances

impose restrictions short of permanent ban of pharmacist convicted of improper, inappropriate, or illegal dispensing of controlled substances, and pharmacist licensed in another state that is disciplined for improper, inappropriate, or illegal dispensing of controlled substances shall have at a minimum the same disciplinary action imposed in this state.

In 1976, a California case established that a health care provider has a duty to disclose information that would protect an innocent third party from harm (Tarasoff v. Regents of the University of California, 1976). The Tarasoff decision and other case decisions have found that privacy is not absolute. The duty to protect third parties from harm is even stronger when the third party is dependent or in some way vulnerable (D v. D, 1969; In re Doe Children, 1978).

And what may this mean for the Pharmacist Recovery Network, the KARE program, and KPHF?

In Oregon we had a first PRN person laid off after 4 years with no problems on the job due to downsizing and another one 6 months ago although WalMart continue to hire in the area. It seems we are now a risk management problem. Oregon has also seen Walgreen go this direction. I have been working with the DM but they tell me that their hands are somewhat tied unless he has some very good reason the override the risk management.

For further information: Brian Fingerson, RPh Brian Fingerson, Inc. dba KY Professionals Recovery Network (KYPRN) 202 Bellemeade Road Louisville, KY 40222-4502 O/H: 502-749-8385 Fax: 502-749-8389 Cell: 502-262-9342 kyprn@att.net

www.counselormagazine.com/columns-mainmenu-55/1091?..

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol31998/No3Dec1998/PrivacyIssues.html

http://apt.rcpsych.org/content/11/5/330.full

http://www.reneweveryday.com/blogs/peer-to-peer-mentoring/selfdisclosure-the-good-bad-ugly/