Competence and Telehealth in a New Specialty
Dr. Ramirez is a licensed clinical psychologist with 15 years of experience treating anxiety and depression in adults. She is asked to provide telehealth therapy to a 14-year-old with severe OCD and comorbid tics. The family lives in a rural area with no local child OCD specialists. Dr. Ramirez has limited training in pediatric OCD and no formal training in tic disorders. She has taken a 2-hour online continuing education webinar on pediatric OCD but has not supervised cases. The family is desperate and willing to consent to treatment. Dr. Ramirez is considering taking the case because she believes she can learn on the job and there are no alternatives. She plans to consult with a colleague who is a child OCD expert once a month.
1. Evaluate Dr. Ramirez's competence to take on this case according to the APA Ethics Code. What are the relevant standards, and what should she do?
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Relevant APA Ethics Standards:
Standard 2.01 Boundaries of Competence: Psychologists must provide services only within their competence based on education, training, supervised experience, consultation, or study. Dr. Ramirez has limited training (a 2-hour webinar) and no supervised experience with pediatric OCD or tics. This is likely insufficient to establish competence.
Standard 2.03 Maintaining Competence: She must engage in ongoing professional development, but this does not justify practicing outside her competence.
Standard 3.04 Avoiding Harm: Taking on a case beyond her competence could cause harm if treatment is ineffective or if tics are mismanaged.
Standard 4.06 Consultation: She plans monthly consultation, which is good, but consultation alone may not suffice if she lacks foundational knowledge.
Options:
Decline and Refer: If there are truly no local alternatives, she could refer to a telehealth specialist elsewhere. However, the family has already sought her out, and there may be barriers (cost, insurance, technology).
Obtain Competence: She could pursue additional training (e.g., an intensive course in pediatric OCD and tic disorders, supervised cases) before taking the case. This may delay treatment.
Collaborative Care: She could take the case only if she establishes a formal collaborative relationship with a child OCD expert who can provide regular supervision and co-management. The frequency of consultation (monthly) may be inadequate; weekly or biweekly supervision might be needed initially.
Informed Consent: If she proceeds, she must fully inform the family of her limited experience and the risks, and obtain their consent. She should also document her plan for consultation and training.
Recommendation: Dr. Ramirez should not take the case without additional training and supervision. She should first consult with the child OCD expert to determine if she can safely proceed with intensive supervision. If not, she should help the family find a qualified telehealth provider, possibly through professional networks or online directories. She could also offer to provide supportive therapy while the family seeks specialized care, but only if she is clear about her role and limits.
2. If Dr. Ramirez decides to proceed with the case, what specific steps must she take to ensure ethical practice and minimize risk?
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If Dr. Ramirez proceeds, she must:
Obtain Informed Consent: Clearly explain her limited experience with pediatric OCD and tics, the potential risks and benefits, and the plan for consultation. Obtain consent from the parents and assent from the adolescent. Document this process.
Arrange Intensive Supervision: Secure regular supervision from a qualified child OCD expert. Monthly consultation is likely insufficient; she should arrange weekly or biweekly supervision initially, with the option to reduce frequency as competence grows. This supervision should include case review and guidance on evidence-based treatments (e.g., exposure and response prevention, habit reversal training).
Pursue Additional Training: Enroll in a comprehensive training program on pediatric OCD and tic disorders, and read current treatment manuals. She should document her training activities.
Use Evidence-Based Treatments: Ensure she is using treatments with empirical support for pediatric OCD and tics, and monitor outcomes carefully.
Monitor for Deterioration: Regularly assess symptoms and adjust treatment. If the client is not improving or deteriorates, she should reconsider and refer.
Maintain Boundaries: Be clear about her limits and be prepared to refer if the case becomes too complex.
Document: Keep detailed records of supervision, training, informed consent, and treatment decisions.
Consult on Tics: Because tics are comorbid, she should consult with a specialist in tic disorders or consider a multidisciplinary approach.
Even with these steps, if at any point she feels she cannot provide competent care, she must refer.