For a couple of years now, I have been reminded of a conversation I had on Facebook regarding a certain well-known therapy technique. During the course of this conversation, several private practice SLPs (and a couple school-based SLPs) stated they (and I’m paraphrasing) didn’t care if a product was evidence based because …
parents were specifically requesting them. In fact, they were specifically stating they were requiring all of their employees be trained in these techniques and wouldn’t hire them if they weren’t trained. They believed, strongly, that if a parent requested a specific therapy technique, such as PROMPT, then they needed to offer it to the parent regardless of the evidence behind it or they parents would go elsewhere and the private practioner would lose money…or in the case of the schools, the parents would litigate.
Today, as I was preparing to submit proposals to ASHA17, I came across this gem in our new 2016 Code of Ethics:
“Rules of Ethics III
B: Individuals shall avoid engaging in conflicts of interest whereby personal, financial, or other considerations have the potential to influence or compromise professional judgment and objectivity”
So…where does this put those practioners?
Is it a conflict of interest when a clinician knowing the product/technique/method is NOT evidence-based agrees to serve a client using that method because the parent’s request it? Does it make a difference if the reason they’re doing it is because they know the parents will go elsewhere and get their wants met and so the SLP would lose money?
Is it morally and/or ethically acceptable to accept a client/FMSO request for a treatment strategy that you know (or suspect) is NOT EBP so that you don’t lose the client and therefore don’t lose the money?
Is it morally and/or ethically acceptable for a school/institution to accept a parent’s request for a specific program/treatment methodology without the EBP to back it up simply to avoid the potential lawsuit?
Or, conversely, does the “it most likely won’t hurt anything – and may possibly help” thought offset the non-EBP for pay conflict?
I’m not sure what the answer is, but I’d love to hear your comments. Please, drop me a line here and let me know your thoughts. I’m hoping to share some of them with my student clinicians.
Until then…Adventure on!
14 thoughts on “SLP, Code of Ethics, and me…”
This is a great conversation starter! I guess a couple thoughts that I have are: is the protocol that the parent is requesting contraindicated by EBP or is it a protocol that has not been sufficiently researched and is therefore not EBP for lack of research? I think the answer to those two questions is quite possibly where the ethical dilemma lies. It would seem highly unethical to provide a therapy that has been proven repeatedly to be a bogus treatment. However, if there is no evidence to suggest that the therapy would be beneficial or not, it is difficult to determine whether or not that is ethically unsound-especially if the basis for providing the therapy is founded on previous research that could parlay to the preferred therapy. That is one thing that has been more and more apparent to me as I finish up my last year of grad school-there is a lack of research for therapies in this field–which is why I can see why some clinicians advocate for a blend of evidence based practice and practice based evidence.
Excellent point Jennifer.
There is definitely a difference between a product that has been contraindicated or shown to not be effective and those that are simply not researched enough.
What about those that have been shown to have no significant impact beyond traditional methods? But because of the marketing, the parents see it as the “cure?” Where would that lie?
That’s a great question. I guess my thoughts would be, if this doesn’t cause harm and would be as beneficial as traditional approaches, why not meet the parents’ requests? I think this is where sufficient parent education should be implemented to insure that the parents are aware of the lack of research and that there isn’t sufficient research to state that their desired therapy is better than a traditional therapy. There’s an article by Kamhi (2006?) that basically presents the research to advocate that “what” is taught in therapy is more important than “how” it is taught. So, I guess with that line of reasoning as long as the preferred therapy would be on par with EBP txs, I don’t see the ethical harm. I’m very open to other perspectives and really like this line of questioning.
Okay…But IF that “parent preferred” therapy (for lack of a better word) allows the clinician to charge more because of the specialization – then does it become an ethical issue – according to the new COE? There’s personal and financial gain with no clear evidence…
Just to play devils advocate, I don’t know that a specialization would allow an SLP in and of itself to charge more, as in one SLP without X training charges $140/hour and the SLP with X training charges $150–at least, that’s not how I see it happening in my area. I do see better marketing etc allowing an SLP to charge more, though. Like, a bigger advertising and charity presence, or even as simple as someone who takes the time to list all the conferences/webinars attended and populations served in past jobs. Or, I know some SLPs who are kid magnets and are able to charge more because their clients LOVE them. If you want to be really strict, these could end up being conflicts on interest when it affects an SLP’s judgment or objectivity. But I don’t go that far.
But yes, if you don’t believe there’s any evidence for something, it is unethical to offer that just so you don’t lose a client. I just wouldn’t term it a conflict of interest.
Fair enough Janelle…and thanks for commenting.
If I’m understanding you correctly, you’re saying providing the therapy technique simply so you don’t lose the client, when you know there’s no evidence to support it’s use is unethical. Is there a change if it is just ambiguous? As in, there’s nothing to show that it works better than anything else – but there’s nothing to show that it’s harmful either? Is that still unethical?
I am an slt working for the nhs in the uk and we are quite lucky I suppose to be able to refer to NICE guidelines when recommending treatment, but it is very disheartening when independant practioners recommend therapy that is not evidence based to parents alongside our advice. The danger for us is that in the uk parents can request a certain treatment is adopted as part of their education health and care plan. This leads to costly tribunals, upset and geartache all round. I tend to be very up front with parents about evidence bases and make it very clear that public funds can only be used to support evidence based practice. I often wonder how tgese people sleep at night.
Thank you for the comment Monica.
Parents can request here as well, but it is up to the individual therapists to educate parents or simply go along with the request.
I’ve had many parents ask for information on certain treatment methods. I provide them research (both for and against if available) and discuss it with them thoroughly. They can’t make informed decisions otherwise. I’ve had some that still chose to seek out non-EBP treatment from other people and some that were content to follow my suggestions.
The difficulty here is that these aren’t public funds necessarily (although I have made that argument while I was in the schools). But parents are paying out of pocket or billing insurance for these treatments. That’s why I question the ethics of the situations. The SLPs could be accused of taking payment for treatment they know isn’t effective…or charging more for specialized treatment that isn’t necessarily more effective than traditional treatments. I’m not sure where one line stops and the other starts.
I have a situation where a parent is trying to get the school to incorporate RPM (Rapid Prompting Method) into our “bag of tricks” to use with her child. They pay an outside provider to work with her using these methods. If you are not familiar with it, the information suggests that it is facilitated communication type of approach. It has not research, but lots of family reports of success. They are trying to sneak in into the IEP by saying that the students uses AAC outside of the classroom and trying to add the use of AAC as a part of her plan. We are trying to arm ourselves with all of the information we need to defend our position to keep it out of the school.
Oh my, that is a problem. So not only is this private practice SLP (assuming that’s who the outside provider is) potentially being unethical by providing non-EBP treatment for profit (provided the original question is in fact true); it has a potential of bringing litigation to the school. Which calls into question the issue of complicity. If the IEP team caves and decides to allow RPM, then you, as the provider, are put in a very difficult situation. That’s a definite no-win situation. I am truly sorry this is occurring.
When I worked in the schools, I was fortunate to have directors that heavily supported EBP and backed us up whenever there was any conflict with parents or teachers. I would also add that in employing discredited or unproven methods, I was breaching my Code of Ethics and it could put my certification and/or license in jeopardy. That was always enough for anyone to back down as they knew that was serious business. This is a great conversation to be having – thanks for sparking it, Mary!
Thanks for commenting Pam
Love this discussion. Just a thought that came to me: There are so many techniques out there that I will admit I am not familiar with, and can’t remember right off hand which are EBP or not, especially the older I get! So what happens when a parent requests a course of therapy and you have never heard of it or can’t remember its EBP status? Do you table the discussion to get the time to research it to make sure what you might remember about it is true? Or are you just expected to know it all! 🙂 Is there a list I can print? 🙂 Yikes!
I think my view on it is you can’t ethically begin a treatment you’re unfamiliar with – so you’d have to step away long enough to get trained, do research, etc…I always tell my students there’s no way you can know it all – you have to have a good understanding of the theories, you know to know the basics (and a bit more) and you have to know where to find the rest.
I think looking at it through the baloney detection view (https://speechdudes.wordpress.com/2011/10/08/quackery-hokum-baloney-separating-science-from-stupidity/) to help make a decision.
Thanks for commenting Shannon…Love the question!
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