Ethical Considerations for Psychotherapists
In today’s rapidly shifting social and political landscape, therapists are navigating new challenges when it comes to documentation. Many clinicians find themselves balancing truthful and ethical documentation with the increased need to protect client confidentiality and safety – particularly for clients in vulnerable situations. All while trying to make sense of and cope with this changing and challenging landscape for yourselves.
Navigating Documentation Anxiety in a Shifting Landscape
The Documentation Wizard Consultation Group recently explored these concerns. We asked the question, “how do we document these external stressors without putting clients or ourselves at risk?”
With political and social issues evolving quickly, many therapists feel uncertain about how to document clients’ experiences, particularly when those experiences involve systemic barriers, job insecurity, and/or discrimination.
Balancing Truthfulness & Protection in an Uncertain World
For many clients, external stressors directly impact mental health.
✔ A government employee abruptly withdraws from a DEI (Diversity Equity & Inclusion) committee for fear of retaliation (job loss) but feels guilty because he “sold out.”
✔ Your trans client of color no longer has access to gender affirming care and is scared about being fired as a DEI hire.
✔ Your client on Disability Social Security and Medicaid can’t sleep, petrified about losing healthcare and Section 8 Housing.
✔ Your immigrant client doesn’t send their child to school terrified of being deported, making you wonder if you are mandated to report to child protection services for neglect.
✔ Your pregnant client is considering an abortion in a state where it’s illegal as is “aiding and abetting.”
While documentation should always be truthful, therapists must also consider how much detail is necessary to protect both client privacy and documentation integrity. Many of the issues are controversial. Personal beliefs may vary. You don’t have to agree with your clients’ beliefs or decisions. But you need to think about how to discuss them and the delicacies of documenting, ensuring client safety and maintaining ethical and accurate records.
It’s a tall order. There is no “final answer” because 1) each client’s situation is unique and 2) we are living in a state of constant change that can throw everyone off balance.
Document Social and Political Factors as Barriers to Treatment
Instead of over-explaining political details, frame these issues as “barriers to treatment.” Barriers to treatment are the social stressors in a client’s life. They provide a clear, ethical way to document their impact. Many of these barriers can be found in the DSM 5TR as ICD 10 Z Codes. Some of them are even billable. (Always check with the covering insurance company to determine billable Z Codes.)
✅ Job instability (Z56.2)
✅ Housing insecurity (Z59.91)
✅ Limited access to care due to insurance restrictions (Z75.6)
✅ Fear of retaliation in the workplace or community (Z56.6)
Vague Vs. Specific Language
Use neutral, factual, and broad language to truthfully document client concerns without exposing your clients or you to potential risks.
For example:
🔹 Fear of Retaliation: Instead of explicitly writing “client fears workplace retaliation for supporting DEI,” consider:
✔ “Client reports increased emotional distress due to political environment impacting workplace decisions.”
✔ “Client is experiencing heightened anxiety related to job insecurity and external pressures.”
🔹 Discussing Abortion: Instead of writing “client is ambivalent about having an abortion,” consider:
✔ “Client experiences increased anxiety about making a difficult medical decision.”
✔ “Client is discussing the pros and cons of a major life decision.”
✔ “Client reports feeling angry due to reduced access to medical care.”
Where and How to Include this Information
✔ Change or add a diagnosis: If external stressors significantly impact the client’s mental health, consider adding the diagnosis, Adjustment Disorder with Anxiety (or Depression or Mixed).
✔ Progress Notes: If these barriers to treatment exacerbate your client’s symptoms, incorporate them into the progress notes as factors affecting treatment. Document how these external stressors influence client distress, mood, and progress – but avoid overly specific or politically charged language.
✔ Reinforce Client Safety & Coping Strategies: Validate the client’s experience. Help them develop agency, resilience, and strategies for emotion regulation. Remind them of the importance of community and not being alone with their feelings. You may even suggest activism to reduce the feelings of helplessness. (And take this advice to heart yourself!)
✔ Connect to the Treatment Plan: find ways to tie the social stressors to treatment goals, such as building coping strategies, learning emotion regulation, or increasing self-advocacy skills. Update the treatment plan, if necessary.
✔ HIPAA & Documentation Ethics: Under certain circumstances, client notes can be used for public health research particularly for analyzing trends and patterns in mental health conditions. What you write matters. Consider how your notes will be used to interpret history. Though mental health records used for research are required to be de-identified, transparency about how documentation is handled should be included in the informed consent and discussed with your clients.
Final Thought: Supporting Clients
While as therapists, you cannot control external circumstances, you can help clients build inner resilience, develop support systems, and navigate difficult situations. Ethical documentation is part of this process – ensuring clients are protected, their experiences are validated, and their care is not compromised.
By documenting thoughtfully and strategically, you can support client well-being while maintaining professional integrity and compliance. You may even help yourself stay grounded during this time of uncertainty and instability.
Feeling documentation dread? You’re not alone.
Learn the simple formula that will help you write notes faster, justify medical necessity, and sleep better at night. Join us for the April 11 LIVE Webinar Training.
Beth Rontal, LICSW, a private practice therapist and the Documentation Wizard® is a nationally recognized consultant on mental health documentation. Her Misery and Mastery® trainings and accompanying forms are developed to meet strict Medicare requirements. Beth’s Documentation Wizard training program helps clinicians turn their clinical skill and intuition into a systematic review of treatment that helps to pass audits, protect income, maintain professional standards of care, reduce documentation anxiety and increase self-confidence. Beth’s forms have been approved by 2 attorneys, a bioethicist, and a billing expert and have been used all over the world. She mastered her teaching skills with thousands of hours supervising and training both seasoned professionals and interns when supervising at an agency for 11 years. Her newest initiative, Membership Circle, is designed to empower psychotherapists to master documentation with expert guidance, efficient strategies, and a supportive community.