By Tina M. Rocco, MA, CCC-SLP, HPCS
- A branch of philosophy dealing with values pertaining to human conduct, considering the rightness and wrongness of actions and the goodness or badness of the motives and ends of such actions.
- Systematic rules or principles governing right conduct. Each practitioner, upon entering a profession, is invested with the responsibility to adhere to the standards of ethical practice and conduct set by the profession.
As licensed providers of therapy services, occupational therapy, physical therapy, and speech-language pathology professionals are required to follow a code of ethics and work within their scope of practice. States have individual practice acts, regulations regarding ethical practice, and documents related to term and title protection. At the national level, the American Occupational Therapy Association (AOTA), the American Physical Therapy Association (APTA), and the American Speech-Language Hearing Association (ASHA) provide therapists with codes of ethics and scope of practice documents. While there are variations between the three organizations, there are also many commonalities. All three organizations address topics related to a therapist’s responsibility to engage in continuing education and to demonstrate proficiency in the treatment tools or strategies they utilize. They all also address topics related to how therapists describe and market their services, and how they bill for these services.
Most relevant to this article is the fact that all three associations recognize not only a therapist’s responsibility to engage in ethical practices, but to report unethical practices if they become aware of them. They all also address a therapist’s professional responsibility to advocate for their profession and to protect consumers. Of particular interest are the following items:
- AOTA Principle 4, Item K: “Report to appropriate authorities any acts in practice, education, and research that are unethical or illegal.”
- APTA Principle 5, Item E: “Physical therapists who have knowledge that a colleague is unable to perform their professional responsibilities with reasonable skill and safety shall report this information to the appropriate authority.”
- ASHA Principle I, item S: “Individuals who have knowledge that a colleague is unable to provide professional services with reasonable skill and safety shall report this information to the appropriate authority, internally if a mechanism exists and, otherwise, externally.”
- ASHA Principle IV, Item N: “Individuals shall report members of other professions who they know have violated standards of care to the appropriate professional licensing authority or board, other professional regulatory body, or professional association when such violation compromises the welfare of persons served and/or research participants.”
In addition to state and national regulations, therapists also have a responsibility to follow the AHA, Inc. Statements of Best Practice for the Use of Hippotherapy by Occupational Therapy, Physical Therapy, and Speech- Language Pathology Professionals. The statements were published in 2015 and revised in 2017 and address three main areas: treatment team, professionalism, and safety.
What does this mean for you as a licensed therapist? Ultimately, licensed professionals not only have a responsibility to be aware of and follow the national and state guidelines that are relevant to their practice, but they also have a responsibility to address and report ethics issues when they become aware of them. Let’s go through a few scenarios.
You are a licensed physical therapist who owns a private practice called Appleseed Physical Therapy. Your practice offers physical therapy services that incorporate a variety of treatment tools, including hippotherapy. You have completed several continuing education courses related to hippotherapy and you are pursuing certification through the American Hippotherapy Certification Board. You appropriately market your services as physical therapy and provide clear, evidence-based information to clients about how and why you utilize equine movement within your practice as part of a larger total plan of care. You follow the AHA, Inc. Best Practice Statements and utilize AHA, Inc. terminology in marketing materials.
You have become aware of another physical therapy practice located 15 minutes away. The practice just opened and is called ABC Horse Therapy. It operates on the property of a show barn. The practice is owned by a physical therapist named Jessica. Jessica has always loved horses but doesn’t know much about them. She has never taken any continuing education courses related to hippotherapy, however she has heard wonderful things about it and thinks that it sounds fun. The owner of the show barn is a friend of hers and encouraged her to open the practice. The show barn allows Jessica to use their retired horses for a small fee. The horses are usually well behaved, however most of them are unsound, no longer in a training or conditioning program, and several have difficulty keeping weight on due to their age. The owner of the horses says that it is ok for them to be used in the physical therapy sessions because they are only walking. She feels it will help to keep them fit and give them a purpose.
Jessica does not have a clinic or appropriate space to complete evaluations or to provide therapy when clients cannot go on a horse, therefore she uses evaluations from schools, other private therapists, or just does an informal assessment during the first therapy session and writes up a short evaluation based on what she sees the client do on the horse. She cancels therapy when weather doesn’t allow her to use the horses, resulting in inconsistent treatment and limited progress for her clients. Jessica markets hippotherapy as if it is a stand-alone service on her website and in her brochures. Some of her marketing materials don’t even mention that she is a physical therapist, and in several places the marketing materials refer to her as a hippotherapist. She frequently uses terms such as “hippotherapy program,” “hippotherapy sessions,” “hippotherapy practice,” “hippotherapy center,” and “hippotherapy services.” The owner of the show barn is well-connected with the local press, and she promotes that they now offer equine therapy. When they appear in the press, Jessica and the owner of the show barn talk about “the power of horses to heal people and cure a number of aliments.” They refer to the “magic of horse therapy” to help clients improve their mobility and walk better. While the press is positive, it is inaccurate and misleading.
You are aware that the actions of ABC Horse Therapy, Jessica, and the show barn are not ethical, put clients at risk, and raise issues of equine welfare. You also have concerns that the way that Jessica speaks about physical therapy services incorporating hippotherapy can lead to challenges with reimbursement for all therapists in the area. You think about what you can do to address the issue, but ultimately you decide that the best course of action is to ignore the situation. You assume that in time clients will realize that it is not the best place to go for therapy. You will just mind your own business and continue to run your own practice in the most ethical way that you can, and hope for the best.
POTENTIAL ETHICS ISSUES IN THIS SCENARIO:
- Jessica has misrepresented physical therapy services through her practice name (ABC Horse Therapy) and through the use of terms such as “equine therapy,” “horse therapy,” “hippotherapy services,” “hippotherapy sessions,” and “hippotherapy practice.” Jessica is not following the AHA, Inc. Best Practice Statements related to terminology, item 2.7.
- Jessica has failed to complete a proper initial evaluation prior to starting treatment with her clients.
- Jessica is not acting in her clients’ best interest. Because she does not have an appropriate evaluation or treatment space, she is only treating clients on the horse and is not utilizing hippotherapy as it is intended, as part of a larger total plan of care. As a result, she is not following the AHA, Inc. Best Practice Statements, item
- Jessica is utilizing unsound, unfit, and underweight horses. This raises issues from an equine welfare perspective. In addition, unsound, unfit, and underweight horses do not produce appropriate symmetrical movement needed for hippotherapy. Further, putting clients on unsound, unfit, and underweight horses creates potential safety concerns, putting her whole team and her clients at risk.
- Jessica is marketing her services in a manner that violates the APTA code of ethics. She is speaking about the services as if they are “magical” and a “cure.” She is not utilizing evidence-based practices and research to support her clinical decision-making, and she is making unrealistic and unsubstantiated claims about prognosis.
- Jessica has not completed any continuing education in the use of hippotherapy in treatment and has limited experience with horses. This puts her clients at risk and limits her ability to effectively utilize hippotherapy as a treatment tool. It also violates the APTA code of ethics.
- You are aware of the unethical behavior of your colleague; however, you have failed to act. While it is unlikely that you will get in trouble for not taking action, you do have a professional and ethical responsibility to do so. You have failed to help protect consumers and to advocate for your profession.
WHAT ACTIONS COULD YOU TAKE AS A PHYSICAL THERAPIST IN THIS SCENARIO?
- Reach out to Jessica directly. Let her know some of the potential concerns, and direct her to appropriate continuing education resources, the APTA code of ethics, the AHA, Inc. Best Practice Statements, and any other relevant state-specific resources.
- If the behavior continues, or if you do not feel comfortable contacting Jessica directly, you still have an ethical responsibility to act within the APTA code of ethics. If you are not sure about what you should do, you could contact the AHA, Inc. Ethics & Advocacy Committee, APTA, your state physical therapy association, or your state licensing board for input prior to filing an official complaint.
- You could contact the local media outlets and provide them with educational resources and the media kit from the AHA, Inc. website to help them to understand the right terminology and information to include in future news segments related to the integration of hippotherapy in practice by physical therapy, occupational therapy, and speech-language pathology professionals. You can encourage them to fact-check future stories and offer to serve as a reputable resource for other segments.
- If you have concerns about the welfare and treatment of the horses you should contact your local humane society.
You are a licensed occupational therapist who works in a school district. A local PATH Intl. Accredited Center advertises that they offer therapeutic riding lessons. On their website, they state: “Therapeutic riding lessons are a form of physical therapy. In fact, our therapeutic riding lessons give all the benefits of physical therapy, occupational therapy, and speech therapy, but in a less sterile and cold environment.” The website goes on to refer to the “benefits of therapeutic riding” and states that “therapeutic riding improves sensory processing, fine motor skills, speech, social skills, muscle tone, and gait,” despite there being little research to support these claims. The center has three PATH Intl. Certified Instructors at the registered level working on-site. They refer to their instructors as “therapists” even though none of them are licensed professionals. The instructors at the center typically do not teach riding skills. Instead, they target behavior, educational goals, fine motor skills, gross motor abilities, and speech and language skills. When lesson planning, the instructors often use Individualized Educational Plan (IEP) goals that were written for school-based occupational therapy sessions, physical therapy sessions, speech-language pathology sessions, and special education services. They tell parents that they are able to address any and all IEP goals at the PATH Intl. center. Further, the instructors are now asking to attend and participate in IEP meetings and give input on goals. They have requested that the occupational therapy goals on the IEP be modified because they don’t agree that the school’s occupational therapist has set appropriate goals.
POTENTIAL ETHICS ISSUES IN THIS SCENARIO:
- The center is claiming that they offer a form of physical therapy. This is considered practicing without a license and is illegal in all 50 states.
- The center is misrepresenting riding lessons as a service that is comparable to occupational therapy, physical therapy, and speech therapy. This may be a violation of term and/or title protection laws, depending on the state. In addition, misrepresentation of riding lessons as therapy services is a violation of the PATH Intl. code of ethics, principles 2.1 and 4.1.
- Further, misrepresentation of the riding instructors as therapists is a significant issue of consumer protection. The consumer may not realize that they are not working with licensed therapists due to the misleading marketing and the description of the instructors as therapists on the center’s website.
- An IEP is a legal document. The goals within the document are selected by licensed professionals and special education teachers. They typically list the type of professional who is responsible to address the goals. The center’s claim that that they can address IEP goals without having the appropriate educational background or licensure is unethical.
- Attempting to rewrite or change the IEP’s occupational therapy goals infringes on the scope of practice of the occupational therapist.
WHAT ACTIONS CAN YOU TAKE AS A SCHOOL-BASED OCCUPATIONAL THERAPIST IN THIS SCENARIO?
- Request to discuss your concerns with administrators in your school district. You should provide educational resources to ensure that the district is aware of why the actions of the center are inappropriate and unethical.
- You or your school administrators can contact the riding center and provide them with educational resources. They should clearly express their concerns about the center’s actions in a non-confrontational manner.
- If you or your school representative is not comfortable doing this, or if the center is not receptive, there are several other options. The most appropriate course of action may vary by state. Here are some things that could be considered:
- a. Since the center is a PATH Intl. Accredited Center and the instructors are PATH Intl. Certified Instructors, both the center and the individual instructors have a responsibility to follow the PATH Intl. Code of Ethics. You or a school representative can contact PATH Intl. with their concerns or visit the PATH Intl. website and follow the process to file a grievance against the center and the individual instructors who are misrepresenting their services. If the riding center was not affiliated with PATH Intl. this option would not apply.
- b. You can contact AOTA, your state occupational therapy association, and your state occupational therapy licensing board with your concerns regarding scope of practice infringement and misrepresentation of riding lessons as a replacement for occupational therapy services.
- c. You can also contact the state physical therapy and speech-language pathology associations and licensing boards to let them know about the issue. In addition, you can alert the state physical therapy licensing board that the center is claiming to provide physical therapy and is therefore practicing physical therapy without a license.
- d. If your state has term and title protection for occupational therapy, physical therapy, and speech-language pathology services, you can alert them to the violation.
- e. You may also contact the state attorney general or the state’s Better Business Bureau to alert them to the unethical practices.
- f. You can reach out to the AHA, Inc. Ethics & Advocacy Committee for guidance and support in determining the most appropriate course of action in your state.
You are a licensed speech-language pathologist who works for a large agency. The agency has paid for you to attend an AHA, Inc. Level I Treatment Principles course and has asked you to begin “providing hippotherapy” on their behalf at a local riding center. They are “thrilled to offer hippotherapy” and feel it will make their agency stand out from the rest.
A 4-year-old boy is referred to you; his parents would like him to “receive hippotherapy” to help improve his gait. The parents have heard that being on a horse can have a lot of benefits and might help him walk better. He already receives physical therapy; however, they want to get him on a horse as soon as possible. The local riding centers will not allow him to take lessons until he turns 5.
At the initial evaluation, the client’s speech and language skills are found to be within normal limits. The client presented with distortions of his /l/ and /r/ sounds, which are considered developmentally appropriate at his age, but the agency still thinks he would benefit from hippotherapy and pressures you to take the case. They indicate that because they have paid for you to complete the AHA, Inc. Level I training and none of their physical therapists have done so yet, it would be most appropriate for you to take the case. They indicate that they will switch the client to a physical therapist as soon as they can find one who is interested in hippotherapy. Until then, you can work on his /l/ and /r/ sounds and address his gait informally.
POTENTIAL ETHICS ISSUES IN THIS SCENARIO:
- By asking a speech-language pathologist to address a client’s gait, the organization has asked the therapist work outside of her scope of practice.
- By asking a speech-language pathologist to treat the client /l/ and /r/ distortions at age 4, they are asking the speech-language pathologist to bill for a service that is not medically necessary. This is a violation of the ASHA code of ethics.
- The agency refers to “hippotherapy” as if it is a stand-alone service by saying they “now provide hippotherapy” and that they are “thrilled to offer hippotherapy.”
WHAT ACTIONS CAN YOU TAKE AS A SPEECH-LANGUAGE PATHOLOGIST IN THIS SCENARIO?
- Refuse to begin treatment, indicating that speech-language pathology services are not warranted at this time.
- Refer the client to a physical therapist who has training in the inclusion of hippotherapy in treatment.
- If the family cannot find a physical therapist in the area with training in the use of hippotherapy in treatment, encourage the family to continue physical therapy services as they are now and enroll the child in riding lessons when he is old enough.
- If the agency continues to pressure you to engage in unethical practices it may be appropriate for you to leave the agency or report the agency to the state licensing board.
- Remind the agency to use correct terminology when marketing and talking about the inclusion of hippotherapy in treatment. A better way to describe it is, “our speech-language pathologist is now able to include hippotherapy within treatment sessions,” or “we now offer speech therapy incorporating hippotherapy.” Remind them to always lead with the therapy.
Each ethics scenario differs, and sometimes it is hard to know what to do or how to respond. It is not a comfortable situation to find oneself in. However, being a licensed therapy professional includes the legal and ethical responsibility to address and report ethics issues when you become aware of them. AOTA, APTA, and ASHA offer resources and support for therapists, as do the state therapy associations and licensing boards. In addition, the AHA, Inc. Ethics & Advocacy Committee is available to help answer questions and guide therapists in addressing challenges in professionalism, ethics, consumer protection, scope of practice infringement, misrepresentation of services, and fraud. If you require assistance, please contact the AHA, Inc. office for more information. ◀