Concealed Conflict of Interest Guidelines
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We address conflict of interest for referral sources and marketers together on a separate page from the articles on those topics because the same issues apply to both groups.  

As we consider concealed conflict of interest, we need to recognize that trusting professional relationships are formed in a variety of ways, that these are highly subjective, and they do influence both referring professionals and parents.  Parents will often be influenced by whether or not they develop trust with the admission person representing a school or other program.  Over the years we have learned to trust some individuals in education and treatment services and our referral patterns reflect that, notwithstanding the absolute fact that some we do not know as well might be just as worthy of that trust.  We affirm that those we have not gotten to know quite so well have every right to reach out to us to attempt to build equivalent relationships.  Frankly those who take initiative are likely to be most successful at that endeavor. It is not a perfect system, but we are at peace with the standards we set for ourselves.

The worst of conflict of interest occurs when people who recommend programs motivated by cash incentives and do not inform the family they are referring that their referral is not motivated by objective research but by dollars.  Some schools even provide a month of free tuition to a family who recruits another family.  These issues are addressed in greater depth in our article Guidelines for Marketing and Promotion.  Other schools and programs that are considered respectable offer lavish gifts, entertainment, and junkets.

This kind of thing can be subtle.  One large chain of schools and programs sponsors lavish educational events twice a year: In the fall in the West and in the spring in the East.  These educational events usually involve all expense paid travel of the referring professional.  Usually this includes some excellent educational programs, tours of nearby schools and programs owned by the sponsoring company, lavish dinners with live chamber music, entertainment, etc.  The chief marketing officer of the sponsoring company has been known to describe the events as a “thank you” for referrals.

Sometimes it is not so subtle.   Our story begins when our consultant, Tom Croke, went to visit a new program for substance abusers operated by one of the larger provider companies.  The program was billed as innovative, offering some elements of wilderness, some of psychiatry, innovative parent work, some of twelve-step work, some of alternatives to twelve-step work.  It certainly sounded interesting. 

When Tom interviewed the executive director and clinical director of the program, he asked how the program worked.  In fact he referred to advice once given by an executive officer of the same provider company to consultants: “When you visit a program, ask what their philosophy of change is.  If they can’t clearly answer that in a way that you – the consultant – can understand it, you probably should not refer to them.” (not precise words spoken, but that is the substance of it).  In asking how the program worked, Tom was essentially following advice given by one of the executives of the company that employed the executive director and clinical director. 

In responding to that question, the executive director and clinical director made references to their “curriculum” which they told me covered that issue.  Tom began to ask about the content of the curriculum, but the answers did not give a clear picture. Tom inquired about getting a copy of the curriculum, aware that on tours many programs routinely distribute handbooks, program descriptions, and detailed information about their therapeutic process in print form so it can be studied after the visit.  However, he was told that the curriculum was proprietary information.  The executive and clinical directors went on to point out that they had put a lot of work into developing it and they did not want other programs copying what they had done, so they don’t want it circulation.  Tom then inquired about handouts derived from the curriculum given to parents and residents.  No, they were also proprietary. 

Still trying to understand the program and make a connection, Tom inquired whether or not it might be helpful to copyright those documents to prevent abuse of their intellectual property but allow the program to be described.  That led into an unproductive discussion of copyright law that distracted from Tom’s real concern. Tom acknowledges responsibility for that distraction.  

In fairness, it did not appear that the clinical director and executive director were being intentionally evasive about their process.  To some degree the explanation did seem to lack specifics but when specifics were given, it was difficult to fully absorb the information.  Tom needed to be able to study it in writing.  One thing that was never made clear to Tom’s understanding was the degree to which the program was twelve-step based or why.

At that point, they told Tom they would provide him with the curriculum if he referred a number of clients.  They seemed to think Tom regarded the curriculum as valuable and entirely missed the point that they had not explained the program adequately.  Tom left, dissatisfied.  He had a gut sense that this was a good, innovative program but lacked the information necessary to having confidence in it.

Subsequently, Tom brought up the problem to a marketing representative.  She arranged a further meeting with the executive director at a conference both would attend to clear up the situation and later to have Tom sit next to the clinical director at a dinner at a different conference.  In the meeting with the executive director, the same interaction repeated: no adequate explanation; a quid quo pro offer of a copy of the curriculum if there would be a series of referrals.  At dinner with the clinical director, things took a different twist: Tom tried to explain the problem in detail, slowly, clearly.   This is not about considering the curriculum an item of value.  It is about understanding the program prior to making a referral. She responded by improving the offer: Only one referral would be needed to supply the curriculum. 

At that point Tom responded by characterizing the ethics of what was happening.  The clinical director got up and left in a huff. Tom went back to the marketing representative and asked for a meeting with the corporate officer to whom the executive director of this facility reports.  When that meeting occurred it was attended by the corporate officer who directs marketing, the corporate officer to whom the executive director of this facility reported, and the marketing representative, along with Tom.  The corporate officer overseeing the program remained largely silent.  The corporate officer in charge of marketing revealed that she had a personal relationship with the clinical director, and she understood Tom’s behavior as a personal attack on the clinical director. From what was said, one might have suspected that the corporate head of marketing was the line supervisor of this program and the corporate officer said to be supervising the program was a mere figurehead.  The corporate marketing officer proceeded to engage in a verbal assault on Tom for daring to criticize the clinical director, never actually addressing the problem at hand.  That marketing division of that company, which had been courting FamilyLightsm business, subsequently cut off communication with FamilyLightsm.  (Actually after that there was some communication between Tom and the clinical director resulting in a better explanation of the program)  However FamilyLightsm has never been comfortable with referring to that particular facility and makes only minimal use of any programming under the supervision of the corporate officer who oversees that program.

The corporate officers involved in the above exchange characterize what is wrong in this business, and why the general public needs to be on guard against corrupt referral practices.  Their behavior is not illegal and to our knowledge not clearly contrary to any universally recognized ethical standards.  But apparently the only kind of marketing that company understands at the corporate level is quid pro quo, and simply – at the corporate level – does not get the concept of informing as part of marketing or the need for ethical referral people to understand how a program works if we are going to refer.   Its core understanding of marketing is to engage in practices we believe ought to be labeled as corrupt.  (Staff connected to individual programs in their company tend to be more information based, ethics conscious, and reliable).  This affair epitomizes the issue of marketing by concealed conflict of interest, which appears to be the only way this company knows how to do it.  That is a shame because they do have some high quality schools and programs.  Apparently they don’t have sufficient confidence themselves on their own quality to be able to sell their services on the basis of quality and legitimate trust building alone.  

IECA membership and NATSAP are organizations that make a serious effort to uphold ethical standards.  To be fair about it, IECA probably has the strictest standards for avoiding conflict of interest of any professional organization of referring professionals.  NATSAP has stated that their ethical standards for programs "mirror" those at IECA. We believe that at least in IECA the overwhelming majority of people active in the organization are decent people who are concerned about ethical behavior.  However, there is no guarantee that these organizations will prevent unethical behavior.  We suspect that most of our colleagues conscientiously believe we are exaggerating the situation, and even with the most aggressive attempts at enforcing high standards, it is not an easy thing to do. 

We believe that IECA and NATSAP are making serious effort to raise ethical standards, but we have a serious distance to go even for our membership. This paragraph replaces one that is temporarily removed explaining those problems.  This was done at the request of people connected with IECA who are seeking a constructive solution. 

The Principles of Good Practice of IECA are a good start toward standards of avoiding conflict of interest, but we do not believe they go quite far enough and enforcement is difficult. 

We have heard officials of NATSAP state that NATSAP would adopt and enforce ethics provisions that mirror the IECA regulations.  If NATSAP were doing that, we expect that some of these practices would cease.  If NATSAP were to do this, not only would expensive travel and entertainment junkets for IECA member consultants stop, but the same practices would end for employee assistance professionals, psychiatrists and other  private practitioners, etc.  Frankly we haven’t seen evidence of NATSAP attention to these efforts at all except for some effort focused on the particular relationship between IECA member consultants and NATSAP member schools and programs, and that has seemed less than adequate to us. 

Having challenged the situation at IECA and NATSAP and among the members of both organizations, we would like to point out that so far as incorporated professional organizations go, these represent about as high standards as exist anywhere.  Yes, thankfully, there are referring professionals and providers who keep very high standards and meet our guidelines, by contrast with what we have described.  It is still appropriate for parents and other consumers to question the conflict of interest standards of the IECA member consultant you consider engaging.  You should question the same with  any referring professional.  You are welcome to question us on that. We welcome those questions.  There is no formally constituted organization we are aware of that is prepared to enforce the standards we believe are appropriate.

One issue we find very difficult to resolve is the matter of referral from schools and programs to consultants. This could carry the appearance of currying favor and could be viewed as the ultimate quid pro quo.  We can call upon referring professionals to avoid being influenced in this way, but there is probably no way to enforce that.   We do suggest full disclosure of numbers of referrals to the referring professional from a school or program and how many are referred to that school or program.  This would help but does not solve the problem.  We will not back the notion of asserting that all such referrals are unethical, as there are times that the expertise of the referring professional is simply needed and we know of no way to remove the appearance of quid pro quo without taking away that resource. 

As of 2009, we are tracking statistics on referrals FROM schools and programs. Once we receive a referral from a school or program, we will track our referral pattern to that school, program and other schools and programs controlled any parent organization of that school or program. 

We do not believe we have found the perfect set of guidelines to prevent problems. 

We are frankly unable to determine specific guidelines that would lead to transparently clean standards without creating negative unintended consequences.  We are not satisfied with what we offer here in that regard, but we do not currently see a better choice at the moment. We welcome suggestions.  But we will not back away from resistance to concealed conflict of interest. 

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Return to Referral Guidelines

Feedback is invited. We will publish selected feedback.  Email

Disclaimer: No  program review, no matter how positive, is a blanket endorsement. No criticism is a blanket condemnation.  When we express our level of confidence in a school or program, that is our subjective opinion with which others might reasonably disagree.  When we assert something as fact, we have done our best to be accurate, but we cannot guarantee that all of our information is accurate and up to date. When we address compliance with our guidelines, you need to remember that these are only OUR guidelines -- not guidelines from an official source.  We have also set the bar very high, and do not expect any school or program to be in total compliance.  It is not appropriate to draw a conclusion of impropriety (or even failure to live up to conventional wisdom) from our lack of confidence in a school or program or from less than perfect conformity to our guidelines.  Some will say we expect too much. Readers are responsible for verifying accuracy of information supplied here prior to acting upon it. We are not responsible for inaccuracies.

Last updated 1-04-09; Minor edit 7-9-09

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