Ethics for Psychologists in Medical Settings by William W. Deardorff, Ph.D., ABPP 3 Credit hours - $74 Last revised: 05/15/2007 Course content © copyright 2007 by William W. Deardorff, Ph.D., ABPP. All rights reserved. ContinuingEdCourses.Net is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. ContinuingEdCourses.Net maintains responsibility for this program and its content. ContinuingEdCourses.Net is approved by the Association of Social Work Boards (ASWB) to offer continuing education for social workers, through the Approved Continuing Education (ACE) program. ContinuingEdCourses.Net maintains responsibility for its courses. ASWB provider #1107. ContinuingEdCourses.Net is approved by the National Board for Certified Counselors (NBCC) as an NBCC-Approved Continuing Education Provider (ACEP) and may offer NBCC-approved clock hours for events that meet NBCC requirements. ContinuingEdCourses.Net solely is responsible for all aspects of the program. NBCC provider #6323. ContinuingEdCourses.Net is approved by the California Board of Behavioral Sciences (CA-BBS) to offer continuing education for MFCCs (MFTs) and LCSWs. CA-BBS provider #3311. ContinuingEdCourses.Net is approved by the Ohio Counselor, Social Worker, & Marriage and Family Therapist Board (OH-CSWMFT) to offer continuing education for counselors, social workers, and MFTs. OH-CSWMFT provider #RST080501 & #RCX010801. Take the Course Take the Test Buy your Certificate

LEARNING OBJECTIVES

This is an intermediate course that assumes the psychologist has some familiarity with general ethical principles and the 2002 APA Ethics Code.  After completing the course, the psychologist will be able to:

• Apply knowledge of the APA Ethics Code to patient care, especially in medical settings
• Apply ethical principles to unique situations that arise when working in medical settings collaboratively with physicians
• Understand special ethical problems that occur in the practice of clinical health psychology
• Understand unique ethical issues related to boundaries of competence, maintenance of current knowledge, psychological assessment of medical patients, and dual relationships
• Manage ethical situations related to confidentiality and informed consent when working in medical settings
• Understand ethical principles as they apply to the newly emerging area of E-therapy and Internet treatment in clinical health psychology
• Differentiate between understanding the ethical principles and applying them

COURSE OUTLINE

1. Introduction to the Course
2. Recent Revisions of the Ethical Code
3. Special Ethical Problems in Clinical Health Psychology
   1. Competency in Training and Practice
   2. Recognition of One’s Boundaries of Competence
   3. Maintenance of Current Knowledge
   4. Psychological Assessment
   5. Recognition of Personal Problems
   6. Imposition of Values onto the Patient
   7. Advertising for One’s Own Services and Endorsements
   8. Avoiding Improper and Potentially Harmful Dual Relationships
   9. Providing Mental Health Services to Those Served by Others
   10. Professional Responsibility
       1. Physical health
       2. Interacting with the medical hospital system
       3. Consult, refer, cooperate
       4. Consult with colleagues
       5. Personal behavior
   11. Privacy and Confidentiality
   12. Informed Consent
   13. Conflicts of Interest
   14. Patients Who Do Not Benefit from Treatment
   15. E-Therapy and Internet Therapy
       1. Verifying patient and clinician identity
       2. Initial assessment of online patients
       3. Clinician availability
       4. Standard of care
       5. Privacy and confidentiality
       6. Informed consent
       7. Interstate practice
   16. Understanding Versus Applying the Ethical Principles
4. Suggested Readings
5. References

AUTHOR DISCLAIMER

This course provides an analysis of some ethical issues that may arise in the practice of clinical health psychology.  This course does not provide legal advice; nor should it substitute for the assistance of legal counsel, if a practitioner encounters ethical or legal issues in his or her practice.

This course is not a final decision on any ethical or legal subject, as all ethical and legal issues are constantly under revision and consideration.  This material is not meant as a personal or clinical consultation, nor is it meant as a substitution for contact with an ethics committee, attorney or professional consultant. 

The proper handling of any particular situation depends on the facts unique to that situation, as well as applicable ethical principles and laws. Those laws may differ from state to state and also may change with some frequency. Psychologists who encounter ethical or legal issues in their practices should consult with a competent attorney familiar with the laws in their state.

INTRODUCTION TO THE COURSE

Because of the special settings and patient populations encountered, the practice of clinical health psychology brings with it unique ethical issues. The Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 2002) are, of course, still applicable. (If you don't have a copy of this code handy, you may wish to view the online version at www.apa.org/ethics/code2002.html or a nice printable version at www.apa.org/ethics/code2002.pdf.) In clinical health psychology, it is just as important to be knowledgeable of the ethical principles as in any other area of practice. The Ethics Code (Introduction and Applicability) states the following:

Membership in the APA commits members and student affiliates to comply with the standards of the APA Ethics Code and to the rules and procedures used to enforce them.  Lack of awareness or misunderstanding of an Ethical Standard is not itself a defense to a charge of unethical conduct. 

As will be discussed, it is important for all psychologists whether APA members or not to be knowledgeable of the Ethics Code since they are one aspect of establishing the professional standard of care in any malpractice or licensing board action.

This course will present an overview of Ethical Principles and situations especially relevant to the practice of clinical health psychology.  The practice of clinical health psychology entails a number of areas such as primary care psychology, psychologists working collaboratively with physicians to address medical problems, and psychologists working in medical settings as consultants.  The areas of clinical health psychology and primary care psychology are rapidly expanding as health care becomes more interdisciplinary.  The important role of psychological factors in medical conditions has now become widely accepted in the professional health care provider community.  With this increased presence of psychologists working with medical patients, comes unique ethical situations and challenges that do not occur in the more general practice of clinical psychology.  Anyone who collaborates with physicians and provides treatment for health related conditions must be familiar with these unique ethical situations.

This course is based upon a chapter from the book, Clinical Health Psychology in Medical Settings: A Practitioner’s Guidebook, 3^rd Edition (Belar & Deardorff, in press).  This book was originally published in 1987 and is now in its third edition.  The updated book is being published by the American Psychological Association.

RECENT REVISIONS OF THE ETHICAL CODE

An understanding of the development of the ethical principles can be very helpful in applying them effectively to the area of clinical health psychology.  The ethical principles of psychologists have been revised many times since their initial formulation in 1952 (American Psychological Association, 1953). Pope and Vetter (1992) provided an excellent review of their initiation and evolution. The authors noted that the method for formulating the original ethical code was markedly different than any method previously used by other professions. Traditionally, professional ethical codes were developed by committee, in which ethical codes from other professions, the wisdom and experience of the most mature clinicians, and the available literature were used to construct ethical guidelines. These would then be submitted to the membership for approval. This is the so-called “armchair” or rational approach to ethical guideline construction.

In making a significant departure from this process, the American Psychological

Association decided to use an empirical method to develop an ethical code. A representative sample of member psychologists involved in a wide variety of professional activities were assessed for ethical dilemmas they encountered. On the basis of these data, the original ethical code was developed. In addition, it was planned that future revisions would be based not only on recommendations from ethics committees but also data collected from the membership about the dilemmas experienced in everyday practice.

The Ethics Code was most recently revised in 1992 and again in 2002. The revision process of the 1992 code was started in 1986 and was completed in 1992 (American Psychological Association, 1992). The revision was done to ensure that the ethics code continued to be relevant to the most current issues in professional practice, research, and training. The revision included many substantive changes, including the organization of the document as well as a narrative introduction and overview. During the course of developing the revised code, the ethics committee had to address problems with the earlier ethics code that had been the subject of an investigation by the Federal Trade Commission (FTC). This primarily focused on the language used to prohibit referral fees and advertising claims. The 1992 code of ethics dealt with these objections by the FTC.

The revision process of the 1992 ethics code (American Psychological Association, 1992) was started in 1997 and was completed in 2002 (Smith, 2003). The revision was done to ensure that the ethics code continued to be relevant to the most current issues in professional practice, research, and training. According to Smith (2003), some of the substantive changes in the 2002 revision include eliminating the prohibition that prevents psychologists from releasing raw test data to individuals who are not qualified to use them (9.04, 9.11), adding new sections on assessment standards (9.02, 9.03), changes to informed consent for “new treatments” (10.01b), guidelines for terminating therapy when threatened by a patient (10.10b), defining multiple relationships more clearly (3.5a) and addressing issues related to use of the Internet and electronic transmission (throughout the Code).

SPECIAL ETHICAL PROBLEMS IN CLINICAL HEALTH PSYCHOLOGY

The following discussion examines the most current ethical principles as relevant to the practice of clinical health psychology.

Competency in Training and Practice

Psychologists planning to provide services, teach, or conduct research involving populations, areas, techniques, or technologies new to them undertake relevant education, training, supervised experience, consultation, or study (2.01c). 

In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm (2.01e).

Psychologists’ work is based upon established scientific and professional knowledge of the discipline (2.04).

There are two types of personal competencies that are necessary for high quality practice (Koocher and Keith-Spiegel, 1998; Pope and Brown, 1996):  Intellectual competence is the acquisition of empirically based knowledge and sound clinical judgment in practice with a particular patient population. Possessing intellectual competence is also being able to recognize what one does and does not know.  Emotional competence is the clinical health psychologist’s ability to emotionally manage clinical material that emerges in treatment. This includes detecting and addressing personal biases, having a capacity for self-care, and accepting that “not all therapists can work with all clients or all kinds of problems” (Koocher and Kieth-Spiegel, 1998, p. 55).  The concepts of intellectual and emotional competence parallel the education, training and personal characteristics necessary for competent and ethical practice in clinical health psychology. 

Since the 1983 Arden House Conference (Stone, 1983), there has been further development of guidelines for training practitioners in health psychology. As was the case even in 1983, it is well recognized that weekend workshops do not produce a clinical health psychologist. Core training and preparation for clinical health psychology practice should include specific graduate-level courses in the area as well as supervised practical experience. The Division of Health Psychology of the American Psychological Association (Division 38) website has extensive information about training for health psychology careers (www.health-psych.org).  A psychologist should not present him- or herself as a “clinical health psychologist” unless training has been adequately satisfied. A psychologist is not eligible for a board certification in clinical health psychology from the American Board of Professional Psychology unless certain educational requirements have been met.  In addition, Ethical Principle 2.04 suggests that the practitioner should be familiar with evidence-based guidelines relative to clinical health psychology.

Recognition of One’s Boundaries of Competence

Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience (2.01a). 

A psychologist must ensure the best interests and welfare of the patient who presents with a problem of psychological factors related to a medical problem. Consider the following example:

Dr. Smith, a clinical psychologist, works in private practice setting, serving mostly adults. In the course of her work, she began treating a 22-year-old man who was referred by his physician and was suffering from muscle contraction headaches. Dr. Smith had done some reading about the treatment of muscle contraction headaches but had never actually treated a person with this problem. She continued treating the patient but received supervision by a clinical health psychologist experienced in the treatment of chronic headaches.

Dr. Smith acted appropriately and ethically in this example. Had she not received the outside supervision, she could have been acting unethically in providing treatment outside her area of competence  (American Psychological Association, 2002, Standard 2.01a). This is especially true in cases of psychophysiological disorders, because there are often clearly specified and empirically validated treatment approaches available for use. Another option might have been for the psychologist to refer the patient to a colleague for concurrent treatment of the headache problem.

Related to this issue, it is unlikely that a psychologist could be proficient in all areas of practice that fall within the field of clinical health psychology. Clinical health psychology includes such diverse problems as eating disorders to headaches and such diverse assessments as neuropsychological evaluations to chronic-pain patient workups. The skills necessary for these different clinical tasks are extremely varied. As in the preceding example, the clinical health psychologist must be aware of his or her limitations even within the field of clinical health psychology and take steps to assure ethical professional behavior.

Maintenance of Current Knowledge

Psychologists undertake ongoing efforts to develop and maintain their competence (2.03)

In a field as rapidly changing as clinical health psychology, it is essential to keep abreast of current literature. This is addressed in the Ethical Standard 2.03 (Maintaining Competence). Attending continuing education workshops, belonging to professional organizations, completing ongoing Internet research about specific cases, and subscribing to health psychology journals can facilitate this continuing education process. It has been said that the half-life of a PhD in clinical psychology is about 10 years when no further postgraduate education is sought (Dubin, 1972). In the area of clinical health psychology, this estimate may be much less, because of the high level of research and clinical activity.

Work With People of Different Backgrounds

Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals…(2.01b)

It may be that clinical health psychology patient populations represent more of a cross-section of society than the populations presenting to services at mental health clinics. As such, to meet this ethical guideline in the practice of clinical health psychology, an understanding of patients’ health belief models is essential. Furthermore, it is important to have an appreciation for cultural and other factors that influence patients’ explanatory frameworks for medical problems.  The following is an overview of a conceptual model useful in accomplishing these goals.

A conceptual distinction among disease, illness, and sickness is helpful for understanding patients presenting to clinical health psychologists (Engel, 1977; Fabrega, 1974; Hoffman, 2002; Kleinman, Eisenberg, & Good, 1977; 2006). Disease is an abnormality in physical structure or bodily function; it is the focus of biomedicine. Illness, on the other hand, is the human experience of sickness and is influenced by interpersonal, social, and cultural variables (Hoffman, 2002; Landrine & Klonoff, 1992; Mechanic, 1972). Illness entails explanation of the disease and how one is supposed to act when ill. It is how we perceive, experience, and cope with disease. In keeping with this model, there is rarely a one-to-one relationship between disease and illness (Beecher, 1956; McMahon & Koltzenberg, 2005; Melzack & Wall, 1983). The combined influences of disease and illness yield what we ultimately observe clinically as sickness. Patients are generally much more concerned with the treatment of their illness than with simply the “cure” of the disease.

Ethical Standard 2.01b dictates that the clinical health psychologist has an understanding of the model discussed above. The domain of clinical health psychology treatment is often illness behavior, explanatory beliefs, and sickness. When there is a significant discrepancy between the doctor’s and patient’s explanatory models, problems in treatment can occur.

Mrs. A. B. was 56-year-old woman who was recovering from pulmonary edema secondary to atherosclerotic cardiovascular disease and chronic congestive heart failure on a general medical unit. Her physical status was improving, but she was frequently inducing vomiting and urinating into her bed. She became very angry when told by the staff to stop these behaviors. Psychological consultation revealed that her physician had told the patient that part of her medical problem included “water in the lungs.” Because of her family’s occupation as plumbers, her conception of her anatomy consisted of a pipe connecting her mouth and urethra. She was therefore attempting to remove as much water from her body as possible through vomiting and urinating. She was hesitant to share this belief model with her physician because “he was so rushed” and she felt embarrassed. A sharing of the doctor and patient explanatory models, including a careful didactic session about her anatomy, resulted in a resolution of the problem behaviors and feelings of anger. (Case example adapted from Kleinman et al., 1977)

Other common examples of patients’ misconceptions about medical treatments include the following: (a) If one pill is good, then two or more must be better; (b) if symptoms are not occurring, then the pills are not necessary (often seen in medication usage for hypertension and diabetes); and (c) continued use of any medication is “overdependence.” As can be seen, any of these beliefs will have serious consequences for medical treatment.

Kleinman et al. (1977) suggested that in addressing a patient’s belief model, one should attempt the following: (a) to elicit the patient’s belief model with simple, straightforward questions; (b) to formulate the physician’s model in terms the patient can understand and communicate this to the patient; (c) to openly compare models to identify contradictions; and (d) to help the physician and patient engage in a negotiation toward shared models related to treatment and outcome. Awareness of cultural and social issues related to a patient’s belief model is crucial in guiding this process. It must also be realized that subgroups other than identified minority cultures may have beliefs about illness that affect behavior (as portrayed in the above example). It may be unethical to fail to address these issues.

Psychological Assessment

Psychologists administer, adapt, score, interpret, or use assessment techniques, interviews, tests, or instruments in a manner and for purposes that are appropriate in light of the research on or evidence of the usefulness and proper application of the techniques (9.02a)

Psychologists use assessment instruments whose validity and reliability have been established for use with members of the population tested. When such validity or reliability has not been established, psychologists describe the strengths and limitations of test results and interpretation (9.02b).

Psychologists do not promote the use of psychological assessment techniques by unqualified persons, except when such use is conducted for training purposes with appropriate supervision (9.07)

Psychologists do not base their assessment or intervention decisions or recommendations on data or test results that are outdated for the current purpose (9.08a).

Psychologists do not base such decisions or recommendations on tests and measures that are obsolete and not useful for the current purpose (9.08b).

Regardless of whether the scoring and interpretation are done by psychologists, by employees or assistants, or by automated or other outside services, psychologists take reasonable steps to ensure that explanations of results are given to the individual or designated representative unless the nature of the relationship precludes provision of an explanation of results (such as in some organizational consulting, preemployment or security screenings, and forensic evaluations), and this fact has been clearly explained to the person being assessed in advance (9.10).

In psychological assessment with medical patients, the clinical health psychologist must be acutely aware of using the proper standardization data for medical patients when available (9.02a), differences in test interpretation with a medical-surgical patient population versus a psychiatric population (9.02b), increased risk of inappropriate use of test results by nonpsychologist health care professionals (9.07), the language of the test interpretation and risk of misinterpretation (9.06), and systemic issues hampering the patient’s right to be informed of the test results (9.10). Consider the following relatively common example:

The patient was a 34-year-old woman who presented to her primary physician with diffuse and vague somatic complaints, including pain. The patient also expressed that she had been recently experiencing some significant life stressors.  The physician hypothesized that these might be contributory to her physical complaints. Initial physical evaluation was negative and, in keeping with the physician’s hypothesis, and the patient was referred for psychological evaluation, including psychological testing. The consultation request was to “determine if the symptoms might have a functional rather than organic basis.” The psychologist preferred using the original MMPI since she was more comfortable with it and had her own computer scoring and interpretive software.  The MMPI was scored using standard normative data, the patient obtained a classic “conversion V” profile with Scales 1 and 3 primed and all other scales below a T-score of 70. 

The psychologist gave the following interpretation for the MMPI and sent the recommendations to the physician without discussing them with the patient. (Release of confidentiality had been obtained to release the test results to the physician.)

Patients with similar profiles present themselves as normal, responsible, and without fault. They make extensive use of such defenses as projection, denial, and rationalization and blame others for their troubles. They prefer medical explanations for their symptoms, and lack insight into the psychological basis for their symptoms. These patients are generally considered to be converting personally distressing problems into somatic complaints, which are more socially acceptable. Although these patients are resistant to change, because of firmly entrenched defense systems, a course of psychotherapy targeting the patient’s actual source of distress may be useful. (Interpretation based on Graham, 1977; Greene, 1980, 1991 for the original MMPI).

The physician referred the patient for psychological treatment, on the basis of the above evaluation, after discussing with the patient that the psychological testing substantiated that her physical symptoms were “psychosomatic”. The psychological treatment was successful in resolving the stressful life circumstances with which the patient was having trouble, but the physical symptoms persisted. The patient was ultimately diagnosed as having multiple sclerosis when further diagnostic work was done.

This example illustrates several major ethical issues related to psychological assessment in clinical health psychology. First, the psychologist used the original version of the MMPI, which was officially withdrawn from use by the test publisher as of September 1999.  Even though it is now considered obsolete (Pope, Butcher & Seelan, 2006), one often finds that it is continuing to be used in practice.  In addition, the psychologist used standard normative data to derive the patient’s profile. Although this can be adequate if the use of such norms is taken into account in the interpretation, a more useful approach would be to use both the standard norms and those for medical patients (either norms generated in one’s own clinic or those published in the literature, e.g., Graham, 2005; Greene, 1980, 1991) and compare the difference.  Even the MMPI-2 must be interpreted cautiously when used with medical and pre-surgery patients, based upon research applicable to the patient population being assessed.

Other issues in this example, and more important ones as they influenced the course of the patient’s treatment, were the consultation request itself and the interpretation of the results. First, the physician requested an inappropriate use for psychological testing. Although this type of request is commonly received from medical personnel, reviews of the literature suggest that psychologists who use the MMPI/MMPI-2 to assess pain patients should “not attempt to classify patients as organic, functional, or mixed (Prokop & Bradley, 1981, p. 96; see also Bradley, McDonald-Haile, & Jaworski, 1992; Graham, 2005). Second, the psychologist used a standard interpretation developed on psychiatric patients. This included conjecture as to the etiology of the physical symptoms as well as several personality labels that might be cast as pejorative by a non-mental health professional.

Another problem with the response to this referral was that the language of the interpretation might not be in keeping with ethically guarding against the misuse of assessment results and promoting the best interests of the client. Without further explanation, the physician may well have changed his or her opinion of this patient and have tended to see the patient as somehow volitionally controlling the presentation of symptoms or consciously malingering-while there was no evidence bearing on this.

The last ethical issue related to this case is that the psychologist did not “ensure that an explanation of the results is provided using language that is reasonably understandable to the person assessed” (Ethical Standard 9.10; Explaining Assessment Results). Although Standard 9.10 does not state that the explanation must be done directly by the psychologist, he or she must ensure that an adequate and understandable explanation is given. This can be done most effectively if the explanation is done directly by the psychologist. This explanation and feedback process, however it is accomplished, is ethically mandated (Standard 9.10) unless explicitly waived as part of the informed-consent process.

Related to this issue, sometimes the consultant will discuss findings with the referring physician and not directly with the patient. This can be problematic, and it is recommended that where possible, follow-up with the patient be provided. It should at least be offered as an option if the patient would like further clarification after feedback from their physician. It is also prudent to inform the referral source of the importance of the feedback process with the patient. Pope (1992) provides guidelines for providing psychological test feedback to patients-including feedback as process, clarification of tasks and roles, informed consent, framing the feedback, documentation, and follow-up.

In summary, in this case, the test results were not used in the best interests of the patient. Even if the patient had not ultimately been found to have multiple sclerosis, psychological evaluation should rarely preclude thorough medical evaluation. Exception to this guideline might include extreme cases, such as somatic delusions or factitious disorders, in which there is a documented history of unnecessary extensive medical evaluations and procedures. Even in these cases, it is important to have an open line of communication with the physician. Remember, people with these types of psychological problems (e.g., somatization or symptom amplification) get sick just like everyone else.

Clinical health psychologists must be aware of special psychological assessment issues in working with medical patients, because general-practice assessment skills are not always applicable. When the psychologist is not familiar with current literature in the area, he or she is at higher risk for unethical practice. A complete discussion of assessment issues in health psychology can be found in Belar & Deardorff (in press).

Computerized Psychological Testing

When interpreting assessment results, including automated interpretations, psychologists take into account the purpose of the assessment as well as the various test factors, test-taking abilities, and other characteristics of the person being assessed, such as situational, personal, linguistic, and cultural differences, that might affect psychologists' judgments or reduce the accuracy of their interpretations. They indicate any significant limitations of their interpretations (9.06).

Psychologists who offer assessment or scoring services to other professionals accurately describe the purpose, norms, validity, reliability, and applications of the procedures and any special qualifications applicable to their use (9.09a).

Psychologists select scoring and interpretation services (including automated services) on the basis of evidence of the validity of the program and procedures as well as on other appropriate considerations (9.09b).

Psychologists retain responsibility for the appropriate application, interpretation, and use of assessment instruments, whether they score and interpret such tests themselves or use automated or other services (9.09c).

The use of computer-based test interpretation (CBTI) has continued to increase over the past several decades (Butcher, Perry, & Atlis, 2000). The ethical principles of assessment listed previously and the Standards for Educational and Psychological Tests (American Educational Research Association, AERA, 1999) address issues related to computerized testing. The Test Standards applicable to CBTI’s are as follows (AERA, 1999):

When computer-prepared interpretations of test response protocols are reported, the sources, rationale, and empirical basis for these interpretations should be made available, and their limitations should be described (5.11).

Test users should not rely on computer-generated interpretations of test results unless they have the expertise to consider the appropriateness of these interpretations in individual cases (11.21).

Those who use computer-generated interpretations of test data should evaluate the quality of the interpretations and, when possible, the relevance and appropriateness of the norms upon which the interpretations are based (12.15).

Specific and practical guidelines for users have also been discussed in various published works (Bersoff & Hofer, 1995; Butcher, 2002; Hofer & Bersoff, 1983).  Butcher (2002) has identified nine important issues when evaluating CBTI’s.  These include validity of the underlying test, expertise of the developers, availability of documentation, availability of updates and revisions, adherence to the APA guidelines, detection of response sets, relationship to published test interpretation research, quality of technical support, and inclusion of appropriate interpretative cautions in regard to interpretation. 

There are really two major concerns relative to CBTI’s: (a) the adequacy of the scoring algorithms and the classification system used to assign statements to particular test scores and (b) the validity of the interpretations inferred from test results. Williams and Weed (2004) empirically tested these issues by sending the same MMPI-2 raw data to six different interpretative services.  The researchers concluded, “Among the CBTI reports, interpretative differences for the sample case were striking” (Williams and Weed, 2004, p. 80).  Findings included the following: 

• “Treatment recommendations also differed among the CBTI reports” (page 80)
• “There were also dramatic differences among the diagnostic impressions offered for each report” (page 80 and illustrated in Table 3 on page 82).
• “The content of the CBTI reports reviewed here varied substantially when reporting on the same MMPI-2 profile” (page 81).
• “Most unfortunate, despite the popularity of these programs, CBTI publishers do not provide users with much direct evidence in support of the used of their programs” (page 81).  
• “The differences suggested by Table 3 (from 23 possible diagnoses to none suggested) imply substantially different parameters underlying test interpretation” (page 81) 

First, the user should be sure that the CBTI scores (raw or scaled) are in keeping with those derived through the traditional methods. Although, computer hard copy looks accurate, such is not always the case even after extensive field-testing by the company. Second, the user should have available data on the decision rules used to match test scores with interpretative statements. When this is not possible, the user should be aware of existing research on the computer programs being used. Unfortunately, this is often not available. Third, it is important to know which interpretive statements are linked to which test scores. Many CBTI’s do not provide such information stating that it is proprietary and this makes the guideline difficult to satisfy. Often one can scan the interpretative reports, comparing interpretations with test scores, to help assure validity. Once again, application to clinical health psychology requires use of appropriate norms in interpretation.

Fourth, it must always be kept in mind that computerized interpretive reports are tools of the qualified professional. The clinician is ultimately responsible for the report’s validity and use. This means that the clinician might need to edit or amend the computer-generated psychological report to take into account sound clinical judgment. Clinical health psychologists are often involved in computerized psychological testing in the context of a medical center, a comprehensive treatment program (e.g., a chronic-pain program), or on an individual clinical treatment level. At a very early stage of CBTI development, Matarazzo (1986) voiced concern that “the tremendous advances during the past five years in microcomputerized psychological testing hardware and software have made it possible and economically seductive for a psychologist, a physician, another health service provider or a hospital administrator to offer such testing to unprecedented numbers of patients and clients” (p. 17). 

The prediction of Matarazzo (1986) has come true since major publishers of CBTI’s now market directly to a variety of non-psychologist health care providers.  Aside from being used by psychologists, computerized interpretive reports are being used by other health care professionals, who are often accustomed to ordering lab tests from technicians. It is difficult enough for psychologists to force themselves to scrutinize the “slick” computer report. Those professionals untrained in psychometric assessment and unaware of the special ethical issues related to computerized psychological assessment are even less likely to be able to make adequate judgments. It would be easy for these reports to become just another piece of data, without interpretation by any psychologist familiar with the case. One negative effect of this might be the physician’s prematurely ascribing symptoms to emotional distress on the basis of psychological testing and doing an inadequate diagnostic workup. Cummings (1985) was able to empirically demonstrate this in showing that the number of missed diagnoses by physicians increased significantly in proportion to the amount of psychological assessment information rendered to them.

Recognition of Personal Problems

Psychologists refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner (2.06a).

When psychologists become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work-related duties (2.06b).

As with any area of professional practice, the clinical health psychologist must be aware of any personal problems that could impact his or her ability to perform duties adequately. This problem is addressed in Standard 2.06 (Personal Problems and Conflicts).

The unique settings (e.g., the acute-care hospital) and environments (e.g., working with medicine) in which clinical health psychologists find themselves add to the stress of the work and may result in professional burnout. The clinical health psychologist may tend to deny the impact of the work and deal with the stress in a destructive manner including emotional detachment and substance abuse.   As reviewed by Koocher & Keith-Spiegel (1998), “Burnout has generally been described as a kind of emotional exhaustion resulting from excessive demands on energy, strength, and personal resources in the work setting” (p. 69).  They go on to discuss eleven factors that can predispose a person to professional burnout and these include role ambiguity at work, conflict and tension in the workplace, lack of social support at work, chronic helplessness, and overly high expectation on oneself.  The clinical health psychologist who works with a variety of medical practices, consults to different hospitals, and is not part of group of practitioners, may be at increased risk for burnout. 

Important research suggests that a practitioner’s beliefs about whether it is unethical to practice in a state of burnout will affect whether steps are taken, such as decreasing one’s weekly caseload, when impairment is realized (Skorupa & Agresti, 1993). In the settings where clinical health psychologists are more likely to practice (e.g., an acute-care medical hospital), it may be easier to “get away with” practicing while impaired and providing substandard care, because of diffusion of responsibility issues, which are discussed shortly.

Imposition of Values Onto the Patient

Psychologists do not knowingly engage in behavior that is harassing or demeaning to persons with whom they interact in their work based on factors such as those persons’ age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability language, or socioeconomic status (3.03).

In keeping with this ethical principle, the clinical health psychologist is not justified in imposing rigid criteria for “healthy behaviors” onto patients. Working within the patient’s health belief model and expectations for treatment is necessary to the formulation of treatment goals. For example, the Mexican-American patient who suffers from ulcers may be willing to modify his or her spicy diet but may reject an admonition to switch to bland food. The clinical health psychologist could be doing an injustice by holding to the latter treatment goal. This course of action would be not only risking a treatment failure but also decreasing the probability that a future intervention would be successful.  The same issue might apply relative to helping a patient lose weight loss, stop smoking or starting a regular exercise program.

Advertising for One’s Own Services and Endorsements

Psychologists do not make false, deceptive, or fraudulent statements concerning (1) their training, experience, or competence; (2) their academic degrees; (3) their credentials; (4) their institutional or association affiliations; (5) their services; (6) the scientific or clinical basis for, or results or degree of success of, their services; (7) their fees; or (8) their publications or research findings (5.01b).

Psychologists who engage others to create or place public statements that promote their professional practice, products, or activities retain professional responsibility for such statements (5.02a).

Guidelines for advertising by psychologists are addressed in the ethical standards of Avoidance of False or Deceptive Statements (5.01), Statements by Others (5.02), Description of Workshops and Non-Degree-Granting Educational Program (5.03), Media Presentations (5.04), Testimonials (5.05), and In-Person Solicitation (5.06). Advertisements may contain such accurately presented information as name; highest relevant academic degree earned from a regionally accredited institution; type of certification or licensure; diplomate status; American Psychological Association membership status; services offered; fee information; foreign languages spoken; scientific or clinical basis for, or results or degree of success of, their services; and policy with regard to third-party payments.

The clinical health psychologist might include in advertising that he or she specializes in the treatment of psychological issues related to health problems or a particular subcategory of practice (e.g., chronic headaches, stress disorders, eating disorders, or smoking cessation). Because the FTC has loosened guidelines on professional advertising, most simple factual information about one’s services is probably reasonable (Koocher, 1983, 1994; Koocher and Keith-Spiegel, 1998). What is prohibited in advertising is exaggeration of the uniqueness of services offered. Unwarranted claims such as “hypnotherapy will end smoking and overeating in 1 day” or “10 sessions of biofeedback will eliminate your headache problem” would be considered unfounded and unethical.

Endorsements.  Beyond advertising for one’s own services, care must be taken in the endorsement of products or printed materials, and it is generally not recommended (See Koocher & Keith-Spiegel, 1998, for a detailed discussion of this issue). In clinical health psychology, there has been an explosion of technology related to practice (e.g., relaxation tapes, hypnosis tapes, self-help manuals, and biofeedback equipment). Unfounded claims related to the efficacy of these procedures might include such statements as the following:

In this manual, you will learn to subliminally reprogram yourself to lose weight, eliminate pain, and quit smoking in a short amount of time using these proven audiotapes.

These tapes will produce a positive restructuring of self-image, alleviate depression, and increase self-esteem.

These relaxation methods are proven to inhibit postoperative swelling, pain, and bleeding and to produce rapid healing. They are also used for all pain management.

The real cause of smoking is stress, and you’ll learn to control it through this proven and tested home biofeedback system.

These hypothetical statements could be considered unfounded and unethical, because they go beyond what has been validated. Furthermore, they do not specify the context within which these technologies have been tested (e.g., as used in a comprehensive psychological treatment package). The psychologist is ethically bound to protect how his or her name is used, even when production or publication rights have been transferred to a marketing company (Standard 5.02: Statements by Others).

Avoid Improper and Potentially Harmful Dual Relationships

A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists (3.05a).

Psychologists do not engage in sexual intimacies with current therapy clients/patients (10.05).

Psychologists do not engage in sexual intimacies with former clients/patients for at least two years after cessation or termination of therapy (10.08a).

Psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances (10.08b)

Dual relationships have been divided into sexual and nonsexual categories. Sexual relationships with patients are prohibited in the ethical standards and in many laws. This area is relevant to clinical health psychology, as in any other area of practice. One issue that might be unique to the practice of clinical health psychology is the frequent interactions with other professions (e.g., physicians, dentists, and attorneys), which have different ethical codes. In some of these other professional ethical codes, there is no prohibition against sexual relationships with patients or former clients. The clinical health psychologist must beware of influences from other professionals, who could be behaving in an ethical manner for their profession but whose behavior would reflect a clear ethical violation for the psychologist.

Nonsexual dual relationships can occur in a number of ways. One area that appears particularly relevant to clinical health psychology is that of financial incentives provided by a third party for either hospital or outpatient services. This is specifically covered under Ethical Standard 6.07 (Referrals and Fees). There are numerous cases in which for-profit hospital and medical corporations entered into unethical and illegal “kick back” schemes in which doctors were some how compensated for placing patients in the hospital or billing for services not actually rendered.   For instance, one news story described a psychiatrist who did what the nursing staff had termed wave therapy on his inpatient cases. He would literally walk through the hospital corridor either waving or saying hello to his patients. These “sessions” were billed as full sessions of psychotherapy treatment. In this same situation, the hospital corporation was paying the doctor’s overhead expenses (e.g., rent and secretarial) in exchange for the unwritten understanding that he would keep the census high in the hospital.

Other similar situations have also been common in the workers’ compensation area, in which financial arrangements had been developed among doctors, insurance adjusters, and attorneys to form lucrative referral networks. These types of arrangements would be in violation of ethical standards, constitute harmful dual relationships (one with the patient and the other with an institution) and are very likely illegal. In these situations, treatment decisions might be based on incentives other than patient needs.

Treating clinician and expert testimony

Another area in which the clinical health psychologist may be more likely to enter a dual relationship is that of being a treating provider who provides expert testimony.  An example of how this might occur is a patient being treated for back pain that was due to motor vehicle accident.  At some point, the psychologist might be asked by the patient’s attorney to provide expert testimony (not just a factual witness) about the psychological sequelae associated with chronic low back pain.  As discussed by Reid (1998), civil and criminal attorneys will often refer clients for treatment and, subsequently, seek expert testimony from the provider to help with the case.  Reid (1998) points out that this dual relationship can create conflict in at least four areas: (1) A treatment relationship creates an ethical and legal obligation to act in the best interest of the patient, while forensic testimony requires objectivity; (2) The clinician may have a personal affinity for the patient’s viewpoint creating a danger of intentional bias; (3) When a treating clinician is aware that reporting to a third party will be required (e.g. the lawyers, the court), this must be disclosed to the patient.  This disclosure will likely affect what the patient discusses and impact the validity of any report or testimony; (4) The clinician’s role and training are not forensic; therefore, he or she will likely not be aware of the rules of legal proceedings and will be open to manipulation by the attorneys.  An article by Greenburg and Shuman (1997, p. 56) outlines these issues nicely.  The authors conclude that,

“Engaging in conflicting therapeutic and forensic relationships exacerbates the danger that experts will be more concerned with case outcome than the accuracy of their testimony.  Therapists are highly invested in the welfare of their patients and rightfully concerned that publicly offering some candid opinions about their patient’s deficits could seriously impair their patient’s trust in them.  They are often unfamiliar with the relevant law and psycho-legal issues it raises.  They are often unaware of much of the factual information in the case, and much of what they know came solely from the patient and is often uncorroborated.  What they do know, they know primarily, if not solely, from the patient’s point of view.  They are usually sympathetic to their patient’s plight, and they usually want their patient to prevail.”

Not all authors are in agreement that a treating psychologist who offers expert testimony is acting unethically.  Although the extensive details of the article are beyond the scope of this discussion, Heltzel (2007) argues that, “Although it should be clear that all psychologists must be aware of the ethical challenges associated with expert testimony, it has been demonstrated that the roles of therapist and expert witness are indeed compatible” (p. 128).  The Heltzel (2007) article was in response to the State Board of Psychology of Ohio (2003) issuing a warning to psychologists who provide expert testimony about their own patients.  The Board (2003) cited the article by Greenburg and Shuman (1997) and stated that providing expert testimony about one’s own patients involved “inherent dual roles and bias” (p.2) and concluded, “Prevailing standards essentially demand that you define and remain within one role with a given client” (p.2). 

The conclusions of Heltzel (2007) were addressed by Greenberg and Shuman (2007).  In the article, Greenburg and Shuman (2007) reiterated their original 1997 position and offered further foundation for their assertion that providing expert opinions relative to one’s own patients is an ethical dual role violation.  The authors cited the work of others (See also Strasberger, Gutheil, and Brodsky, 1998) and also provided evidence that the irreconcilability of therapeutic and forensic roles had gained wide acceptance in ethical guideline interpretations and in the courts.

The details of the arguments for and against this issue are very interesting and any psychologist involved in providing expert testimony should be familiar with these articles.  As a general guideline, it appears that functioning in a therapeutic role and an expert witness role for the same patient is in most cases an ethical violation. At the very least, the psychologist must be ready to defend him or herself and answer the question of why it is not an ethical violation.  The psychologist must also keep in mind that this type of dual relationship does not go unnoticed by defense attorneys and almost always is addressed in cross-examination.  Campbell and Lorandos (2001) specifically outline how an attorney should cross-examine a clinician who has entered into a dual relationship of being treating therapist and expert witness.  Most psychologists would not want to find themselves in the position of having to answer these cross-examination questions.

Providing Mental Health Services to Those Served by Others

In deciding whether to offer or provide services to those already receiving mental health services elsewhere, psychologists carefully consider the treatment issues and the potential client’s/patient's welfare. Psychologists discuss these issues with the client/patient or another legally authorized person on behalf of the client/patient in order to minimize the risk of confusion and conflict, consult with the other service providers when appropriate, and proceed with caution and sensitivity to the therapeutic issues (10.04).

In the practice of clinical health psychology, it is not uncommon to be referred a patient who is already in psychotherapy for other issues. It would not be unethical for the clinical health psychologist to proceed with one intervention while a different psychological intervention continues with another mental health professional. However, this can be a potentially confusing and conflictual situation if not handled correctly. Proper management includes clearly informing the patient as to the nature of the intervention and, with appropriate releases, discussing with the other professional how the treatment focuses will be kept distinct and not work at cross-purposes. The guideline of putting the patient’s welfare first is of absolute importance in making these types of clinical decisions.

Professional Responsibility

Psychologists establish relationships of trust with those with whom they work. They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct, clarify their professional roles and obligations, accept appropriate responsibility for their behavior, and seek to manage conflicts of interest that could lead to exploitation or harm.   Psychologists consult with, refer to, or cooperate with other professionals and institutions to the extent needed to serve the best interests of those with whom they work.  They are concerned about the ethical compliance of their colleagues' scientific and professional conduct. Psychologists strive to contribute a portion of their professional time for little or no compensation or personal advantage (Principle B: Fidelity and Responsibility).

The effective and responsible practice of clinical health psychology includes several areas relative to the Fidelity and Responsibility Principle including:  (1) increased responsibility for physical health, (2) necessary interaction with other disciplines, (3) patient-welfare responsibilities when working in institutional systems such as the medical hospital, (4) consultation with other clinical health psychologists regarding ethical issues,  and (5) ones’ personal behavior.  The clinical health psychologist has increased ethical obligations in all of these areas.

Responsibility for physical health

One unique aspect of clinical health psychology is an increased responsibility for physical health. More so than in traditional practice, the clinical health psychologist deals with psychological factors associated with medical conditions. Therefore, such things as concomitant medical evaluation and management must be assured and this requires consultation and cooperation with one’s medical colleagues.

In addition, the clinical health psychologist is more often interacting with the medical care, both on an individual and an institutional level. This interaction can be intimately tied to patient care (for instance, being sure a particular medical evaluation is completed or helping a patient to confront health care systems problems).

Interacting with the medical hospital system

The clinical health psychologist must be aware of the risk of diffusion of responsibility when working with patient in a medical facility.  Zerubavel (1980) calls this risk the “bureaucratization of responsibility.” He held that within the hospital context, there was an ever-increasing segmentation of responsibility for patients. Hospital patients are cared for by a myriad of specialized clinicians. Thus, the responsibility for the patient does not lie with any one clinician but rather with a collective entity such as “the hospital” or “the team.” (As Zerubavel pointed out, the legal responsibility for the patient lies ultimately with the attending physician.) With such a complex organizational structure, the likelihood of diffusion of responsibility or “floating responsibility” becomes very great. Under these conditions, passivity on the part of the clinical health psychologist can go unnoticed, because so many aspects of care are occurring simultaneously. For example, such things as treatment planning, record keeping, follow-up, communication with other professionals, and informed consent might not be responsibly completed. The psychologist must take care to provide responsible care to patients even when the structure of the system allows for a diffusion of responsibility or passivity.

Consult, refer and cooperate

Ethical Standard 3.09 states, “When indicated and professionally appropriate, psychologists cooperate with other professionals in order to serve their clients/patients effectively and appropriately” and this is also subsumed under General Principle B (Fidelity and Responsibility). As indicated previously, in both inpatient and outpatient settings, multiple clinicians of varying specialties often provide patient care. The psychologist usually provides only one aspect of the complete treatment package. It is imperative that regular communication occurs among professionals. This is often achieved in team meetings but many times is accomplished chiefly through chart notes. A common complaint from physicians is that they have referred a patient to a psychologist (or other type of clinician) and have received no feedback on the evaluation or course of treatment. It is helpful to maintain written as well as verbal contact with other professionals to be sure treatments are coordinated in an appropriate manner.

Having a working knowledge of what competencies are encompassed by other professions facilitates enhancement of professional relationships and good patient care. For instance, on one case there could be a surgeon, infectious disease specialist, nutritionist, physical therapist, nursing staff, and clinical health psychologist. Having an understanding of what each profession does will help the psychologist communicate more effectively, gain respect, and be aware of treatment needs of the patient that are not being met adequately. As noted before, it is also important to be aware of varying ethical principles by which different professions abide.

Consult with colleagues to avoid unethical behavior

It is important to have colleagues to consult with regarding ethical dilemmas that occur in daily practice. This type of consulting is dictated by the Ethical Standards and subsumed under maintaining one’s standard of care in practice.  Although these relationships can be established with those in general practice or other specialty areas, some of the consultants and colleagues should also practice in the area of clinical health psychology. Documentation of these consultations should be completed to substantiate the decision-making process if necessary. In addition, one can find assistance from local ethics boards.

Personal behavior

The clinical health psychologist might be subject to standards of behavior beyond those inherent in general psychological practices. As an extreme example, the clinician who is a heavy smoker, very overweight, drinks an excessive amount of coffee, and consumes more than a moderate amount of alcohol, may have special problems in relationships with professional colleagues (physicians and psychologists) and patients, as well as in representing health psychology to the public. Although this could appear to be an infringement on one’s personal freedom of choice, Principle C states clearly that personal behavior can come under ethical scrutiny as it impacts professional practice. The clinical health psychologist must be aware of personal health habits and make decisions about acceptable, ethical public behavior. These behaviors cannot be rigidly defined, nor should they be, but rather a range of acceptable behaviors must be decided on individually.

Privacy And Confidentiality

Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship (4.01)

Psychologists discuss with persons (including, to the extent feasible, persons who are legally incapable of giving informed consent and their legal representatives) and organizations with which they establish a scientific or professional relationship (1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities (4.02a).

Unless it is not feasible or is contraindicated, the discussion of confidentiality occurs at the outset of the relationship and thereafter as new circumstances may warrant (4.02b).

Privileged versus confidential Information

Privileged communication refers to the legal doctrine that a professional cannot disclose confidential information without a patient’s consent (Reamer, 2003).   The limits of this privilege are determined by state statutes and vary from state to state. The privilege of confidentiality lies with the patient, and except in special circumstances, the psychologist must abide by the patient’s determination.

Confidentiality is an ethical concept, but it is influenced by legal guidelines (e.g., mandates to breach confidentiality to prevent self-harm or harm to others; see Belar & Deardorff, in press). The psychologist must maintain a confidential relationship with the patient and obtain permission before releasing information.

Special confidentiality problems in clinical health psychology

Some of the special confidentiality problems in clinical health psychology include providing information to the referral source, charting treatment notes in a more circulated medical record versus a less available psychological record, and releasing medical records that contain psychological treatment notes to an outside source. Other problems arise in providing services to multiple-bed hospital rooms, case discussion within the context of a multidisciplinary team approach, and discussion of the patient’s psychological status with members of the patient’s family.

Generally, the clinical health psychologist should strive to maximize confidentiality. One should also inform the patient of the limits to confidentiality set either by law or by institutional organization. For instance, finding a setting to conduct confidential psychological services on a medical-surgical unit can be very difficult. Patient consultation rooms are sometimes available, but these are often heavily scheduled. If the patient is nonambulatory and is in a multiple-bed room, it may not be possible to maintain confidentiality (unless services can be scheduled when other patients are out of the room). The patient should be explicitly given the option of declining services if not comfortable with the situation; otherwise, the pressure from an “authoritative” professional may induce the patient to engage in behavior without true consent. Similarly, when a patient’s psychological status is to be discussed in the context of a team-treatment approach, the patient should be informed of what material will be discussed.

Last, pressure from family members to discuss the patient’s psychological status often arises in the case of brain dysfunction; “conversion” disorders; and compliance problems, which can be closely related to family-systems issues (e.g., eating disorders, compliance with insulin-treatment regimens, or chronic-pain management). If the patient is not able to make informed decisions, such as in brain dysfunction cases, legal and ethical guidelines may allow release of confidential information to an appointed person as necessary. Except in these instances, the process of obtaining a written release of confidential information should be followed, as in any traditional psychological case.

Informed Consent

When psychologists conduct research or provide assessment, therapy, counseling, or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person or persons except when conducting such activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Code (3.10a). 

Psychologists appropriately document written or oral consent, permission, and assent (3.10d).

The doctrine of informed consent was developed so that patients could weigh the risks and benefits of a treatment and determine for themselves if they wanted to participate (Barnett, Wise, Johnson-Greene, & Bucky, 2007; Barton & Sanborn, 1978; Knapp & Vande-Creek, 1981; Pizzi, Goldfarb, & Nash, 2001; Simon, 1992). Informed consent was established as a legal standard of care based upon the principle that individuals have rights over their own bodies.  For surgical and medical procedures, the legal aspects of informed consent were well established by the turn of the century (Beahrs & Gutheil, 2001).  However, informed consent for psychological interventions has only just recently been developed.  This was likely due to the fact that psychological interventions are non-invasive, the psychotherapeutic process was seen as “sacrosanct”, patients are conscious and able to monitor the ongoing treatment for themselves, and it is difficult to demonstrate harm resulting from the treatment (Appelbaum, 1997; Beahrs & Gutheil, 2001, p.4).  However, legal and ethical cases over the past 20 years have increased the focus on informed consent for psychological treatment.

In the Ethics Code, informed consent is addressed in several places including Third Party Request for Services (3.07), Informed Consent (3.10), Informed Consent to Research and Recording (8.02 and 8.03), Informed Consent in Assessments (9.03) and Informed Consent to Therapy (10.01).  One can conclude that just based upon the amount of times informed consent is addressed in the ethical code it is an important issue.  The patient should understand the nature of the proposed treatment, the risks and likelihood of success, and available alternative treatments.

Ideally, the procedure of informed consent is meant to force the health care professionals to make the patients “active agents” and more equal bargaining partners in treatment decisions (Beahrs & Gutheil, 2001; A. A. Stone, 1979). Interest in informed consent for medical and psychological treatments has increased with the consumerism movement among patients and judicial involvement in this area (Reamer, 2003; Widiger & Rorer, 1984).  Informed consent was not specifically addressed prior to the 1992 Ethics Code and is addressed several places in the 2002 revision, as discussed previously. 

The legal concept of informed consent includes capacity, information, and voluntariness. Capacity means that a patient must have the ability to make rational decisions (this tenet often excludes children and the developmentally disabled from being able to give informed consent and necessitates proxy consent by a guardian). Information consists of both the substance of the material presented and the manner in which it is given. It is gauged by demonstrated understanding by the patient. Voluntariness means that the patient was able to exercise free choice, without coercion, in making the decision.

Inadequate informed consent is unethical and has been grounds for malpractice in medical and psychiatric/psychological treatments (Beahrs & Gutheil, 2001; Cohen & Mariano, 1982; Reamer, 2003). A significant problem is how much to actually disclose about treatment (Beahrs & Gutheil, 2001; Halperin, 1980; B. M. Schutz, 1982; Simon, 1992). Adequate disclosure is legally determined by the community standard of care (telling patients what other practitioners in the community would tell their patients under similar circumstances) and “the reasonable person” statute (telling the patient what a reasonable person would need to know to make an informed decision). However, these guidelines actually offer the practitioner little guidance (A. A. Stone, 1979).

Other problems are revealed by demonstrations that informed-consent procedures are often inadequate when patient understanding and retention of the material are assessed (Ley, 1982; Pizzi et al., 2001). Such problems are sometimes related to readability of consent forms. For example, Christopher, Foti, Roy-Bujnowski & Appelbaum (2007) completed a review of 154 clinical mental health research studies that utilized informed consent forms.  All forms were assessed using several standard “readability” formulas.  The overall mean readability scores for the informed consent forms ranged from grades 12 to 14.5.  In addition, the higher the risk of the study, the higher the mean readability score of the forms. 

A review of medical informed consent studies reached similar conclusions (Pizzi et al., 2001).  The results of the National Assessment of Adult Literacy most recently completed survey in 2003 (http://nces.ed.gov/NAAL) are now being analyzed and published.  Part of the 2003 survey included a measure of health literacy defined as, “the ability to use literacy skills to read and understand written health-related information encountered in everyday life”.  Although it is beyond the scope of this discussion to define the complex classification system used in the survey, 75 million Americans are estimated to possess Basic and Below Basic health literacy skills with 114 million at the Intermediate level and only 12 million at the Proficient level.  It is very unlikely that Americans with Basic or Below Basic health literacy (and probably a vast majority in the Intermediate group) would be able to read and comprehend most informed consent forms since they are written at a 12 to 15 years of education readability level (See Pizzi et al., 2001 for a review).   Research findings in this area present serious problems for the practitioner in obtaining informed consent. Because of legal pressures, many medical professionals have gone to what might be considered the extreme position of providing all possible risks in graphic detail to ensure completeness. Problems with this approach and suggestions for a process of informed consent are discussed later.

Clinical health psychologists may be involved in several aspects of informed consent in the medical setting. In our work, we are often involved in (a) helping the physician to explore the patient’s health belief model about aspects of treatment and determining the extent of the patient’s understanding or possible misconceptions; (b) working with patients to encourage behaviors that will increase the likelihood of “true” informed consent (including determining what questions the patient has about the medical treatment and teaching the patient how to obtain the information from the physician); and (c) helping patients deal with the increase in feelings of uncertainty about treatment, which often occur after explicit informed-consent procedures are carried out.

Clinical health psychologists must also deal with the issue of informed consent in the course of service delivery of psychological services. Many practitioners view the informed consent with contempt and rarely provide information about alternate treatments. Several authors have suggested that the informed-consent process is a double-edged sword (Beahrs & Gutheil, 2001; Gutheil, Bursztajn, Hamm, and Brodsky; 1983). The positive aspect is that it clarifies options and stimulates understanding. The negative aspect is that it can increase the patient’s having to accept more uncertainty about treatment and decrease belief in the doctor’s ability to cure. As discussed by various authors, (Beahrs & Gutheil, 2001; Gutheil et al. 1983) the informed-consent procedure should be entered into as a process of mutual discovery rather than as a formality. In the informed consent process, it is prudent to include such things as the rationale for service, treatment plan, and goals in an atmosphere of open negotiation. Once a plan is formulated, it is useful to have the patient paraphrase their understanding of the treatment (or evaluation), so that misperceptions can be corrected.

The process of informed consent can often be difficult with patients referred to a clinical health psychologist. Many times, the physician has not given the patient much information about our services, or the physician has given incorrect information. Furthermore, the patient is being expected to shift from a biomedical orientation to a biopsychosocial approach. Overwhelming the patient in the first session with details of a treatment plan and expectations can result in premature termination. The informed-consent procedure can extend over many sessions and, in fact, over the entire course of treatment. Skills in working with people of different backgrounds (Competency) facilitate the informed-consent process.

Facilitating the informed consent process is discussed by Beahrs & Gutheil (2001) and Pizzi et al. (2001), and the following summarizes their guidelines:

1. Check the readability and comprehensibility of informed consent forms.  An overly detailed informed consent form outlining all of the possible risks, benefits, and alternatives to psychological treatment is not necessary and has a great potential to be counter-therapeutic.  Informed consent (verbal and written) should be conceptualized as an ongoing process throughout treatment and not simply the signing of an office form after the first session.
2. Use a semi-structured discussion of informed consent issues to help insure that major issues are covered within the first few sessions.
3. Ask the patient to recall his or her understanding of the informed consent information to test for comprehension. It also opens the discussion regarding areas of misunderstanding and can begin the treatment process.
4. Use educational materials relevant to the patient’s diagnosis, proposed treatment, etc., so that the patient can review them at a later time and bring questions to the next session. 

Clarification of roles and Third Party Requests for Services

Clarification of roles is part of informed consent and is addressed in the Ethical Standards under Multiple Relationships (3.05) and Third Party Requests for Services which states: When psychologists agree to provide services to a person or entity at the request of a third party, psychologists attempt to clarify at the outset of the service the nature of the relationship with all individuals or organizations involved. This clarification includes the role of the psychologist, an identification of who is the client, the probable uses of the services provided or the information obtained, and the fact that there may be limits to confidentiality (3.07).  The principle of informed consent dictates that psychologists clarify the roles they are performing for all relevant parties and function in accordance with those roles. In clinical health psychology practice, this issue usually arises in clarifying one’s role within the context of medical treatment. In the hospital setting, patients are often seen by a variety of providers, and they will often become confused about “who does what.” The patient could mistake the psychologist for a physician or expect a similar type of care. These roles should be clearly identified for the patient. For the patient who is unfamiliar with psychological interventions, the process of explanation of roles may proceed over several sessions.

The services of a clinical health psychologist are often requested by a physician to provide an evaluation, treatment, or both. The psychologist must always determine the extent of the patient’s understanding as to why the consultation was requested and whether services are actually necessary. We find that many times the physician has not told the patient a consultation had been ordered. As with any other case, informed consent must be acquired before proceeding. Furthermore, many consultation requests are found to result from projection on the part of providers, who are experiencing frustration, anger, depression, or some other emotional response to the patient. Intervention is sometimes more appropriately targeted at the staff rather than the patient. A thorny ethical problem that then arises is determining who is going to pay for the staff intervention.

Other areas in which the services of a clinical health psychologist are often requested by a third party include neuropsychological assessment, psychological evaluation for a specific treatment program or procedure, and evaluation as part of filing a workers’ compensation or disability claim. Patients are often not aware that in requesting these programs to pay for services, they must agree to release their psychological evaluation as a condition of reimbursement. In any of the above situations, the psychologist must fully inform the patient as to the nature of the assessment, the purpose, what the results will be used for, who requested the evaluation, and who will pay for it.

Conflicts of Interest

Psychologists refrain from taking on a professional role when personal, scientific, professional, legal, financial, or other interests or relationships could reasonably be expected to (1) impair their objectivity, competence, or effectiveness in performing their functions as psychologists or (2) expose the person or organization with whom the professional relationship exists to harm or exploitation (3.06)

When one interacts with the medical system, conflicts of interest can arise. There can occur a basic, unacknowledged, antagonistic relationship between patient and hospital or employee of the institution (Bazelon, 1974;Koocher & Keith-Spiegel, 1998). As Noll (1976) stated, “whenever the mental health professional is employed by an agency or by an institution, the institution needs will almost invariably supersede those of the patient” (p. 1451). Thus, the clinical health psychologist may have a “hidden agenda” when consulting to a medical-surgical unit depending on the needs of the staff and the reason for the consultation request.

The patient was a 37-year-old, married woman, who had been diagnosed as having lung cancer with multiple metastases. The prognosis was very poor. She had been through several courses of chemotherapy without significant benefit. A more experimental drug had been suggested, but the patient refused, stating that she would rather be discharged to home. A referral for psychological evaluation of the patient’s mental status was made. When the clinical health psychologist arrived on the unit, it was verbally communicated to her by the staff that “the patient needed to be convinced to stay in the hospital for further treatment because it was her only hope of survival.” The psychological evaluation revealed that the patient had carefully considered her options in treatment, was fully informed about risks and benefits of each alternative, and had made a decision with a clear sensorium and intact mental status. The psychologist reported the results of her evaluation to the staff and subsequently dealt with the anger and frustration staff had toward both her and the patient.

In this example, the psychologist might have easily been influenced by staff issues and have thus seen the patient with a goal of convincing her to have the experimental treatment. Psychologists must remember to be responsible to the patient, to take into account the needs of the patient versus those of the staff, and to clarify the nature of their loyalties and responsibilities.

Patients Who Do Not Benefit From Treatment

Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service (10.10a).

If a patient does not benefit from treatment after a reasonable trial, the psychologist is ethically mandated to terminate the treatment and to help with an appropriate referral. The clinical health psychologist will often receive referrals who are “last-option” treatments, in that all previous traditional medical treatments have failed (e.g., chronic-pain syndromes, tinnitus, blepharospasm, or atypical facial pain). In these cases, the psychological referral is to “give it a try,” because there appear to be no other options. These cases represent clinical challenges in which the therapist must gauge carefully, in realistic negotiation with the patient, when an adequate trial of treatment has been accomplished without significant benefit. The following case illustrates such a decision:

The patient was a 78-year-old married woman with a post-herpetic neuralgia secondary to having herpes zoster several years before. The pain, as well as an excoriated skin surface, was distributed in a dermatomal pattern on the right side of the face and neck. Extensive dermatological treatments had failed to provide relief, and the patient was referred for pain management. Evaluation indicated that the symptoms did fluctuate, with stress and tension being related to an exacerbation of the condition and relaxed states being associated with symptom relief. A treatment plan was formulated, including relaxation training with suggestions for hypnotic analgesia. After the patient had gained the ability to relax across all settings and had practiced routinely with the autohypnosis, no pain relief, as documented by symptom charting, had occurred. It was decided that the patient would not benefit from further treatment with that therapist and that an adequate trial had been given. The patient was given a referral to another psychologist experienced in hypnotic analgesia, to see whether a different approach might be beneficial.

In this example, the psychologist had to make a decision, with the patient’s full participation, as to when an adequate trial had been attempted. The psychologist must also provide a referral if other treatments are available. The termination process in these cases must be handled carefully to prevent iatrogenic deterioration effects (e.g., patient being left with a “failure experience”) and to capitalize on the positive effects, however small, of the treatment experience.

E-therapy and Internet Therapy

E-Therapy is the provision of mental health treatment through the Internet. In 2004, 23% of Internet users searched for information on mental health issues and 28% for information on a doctor or hospital (Recupero & Rainey, 2005).  Those numbers are likely much higher now with the continued penetration of Internet use into American households.  In conducting a simple Google search recently, 161,000 hits for “Online Therapy” and 172,000 hits for “E-therapy” were obtained.  There are now professional organizations for online counselors including the National Directory of Online Counselors, the American Association of Online Psychotherapists, and the International Society for Mental Health Online.  These services offer treatment for virtually every DSM-IV diagnosis and, relative to the practice of clinical health psychology, such things as pain management, behavioral management (e.g. smoking, alcohol consumption, weight loss, insomnia, somatization, eating disorders, just to name a few).   These “treatments” are structured in several ways including private online chat (real time), instant messaging, videoconferencing, email sessions, or a combination thereof.  In one of the more interesting arrangements, the “patient” purchases a certain number of words to be placed in a “word bank”.  With each email, the number of words used by the patient is deducted from the bank.  

Although a very new area of research, Web-Based Treatment Interventions (WBTI’s) are in the initial stages of empirical testing.  Ritterband, Gonder-Frederick, Cox, Clifton, West, & Borowitz (2003) have reviewed some of these early studies.  The studies have been done in such diverse area as smoking cessation, weight loss, headaches, body image, posttraumatic stress and pathological grief, physical activity, panic disorder, tinnitus, diabetes management and pediatric encopresis.  As discussed by Ritterband et al. (2003), “These studies all focus on behavioral medicine/health psychology issues, which seem to more adaptable to Internet interventions because of the highly structured treatment approaches to many problems (p. 528; See also, Childress & Asamen, 1998). 

Ritterband et al. (2003) present a detailed model for developing a WBTI including ascertaining the effectiveness of the traditional face-to-face treatment, considering the legal and ethical issues involved in developing a WBTI, transforming treatment elements into a WBTI, building individualization and feedback components into the WBTI, and then testing the WBTI effectiveness against traditional methods. The WBTI research reviewed by Ritterband et al. (2003) generally uses the Internet in a more adjunctive fashion (e.g. patients are selected for the approach, the initial session may be face-to-face, etc.) rather than a patient simply doing an Internet search, finding a therapist who may not be in the same state, paying the money, and starting treatment. As such, the type of rigorous development of an Internet based treatment approach as reviewed in scientific journals is not what is generally experienced when a patient pursues E-therapy at this time.

As discussed by Recupero and Rainey (2005), E-therapy has provoked controversy in the mental health fields.  Proponents argue that E-therapy provides many benefits such as convenience, a certain level of anonymity preferred by come clients, the ability to reach underserved populations, the ability to do less expensive treatment, etc.  However, there are several ethical and liability risks that will be discussed subsequently.   

E-therapy has not been specifically addressed in the 2002 APA Ethics Code but there are plans to address this new intervention approach in future versions.  The only guidance at this time is from “A Statement by the Ethics Committee of the American Psychological Association” issued on November 5, 1997 as follows (www.apa.org/ethics/stmnt01.html):

Delivery of services by such media as telephone, teleconferencing and Internet is a rapidly evolving area.  This will be the subject of APA task forces and will be considered in future revision of the Ethics Code.  Until such time as more definitive judgment is available, the Ethics Committee recommends that psychologists follow Standard 1.04c, Boundaries of Competence, which indicates that “In those emerging areas in which generally recognized standards for preparatory training do not yet exists, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect patients, clients, students research participants, and others from harm.”  Other relevant standards include Assessment (Standards 2.01-2.10), Therapy (4.01-4.09, especially 4.01, Structuring the Relationship and 4.02 Informed Consent to Therapy), and Confidentiality (5.01-5.11).  Within the General Standards section, standards with particular relevance are 1.03, Professional and Scientific Relationship; 1.04 (a, b, and c), Boundaries of Competence; 1.06, Basis for Scientific and Professional Judgments; 1.07a, Describing the Nature and Results of Psychological Services; 1.14, Avoiding Harm; and 1.25, Fees and Financial Arrangements.  Standards under Advertising, particularly 3.01-3.03 are also relevant.

In the 2002 Code of Ethics, the same guidelines still apply.  As discussed by Smith (2003), the 2002 ethical code does not specifically address E-therapy, but language throughout the code addresses Internet and electronic transmission.  Smith (2003) specifically mentions Standard 4.02c which stipulates that psychologists who offer services, products or information via electronic transmission inform their clients of the risk to privacy and limits of confidentiality.

There is evidence that many online counseling websites are not following accepted ethical guidelines even when they are available.  For instance, Shaw and Shaw (2006) used a 16-item ethical checklist to assess 88 online counseling websites.  The checklist was derived from the American Counseling Association’s Ethical Standards for Internet Online Counseling (1999; www.counseling.org).  Results demonstrated that less than half of the online counselors were following accepted practice on 8 of 16 items. It is beyond the scope of this chapter to review in detail the ethical, state licensing board, and malpractice risks that are inherent in E-therapy.  These have been review elsewhere (Koocher and Morray, 2000; Recupero & Rainey, 2005; Ritterband et al., 2003) and are summarized as follows:

Verifying patient and clinician identity

Aside from videoconferencing or telephone contact, in E-therapy it can be challenging for the patient and therapist to identify each other’s identity after a treatment relationship has been established (Recupero & Rainer, 2005).  For instance, the therapist must be assured that emails, online chat, or instant messaging are not intercepted or responded to by someone else.  The clinician must also be sure his or her Internet access is completely secure and this should include the use of encryption.

Initial assessment of online patients

When a patient comes strictly from the Internet for E-therapy (without any face-to-face contact or referral from another healthcare provider), the clinician does not have the benefit of an initial evaluation including face-to-face interview (with all of the non-verbal data), mental status examination, review of background medical records, discussion with collateral sources if necessary, consultation with other treating doctors, psychological testing, etc.  Due to the anonymity afforded by E-therapy, the clinician may not know the actual identity of the patient, may be given incorrect contact information, and may be subject to deception.  These factors place the clinician at risk for misdiagnosis and various treatment mistakes. If this were to occur, in the event of an emergency such as suicidality or homicidality, the outcome could be disastrous. 

Clinician availability

As discussed by Recupero and Rainey (2005), there may be technical problems that either interrupt the treatment session or cause the clinician to be completely unavailable.  This situation might lead to a mis-attribution on the part of the patient if not anticipated before it occurs (e.g. feeling abandoned, etc.).  Also, if the patient needs to reach the clinician in a crisis, having only Internet contact availability may put the client at risk.

Standard of Care

The community standard of care is what the professional’s behavior will be judged against if a question of liability arises.  E-therapy is a very new, essentially unregulated, type of treatment with very little empirical support for its effectiveness at this time. As such the clinician is operating in “uncharted waters” but must always remember that, “One does not cease being a psychiatrist or psychologist when one provides therapy online” (Recupero & Rainey, 2003, p.407).   Any psychologist doing E-therapy must be aware of the rapid development in online healthcare communication.  For instance, The ERisk Working Group for Healthcare is a consortium of liability carriers, medical societies and state board representatives, established to address online communication issues.  They have developed eRisk Guidelines for online doctor-patient communications and these might be held up as a standard of care in the event of an E-therapy liability case (the guidelines are available through www.medem.com).

Privacy and confidentiality

Recupero and Rainey (2003) discuss that the psychologist and patient cannot assume that online interactions are confidential.  Online interactions are essentially written transcripts of all treatment sessions.  Some guidelines for Internet communication between healthcare provider and patient recommend a secure network including authentication and encryption in accordance with HIPAA.  Standard email, instant messaging and online chat do not meet these guidelines.  Recupero & Rainey (2003) present a hypothetical case in which a young woman has been in online therapy and ultimately reveals she has been date raped.  The psychologist encourages her to report the assault to the police, which she does.  The psychologist then receives a subpoena for records from the prosecuting attorney.  The psychologist refuses to release the records and the attorney asserts that E-therapy is not traditional psychotherapy and may be analogous to self-help, in which case there is no doctor-patient privileged.  In addition, the attorney subpoenas the records directly from the Internet service provider.

Informed consent

As discussed previously, informed consent is an important aspect of healthcare practice.  In E-therapy, informed consent should be explicit and outline all the potential risks and benefits (especially the risks, as discussed in this section).  In psychological treatment, informed consent also includes reviewing situations under which confidentiality must be breached.  All states have mandatory child abuse reporting laws, some states have elder abuse reporting laws, and many states have Tarasoff (duty to warn) laws, but some do not.  If a psychologist practices in a non-Tarasoff state (e.g. Virginia) and is providing E-therapy to a patient in a Tarasoff state (e.g. California), what is his or her duty-to-warn obligation if a viable threat is made?  These issues are very unclear at this time.

Interstate practice

There may be problems if a psychologist licensed in one particular state provides E-therapy service to a patient in another state.  This is due to the fact that each state has their own set of professional licensing and practice laws in order to protect their citizens. To assess this issue, Koocher and Morray (2000) conducted a survey of the 50 state attorneys general and asked several questions related to telepsychology.   The researchers asked questions about laws regarding telepsychology practice, whether any charges had ever been brought related to this practice, and how the state handles those telepsychology services provided from another state. At that time, 24 states claimed regulatory authority over practitioners residing in other states that provided E-therapy services in their state.  Seven states acknowledged receiving complaints about E-therapy services and charges had been brought in E-therapy cases in at least two states.  Given the exceptional advancement and use of the Internet in the seven years since that publication, things have likely changed.  For instance, the California Board of Psychology has a notice to consumers regarding those who choose to seek psychological service over the Internet (www.psychboard.ca.gov/internet_therapy.htm).  The notice provides warning about the practice, the requirement for written informed consent, and the statement, “Individuals who provide psychotherapy or counseling to persons in California are required to be licensed in California”.  Similar statutes likely exist in other states and these should be check carefully by the E-therapy provider.

Malpractice Insurance

Although not specifically related to ethical issues, malpractice coverage may be ambiguous in the practice of E-therapy.  The issues include whether a nontraditional treatment like E-therapy is covered, and whether coverage extends from one state (e.g. where the psychologist practices) to another (where the patient resides). 

UNDERSTANDING VERSUS APPLYING THE ETHICAL PRINCIPLES

An important aspect of professional ethics is the difference between understanding and implementing ethical principles. This is the “should” versus “would” discrepancy. Most research suggests that clinicians generally have high-quality ethical decision-making capacity but that this is put into practice to a lesser degree (see Smith, McGuire, Abbott, & Blau, 1991; Wilkins, McGuire, Abbott & Blau, 1990, for review).

For instance, Wilkins et al. (1990) conducted a survey of a random sample of American Psychological Association members. Research participants were presented with four scenarios that reflected ethical dilemmas in the areas of alcohol-related impairment, dual-role sexual abuse of a client, confidentiality, and need for referral related to competence limits. Participants were asked what they should do according to the American Psychological Association Ethical Principles and what they would do if actually faced with the situation. These were rated on a scale from do nothing (least restrictive) to report the individual to the ethics board (most restrictive). Results confirmed that respondents were generally able to recognize ethical conflicts that required action. However, significant differences were found when the “should” ratings were compared with what the respondents “would” do (the “should” results were more restrictive than the “would” results). One important finding was that when the ethical violation was more clear-cut (e.g., misconduct related to sexual abuse or impairment due to substance abuse) and there was a consensus as to what to do vis-à-vis the ethical principles, there was increased congruence between what should and would be done.

These findings are relevant to all areas of psychological practice. All clinicians need to be aware of the likelihood of experiencing the should/would difference. Especially applicable to clinical health psychology is the finding that practitioners will have increased difficulty applying the ethical principles that are defined in a more ambiguous fashion. This might include such principles as those of confidentiality, nonsexual dual relationships, and informed consent. As discussed in previous sections, the clinical health psychologist might be presented with challenges in these areas more frequently than other areas of practice.

SUGGESTED READINGS

American Educational Research Association. (1999). Standards for educational and psychological testing. Washington, DC Author.

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 55, 1449-1455. (also at www.apa.org/ethics/code2002.pdf and www.apa.org/ethics/code2002.html).

Belar, C.D., & Deardorff, W.W.  (in press).  Clinical health psychology in medical settings: a practitioner’s guidebook.  Washington, DC: American Psychological Association.

Koocher, G.P. & Keith-Spiegel, P. (1998). Ethics in Psychology: Professional Standards and Cases, Second Edition.. New York: Oxford University Press.

Pope, K. S. (1990). Ethical and malpractice issues in hospital practice. American Psychologist, 45, 1066-1070.

Pope, K. S. & Vasquez, M. J. T. (2007). Ethics in psychotherapy and counseling: A Practical Guide, 3^rd Edition. San Francisco: Jossey-Bass.

Siegfried, N.J. & Porter, C.A. (2003).  Ethical issues for clinicians in behavioral medicine settings.  In L.M. Cohen, D.E. McChargue & F.L. Collins (Eds.), The Health Psychology Handbook (pp. 443-455).  Thousand Oaks, CA: Sage Publications.

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