This is a beginning to intermediate level course. Upon completion of this course, mental health professionals will be able to:
Authors’ Note: With very few exceptions, all case scenarios presented in this course are adapted from actual incidents. We use improbable names throughout to enhance interest and ensure that the identities of all parties are not discernible. It is not our intention to trivialize the seriousness of the issues. As part of our disguising process we also randomly assign various professional designations and earned degrees or licensure status. Also, for ease of presentation, we use the term "therapist" throughout to refer to anyone delivering psychotherapy or counseling services to clients.
The materials in this course are based on current published ethical standards and the most accurate information available to the authors at the time of writing. Many ethical challenges arise on the basis of highly variable and unpredictable contextual factors. This course material will equip clinicians to have a basic understanding of core ethical principles and standards related to the topics discussed and to ethical decision making generally, but cannot cover every possible circumstance. When in doubt, we advise consultation with knowledgeable colleagues and/or professional association ethics committees.
You will have no choice but to make decisions with possible ethical consequences at some point in any human services career. The decision could be about your own conduct or about that of another. If you are similar to most of your colleagues, you have already faced at least one ethical dilemma that required a decision and possibly action on your part. (It is important to note here that choosing to not make a decision is a decision.) You may not have created the problem, but you may have no choice but to respond. How you react could have significant implications for your reputation and your career. Early recognition of risks can prevent many potential ethical problems from escalating to the point of causing harm.
Recent writings stress how factors such as emotions, personal vulnerabilities, personality, and even the context of situations influence how we make decisions, including ethical ones. Earlier work, including some of our own, focused almost exclusively on step-by-step guides for arriving at a decision most likely to lead to the "best" ethical outcome. Newer work (e.g., Tjeltveit & Gottlieb, 2010) stresses the insufficiency of cognitive strategies to determine how decisions are made. Rogerson, Gottleib, Handelsman, et al. (2011) illustrate many of the nonrational factors that affect our decisions.
The impact of cultural factors on ethical decision-making has also received increased attention in recent years. Therapists working with culturally diverse clients whose values conflict with those in Western civilization require this knowledge when making ethical decisions. Knapp and Vandecreek (2007) propose a “soft universalistic” approach whereby it is recognized that most cultures share the same basic values, but they may not be expressed in the same way. Therapists need to assess this wider perspective by focusing on principle ethics rather than specific actions. Hansen & Kerkhoff (2007) encourage therapists to become more proficient culturally, as well as to make the effort to reflect on the impact of their own beliefs and practices when dealing with culturally diverse clients. For example, a big challenge for North American therapists involves working with immigrants from countries that do not place a high value on personal autonomy.
Ethical dilemmas can occur in many ways, often when we least expect them. Most professionals do not knowingly get themselves tangled up in difficult situations. Some stumble into trouble without recognizing what’s in store down the road. Some give in to temptations that overtake their professional objectivity.
Every now and again, however, an issue of monstrous proportions will surface and affect you directly in some way. For example, a client unexpectedly commits suicide, a client threatens or sues you, a colleague damages your reputation, or your own life goes out of control (e.g., messy divorce, severe economic downturn, or addiction). All such stressors can result in an inability to make sound judgments.
You may confront a situation that offers no choice but to make decisions with ethical implications under ambiguous circumstances. Confusion, pressure, frustration, anxiety, conflicting loyalties, insufficient information, and the tendency to rationalize are common responses to ethical challenges. Such reactions complicate the matter and greatly elevate the chances of errors in decision-making.
The series of scenarios presented below could play out with relatively benign – or more serious – repercussions, depending largely upon how you respond. Ask yourself what you would do.
Your new client always looks brooding and is difficult to engage. He is new to this country and feels lost. He mostly sits sullenly, answering your questions using the fewest possible words, often looking down at his feet. You find his enormous size, flashing eyes, and foreign accent intimidating. Actually, you have come to admit that you are afraid of him. It has even crossed your mind that he may be wanted somewhere for committing a violent crime.
Are you overreacting? Would you terminate him? If so, how would you do that? What would you say? Are you sure you have enough information to make the best decision as to how to proceed? Could your treatment of him have any chance of being effective? Are you sure you have the skills necessary to treat this individual?
A high-spirited client enters your office, pulls a small recorder out of her purse, turns on samba music, and announces that she just won a dance contest. She bounces over, puts her arms around you and squeals, “Let’s dance!”
So, what are you going to do? What will you say to her? Her arms are already around you, so what do you do with them? Might she be seductive? Or is she only in a very good mood today? Can you tell the difference?
Don’t Call Me “Sport”
You have tried so hard to remain objective and compassionate for the last four months, but you dread seeing this client. He reeks of cheap cologne and his hand wringing during the entire session keeps you on edge. Furthermore, he calls you “Sport,” which you find annoying. His sexist comments are irritating, and you feel like you have to bite your tongue every time he refers to women as if they were objects.
Did you let this go on too long? How could you change things around in a way that won’t set you up for an ethics complaint? Or can you? Will you terminate him even though he still has many issues to explore? If so, how? Is it ethical to challenge his sexism when that issue is unrelated to his reasons for seeking counseling?
Your client shows up on time, pays her bill promptly, and often expresses her appreciation for your helpful services. She tells you she has seen many therapists, but you are the best. The problem is that after weekly appointments for a year, she is not improving. The issues that keep her own life off track remain entrenched, and her minimal gains have stagnated. Her only source of pleasure seems to be her weekly sessions with you.
Will you keep trying? Have you instilled a dependency at her emotional and financial expense? Should you terminate her in the hope that someone else may be able to help her more? How could that be accomplished without the client feeling abandoned?
Imagine your surprise when you come home from teaching a month-long seminar and your partner introduces you to the new housekeeper. Your partner is thrilled with the woman’s performance saying, right in front of her, “We are so lucky to have found Eve.” However, the woman is an ex-client you treated in intensive therapy until one day three years ago she flew into a rage and stormed out of the office. You hadn’t been in contact since.
This is awkward to say the least, but this kind of surprise does happen, especially in smaller communities. What are you going to say right then and there? How will you handle this matter with your partner in a way that protects the ex-client’s privacy? Does that last session need to be dealt with now? If so, how? And, is it really a coincidence that the woman applied for this job?
Your client owns a large electronics store and shows up at a session with a new laptop computer. He says, “I see what you have there, and it is almost an antique. This one will work out much better for you.” He is offering the exact make and model that you would buy for yourself if only you could afford it.
OK, you want to take it. That’s human. But, do you? What might come back to haunt you if you do accept this generous gift? What do you say to your client right now?
Couples counseling has resulted in a decision by your clients to dissolve their dysfunctional marriage. They also decide to quit counseling. The wife calls you a week later and asks you to serve as a witness on her behalf in their upcoming child custody dispute.
Let’s assume that you do think that the wife would be the better parent. Do you do it? What ethical problems lurk? What are the risks to you? Do you know for sure that you have the competence to engage in forensic work?
All in the Family
Your sister suspects that her daughter is having unprotected sex and possibly taking drugs. She asks if you will see the teenager as a client. The girl has refused to talk to anyone else, but she will talk to you. Your sister is very wealthy and wants to pay you the full fee. You could really use the money.
A tempting offer. What do you say to your sister? What problems could arise from accepting your own niece as a client even if you would be fully compensated?
After venting frustration toward her spouse for nearly the entire session, your client has a wild look in her eyes as she gets up from her chair, walks for the door, and then turns around and whispers, “He’s messed up his last woman.” You are fairly certain she owns a gun.
Is your client just venting, or was that an authentic threat? How do you make that decision? If you are worried, what exactly should you do now?
Each of these scenarios could be handled quite adroitly by making appropriate decisions and communicating them in a way that does not significantly diminish the client's self-esteem. Or, each situation could turn into a disaster of one sort or another.
Sadly, in the actual incidents from which these examples are loosely adapted, the outcomes were unfortunate. Here is how some of them played out. The “Scary Guy,” despite his size, turned out to be an extremely shy and frightened man who was not quite ready to open up. The therapist's own cultural ignorance and fear-based judgments led to a faulty decision. This newly licensed therapist called the police to check out the client and, in doing so, the police officers told the client who sent them and why. The client’s brother then talked the client into suing the therapist for breach of confidentiality. “Splitting” also resulted in an ethics charge being pressed against the therapist by the husband for breach of confidentiality and conflict of interest. “Let’s Dance” was the spark that eventually led to a sexual relationship and then charges of abandonment when the therapist broke it off. This therapist eventually lost his license.
“All in the Family” ended up destroying the sibling relationship when the disgruntled sister believed that her daughter was not getting better and accused her sister (the therapist) of being interested only in the $150 an hour fee. “Letting Go” continued therapy for another 5 months, then lost her feelings of enchantment for the therapist after entering into a relationship with a controlling man who insisted that she leave therapy as it was “not good for her.” The client ended up telling everyone in the small town that the therapist was "no good."
This course does not offer answers to every ethical dilemma, nor can it advise on every circumstance in which an ethical dilemma arises. Rather it strives to provide clues to help therapists recognize, approach constructively, and reconcile potential ethical predicaments, while at the same time remaining compassionate and attuned to the well-being of those with whom you work.
Ethics is traditionally a branch of philosophy dealing with moral problems and moral judgments. White (1988) defines ethics as the evaluation of human actions. In doing so, we assign judgments to behavior as “right” or “wrong” and “good” or “bad” according to the perspective of a moral principle or ethical guideline. Although we may all strive to be right and good, a gap often exists between the ideal outcome and what can realistically be accomplished.
We acknowledge that ethical perfection lies beyond reach for virtually all of us humans, even if we could completely agree on the ethically correct response in every situation. And, unfortunately, good intentions may prove insufficient to ensure that wrongs will not occur. An effective response requires developed skills, planned resources, the right information, and a pre-established ethical and self-awareness.
The ideal way to avoid a difficult decision is to minimize the chances of having to make one in the first place. A risk management approach to ethics provides a practical way to avoid ethical dilemmas, although it has some ethical (and personal) liabilities of its own, as we will present.
The key to effective risk management is to scrupulously uphold the tenets of relevant laws, policies, professional standards, and ethics codes, taking as many steps as possible to avoid ever being placed in precarious ethical or legal circumstances. The central focus, then, is on self-protection against the hazards of modern-day professional services (Bennett, Bryant, VandenBos, & Greenwood, 1990; VandeCreek & Knapp, 2000; Walker, 1999). Strategies to manage risks include the elements of good practice, such as refraining from having sexual contacts or other intense multiple role relationships with clients, keeping careful notes, reviewing client files often, recording reasons for termination, and consulting with colleagues or appropriate others about very difficult clients (while protecting their identities) and carefully documenting such meetings (Kennedy, Vandehey, Norman, & Diekhoff, 2003).
A potential negative aspect to an overly strict adherence to risk management, however, is that clients who urgently need help can be shut out. Hazard-averse therapists might choose to avoid high-risk clients, even when they are trained to competently treat them. Individuals with borderline personalities (especially if accompanied by substance abuse, impulsive acting-out, or paranoid thinking), or who have a history of dangerous behavior or suicide attempts would have a difficult time finding appropriate help should all therapists ascribe to a rigid risk-management style. Clients who develop rapid and intense transferences may frighten some therapists, causing them to refer the client elsewhere or terminate treatment, a decision not based on sound clinical judgment but on the fear of ethical or legal entanglements.
Therapists who approach their work from too much of a risk-management perspective might also avoid high-risk practice areas such as child custody and other forensic work, and in practice venues where scrutiny will be intense. However, many people desperately need these services. Who will provide them if mental health professionals hide out in a safe zone?
Of course, mental health professionals should pay attention when a client’s behavior suggests that resistances have been mismanaged or that the therapy has reached an impasse or is deteriorating as evidenced by such clues as many missed sessions, nonpayment or late fee payments, overt or covert expressions of dissatisfaction with therapy, or the desire to see another therapist. Nevertheless, therapists can become overly obsessed with avoiding risk, such as by viewing articulate clients with suspicion because if things go badly they could make a cogent complaint, or avoiding clients with anger issues, or putting up extra walls whenever clients disclose a complaint about previous therapists.
Although the scrupulous practice of defensive ethics is understandable in a litigious society, a mindset that views every client as a potential land mine may also become insidiously instilled. Harboring constant apprehension and distrust towards those we were trained to help constitutes an unhealthy foundation for an authentic therapeutic alliance or a satisfying career.
We take the position that the primary rationale for being an ethically aware and sensitive therapist is not for self-protection. There is a far more positive reason. Reaching for the highest standards emboldens us in the face of ethical uncertainty. We respect ourselves and what we do if we feel confident that we are practicing appropriately and within the boundaries of our training and competence. This, in turn, enhances the quality of our services. Maintaining high standards allows us to act with benevolence and courage rather than donning protective armor.
Aristotle speaks of the ethical life as a happy life. This makes sense in our context. Maintaining high ethical standards may well be the prerequisite to a personally gratifying career. The old saw, “Virtue is its own reward” reveals that being a decent, responsible, honest human being elevates both self-respect as well as respect from others.
We see overarching descriptions of “the ethical person” reflected in all mental health professional ethics codes. Below are core ethical principles we believe should serve as an overall guide to the behavior of mental health professionals:
One way to illustrate what defines an ethical mental health professional is to review examples of unethical behavior. The examples presented here are disguised versions of actual cases.
The stereotype of the “unethical mental health professional” is outright unsavory. At times, some therapists willfully, even maliciously, engage in acts they know to be in violation of ethical and legal standards.
A clinical social worker abruptly terminated a client who was still struggling with depression and alcohol dependence. The following day, he called his just-terminated-client and invited her to his apartment to watch a movie. The social worker served popcorn and wine and, during the movie, sexually assaulted her. The client told her minister about the incident, who contacted the social worker for an explanation. The social worker offered the minister a new computer if he could talk the client out of calling the authorities.
A certified counselor plotted against a former client who had accused him of over-billing and was threatening to take the counselor to small claims court. The counselor hired a man to burglarize a business and place the stolen items in the ex-client’s home. The hired burglar was supposed to then call the police with a tip that a person fitting the ex-client’s description was observed leaving the business in a car with the ex-client’s license number. Fortunately for the ex-client, the hired burglar repeated the story to others while drinking heavily in a bar, leading to an arrest and disclosure of the counselor’s plot.
A psychotherapist solicited one of his own clients to kill six people and dump the bodies in the ocean. The client was also instructed to purchase a gun with a silencer, rent a sturdy vehicle that could hold 750 pounds of body weight, arrange a boat rental, buy bait, and locate shark-infested waters. The client reported this bizarre offer to the police.
Thankfully, such extreme cases are very rare and suggest at the very least an inadequate moral foundation. In our experience, the more prevailing portrait of the professional who crosses over the line is muted and complex, and often includes people of decency, intelligence, and emotional fitness caught up in circumstances that they did not evaluate or respond to appropriately.
Most mental health professionals who engage in questionable, unethical, or unprofessional behavior could be described as having one or more of the following underlying characteristics, which are rarely mutually exclusive:
Additional commentary and illustrative scenarios for each type appear below.
The first category illustrates why keeping up with ethical standards, extant policies, and relevant law is so critical. A substantial number of violators appear to be either naive or uneducated about the standards of their profession and how they are expected to behave. Fortunately offenses of ignorance can often be minor and cause no real harm.
Recently licensed Newt Unworldly, Ph.D., accepted the offer of Trendy Cool, his brother-in-law and a marketing specialist, to promote his fledgling private practice. A flashy advertisement in the local paper gave a misleading description of Unworldly’s professional experience. For example, “interned at Memorial Hospital” referred to a summer of volunteer work that Unworldly performed as a high school senior. Another counselor in the agency pointed out that Unworldly himself retained responsibility for such statements and was lax in allowing his advertising agent to run loose around the truth. Unworldly quickly retracted the ad.
For minor violators in this category, educative approaches typically prove sufficient to ensure that the act will not recur. Often inexperienced, these therapists are usually embarrassed upon being informed of their obliviousness or shortsightedness. Sadly, they also frequently insist that such matters never came up for discussion during their formal training.
Alternatively, mental health professionals sometimes operate under the belief that they are aware of an ethical provision when, in fact, no such provision exists. Thus they misinterpret the actual ethics code of their profession.
When questioned by an ethics committee about a sexual affair that went awry with a client he had terminated only a month earlier, Romeo Quickie, Psy.D. replied that the ethics code of the American Psychological Association specifically states that sex with ex-clients is acceptable.
Dr. Quickie’s understanding seems conveniently confused and inaccurate. Not uncommonly, therapists attempt to defend unethical acts with a claim that they were unaware of the relevant content of the ethics code. Ignorance will not let Dr. Quickie off the hook. A thorough familiarity with and a commitment to upholding high standards of conduct safeguards against engaging in ethical misconduct.
For ignorant or misinformed violators who are more experienced but who have lost touch with their professional identity and commitment, remediation can be more difficult.
Hy Upper, Ph.D. was contacted by an ethics panel regarding his alleged distribution of amphetamines during group therapy sessions. He responded that he was “under the distinct impression that psychologists in his state had the same rights to pass out drugs as do physicians.” He claimed to have “read about it somewhere.”
Occasionally, those who you might think would hold special competencies because of their considerable experience come to see themselves as beyond learning anything new or as above the law. In the actual incident, “Dr. Upper” had been in practice for more than 25 years. However, he had clearly drifted far from an awareness of relevant law and professional standards.
The misconduct of mental health professionals can arise from an incapacity to perform the services being rendered. This can result from inadequate training, lack of skill, or both. Sometimes emotional disturbances or substance abuse can blunt the ability to perform satisfactory work, even if the therapist has been properly trained. More often, however, inadequate training and experience are the cause. Many therapists who come to the attention of ethics committees, licensing boards, or the courts have vastly miscalculated the level of their overall skills or their ability to apply specific techniques or services, such as a neuropsychological assessment or expert forensic testimony.
A clinic supervisor recognized that many clients seemed to acquire misdiagnoses or inappropriate treatment plans based on the reports of Remi Partway, Ed.D. When the supervisor asked Dr. Partway to detail her training and experience, Partway admitted she had virtually no training or experience in these specific assessments she had conducted, but believed she was “picking up speed” as she went along.
Dr. Partway’s circumstance occurs all too frequently. Typical training programs cannot teach every skill that a particular employer or client may require. We have run across cases in which employers insist that therapists provide services despite their having full knowledge that the requisite training and experience are lacking.
Although insensitivity is an elusive category, mental health professionals often exceed the bounds of ethical propriety because of insufficient regard for the needs and feelings – and sometimes the rights and welfare – of the individuals with whom they work. Reasons vary and include lack of empathy, a need to exercise control, overzealousness regarding a specific approach, self-absorption, and prejudicial attitudes toward certain people. Often, such insensitivities preclude the recognition that an ethical issue even exists.
Justin Tyme, L.M.H.C., was often late for therapy sessions. When a single mother of four young children complained that she didn’t like waiting for up to a half hour because it threw off her schedule, he responded, “You don’t have a job, so what difference does it make?”
This therapist appears to be revealing a prejudice, perhaps seeing nonworking women with children as having irrelevant schedules and, if receiving assistance, undeserving of dignified treatment. Although this incident did not lead to an ethics complaint, the comment reveals lack of empathy and respect for a client.
Exploitation occurs when mental health professionals take advantage of consumers by abusing their positions of trust, expertise, or authority. Therapists who allow their own needs or temptations to take precedence over those of clients they serve, or who put the lure of financial gain above client welfare, best fit the common stereotype of the unethical professional. Therapists who themselves have character disorders seem most likely to fall into this category although other risky therapists include those who are professionally isolated, those who disclose too much of themselves (i.e., interjecting their own issues into the therapeutic alliance), and those who were not well-trained or supervised adequately in the first place.
Engaging in sexual activity with current clients constitutes the most commonly discussed form of exploitation. Sexual misconduct is what usually comes to mind when we think about exploitation, even though the vast majority of therapists do not have sex with their clients. When people think about therapists who do become sexually intimate with clients, they think of an obvious manipulation, such as the next case.
John Bestman, M.S.W., convinced Marcia Willing that a therapist was the perfect person with whom to have a sexual affair because no one else could better understand her needs or be as trusted.
In fact, most cases are more complex, involving some unheeded early warnings and rationalization processes. In the case above and the two below, the therapists lost their license to practice until they provided adequate evidence of rehabilitation.
Samuel Sorry, Ed.D., a counselor in his late 40s, explained to an ethics committee that his sexual relationship with a 26-year-old client was prompted primarily by a series of rapidly accelerating crises in his personal life. His wife of 25 years left him for another woman and his father recently died. He was feeling lost and saw himself as a failure. His young client had always been trusting and complimentary, and, in his exact words, “She was the only thing [sic] in my life that I looked forward to.”
Simon Inchworm, Ph.D., was attracted to Selma Receptive, his client of several months. Selma readily accepted what Dr. Inchworm believed, at the time, to be a professionally appropriate invitation to attend a lecture on eating disorders, given that Selma's sister had a history of anorexia nervosa. The lecture concluded at 5 p.m., so Dr. Inchworm invited Ms. Receptive to stop for a bite at a nearby bistro. The next week, Inchworm accepted Receptive's gift of a book written by the speaker they had heard the previous week. The following week, Inchworm agreed to a reciprocal dinner at Receptive’s apartment. Afterward, while enjoying a third glass of wine, they looked into each other’s eyes, embraced, kissed for a while, and retreated into the bedroom.
A great many circumstances other than the overtly sexual present themselves in the context of psychotherapy that allow for exploitation, abuse, and harm to clients. Here, we illustrate how such exploitation can occur in subtle and largely undetectable ways:
Tom Stare, D.S.W., created a seating plan in his group adolescent therapy that purposely placed Minny Monroe directly across from his seat in the circle. He confided to a colleague that the entire seating scheme was done to position himself to look at an “adorable chick that wears short skirts and doesn’t always pay attention to what her legs are doing.” When the colleague suggested that his behavior was questionable, Stare countered that the colleague had no sense of humor.
Dr. Stare’s attitude is typical of exploitative professionals. He clearly has no insight into how his notion of harmless gratification probably influences the level of care and genuineness that accompanies his services, especially regarding the client he objectifies as an “adorable chick.” He also takes advantage of a client to whom he owes a professional responsibility, even though she may remain unaware of what he is up to.
The percentage of exploitative therapists who could be described as avaricious and who place financial considerations ahead of professional obligations is probably low, even though they represent a high percentage of cases brought before adjudicating bodies. We sometimes refer to inexperienced or novice therapists in a hurry to become wealthy or successful as “green menaces.” They often try a misguided gimmick or overrate their services. Occasionally, as illustrated in the next case, someone calls them on it.
Jacob Ladder, L.M.H.C., attempted to convince his client, who was a supporting actor in a long-running television series, to pass out Ladder’s business cards on the set and to attest to his “magical skills” as a therapist. When the client expressed discomfort with the request, Ladder expressed considerable anger toward the client, calling him ungrateful and selfish. The client complained, and Ladder was assigned to take an ethics class before he could resume practice.
Some exploitative therapists are recalcitrant and difficult to educate. Their infractions can be serious, such as defrauding insurance companies, accepting kickbacks, using elaborate bait-and-switch techniques, or making highly misleading claims about the effectiveness of their services. The next case describes an outrageous swindle. Incidents of this sort are, thankfully, extremely rare.
Buck Scam, Ph.D., prevailed upon the husband of a couple whom he was treating to acquire an unsecured loan of $150,000 from the husband’s pension fund. The wife was not informed in advance and threatened exposure when she discovered the transaction several months later. The therapist promised to repay what he owed if the wife would agree, in writing, to never contact an ethics committee or licensing board. Upon signing this promise, the therapist presented her with a bill for $120,000 for sessions the therapist alleged the couple never paid for.
This contemptible case clearly reveals how communication breakdowns in a marriage can wreak considerable havoc. That the therapist to whom they came for help is responsible for adding to the couple's problems is unconscionable. In this actual case, the couple did complain to a licensing board, and the therapist lost his license to practice.
Ethical infractions based on irresponsible behavior can manifest themselves in several forms, including unreliable execution of professional duties, shoddy or superficial professional work, and attempts to blame others, cover up, or make excuses for one’s own mistakes or inadequacies.
Janet Turtle, Ph.D., agreed to support her clinical supervisee, Job Hunter, in his quest for employment. However, Mr. Hunter learned that Dr. Turtle failed to return prospective employers’ calls and that the promised letters of recommendation were never written. When Hunter expressed disappointment to Dr. Turtle, she apologized, explaining that she had gotten so busy that she could not even handle her own priorities. In the meantime, the prospective employers offered the positions to others.
Abandonment is a form of irresponsibility and occurs when therapists fail to follow through with their duties in a way that causes clients to become vulnerable, to feel discarded or rejected, or to suffer some other foreseeable harm. Many ethics complaints from therapy clients echo themes of abandonment, as illustrated in our next case:
As Dee Compensating became increasingly ill, Lucia Panicky, Ph.D., felt uncomfortable treating her. Dr. Panicky informed Dee she could no longer see her and told her to find another therapist. When Dee asked for an explanation, Panicky only replied, “I have my reasons.”
All therapists have probably found themselves in situations from which they wished to exit. In many such instances, they probably should go ahead and disengage. Dr. Panicky may well have lacked the competence to continue treating her client, and appropriately recognized this. However, termination of services requires sensitivity and due regard for consumers’ needs and welfare. Dr. Panicky failed in these regards, leaving her client bewildered and adrift. She should have offered appropriate referrals and given the client at least a brief explanation as to why someone else could better treat her.
Cases of mental health professionals who have sought revenge on a colleague, a client, or others who they perceived as having done them wrong are not common and seldom make their way to ethics committees or to the courts. However, some outraged mental health professionals have allowed their emotions to supersede professional judgment. Usually the infraction involves an impulsive act – as opposed to a premeditated plot – to retaliate against an antagonist. The behavior often has a childish quality.
Alotta Deduce, Ph.D., became increasingly resentful of a client who often disagreed with her interpretations of the relevance of past events in the client’s life. Once, after the client doubted whether the loss of a puppy at age 10 had anything to do with his current emotional pain, Dr. Deduce shook her finger and roared, “You are without a doubt the most thick-headed moron on the planet,” and, “I must be crazy myself to agree to keep seeing you.”
Impulsively vengeful therapists often feel remorseful and foolish later and frequently apologize for their loss of control. Unfortunately, damage may already have occurred because the impact of such outbursts cannot always be fully rectified.
Therapists suffering from their own emotional or physical challenges, burnout, marital problems, and other stressors reveal themselves in a substantial number of cases involving professional misconduct (Katsavdakis, Gabbard, & Athey, 2004). Such problems often lead to poor professional judgment and incompetent performance. Although some who fall into this category may be sympathetic characters, they can also cause considerable harm to vulnerable clients.
Cecila Pow, L.M.F.C., had become increasingly frustrated with the lack of progress in all of her clients. She quit taking any notes, resulting in her inability to keep track of what transpired during previous sessions and mixing up clients’ issues. At home, she was caring for her ailing mother while also attempting to keep her two rebellious teenagers from getting into trouble.
Colleagues reported to the clinic manager that Mordred Gloom, Psy.D. failed to keep many appointments and did not call to cancel them. It took some of his clients almost an hour by bus to get to the clinic. A few quit coming at all, complaining to the receptionist that their therapist did not even care about them enough to show up. It was then discovered that Gloom had become so depressed over the recent breakup with his wife that he could not always pull himself out of bed in the morning.
Ed Bellevue, Ph.D. physically attacked a client with an umbrella, claiming that she was an agent of Zormont, the sinister charged ion force that dwells on the dark side of Pluto.
As a sufferer of Crohn’s Disease, Sam Sick, L.M.H.C., had abdominal pain and diarrhea that would frequently cause him to excuse himself in the middle of therapy sessions. One client claimed that she resented paying for partial sessions, some of which lasted only 10 minutes, and pressed ethics charges.
Mental health professionals are not immune to emotional disorders, including serious psychopathology. Dr. Pow may have had reason to be disappointed in some of her clients, but she seemed noticeably affected by burnout; she should have taken immediate steps to refresh herself before her career unraveled. She had already committed ethical errors by showing disrespect for her clients and their welfare.
Obviously, the people we call Drs. Gloom and Bellevue were in need of psychotherapy themselves. Mr. Sick may be viewed as the most sympathetic of the lot because people generally have more compassion and forgiveness for those with physical illnesses as compared to those inflicted with mental conditions. Nevertheless, the client who protested was not being well served. Mr. Sick should not have attempted to treat clients until his condition had stabilized sufficiently enough for him to give clients his full attention.
Twofer Junk, L.M.F.T, had her lower-paying clients schedule appointments on Saturdays in front of her home where she also held weekly yard sales, during which she marketed items that she had bartered in exchange for therapy sessions with other clients. When a customer drove up, the therapy was interrupted and the clients were expected to assist with selling items until another lull occurred at which time therapy would resume. Ms. Junk also hired clients to clean her house, run errands, drive her around, and do her accounting. She also rented an extra bedroom to a client who babysat her two children during the week and while she was running her yard sale/therapy sessions on Saturdays.
An unusual feature of this case is that the therapist argued she was charging her clients only a small amount per hour while allowing them to pay off the rest, thus doing them a favor. However, it could take up to 8 hours for a client to earn what was owed on each session. She was shocked upon being accused of exploitation.
Self-awareness is an agreed-upon hallmark of a well-functioning mental health professional (Schwebel & Coster, 1998). Lack of self-awareness forms the basis of many unethical actions (Bazerman & Banaji, 2004). As Moore (2004) points out, self-interest functions in an automatic, compelling, and often unconscious manner. Self-deception allows one to engage in an “internal con game” – to act out of self-interest while believing that one has acted morally (Tenbrunsel & Messick, 2004).
Over the years, we have found ourselves continually dazzled by the array of defenses therapists use to justify behaviors that objective observers would judge as highly questionable. We offer five examples, the first three being outrageous (including an attempt to blame the victim) and two more that are more representative of what well-meaning therapists get themselves into when they don’t fully think a matter through.
When asked why he had sex with 17 clients even though he knew it was prohibited, Cloudy Thot, Ph.D. replied, “It was my way of giving generously of myself to women who desperately needed love.”
Bucks Allgone sued his counselor for pressuring him to invest in his counselor’s high-risk startup vitamin supplement company. The company went bust, causing Allgone to lose over a half a million dollars. The counselor attempted to defend himself by saying that he only wanted to cut his client in on a deal that should have made them both millions.
Taken Keepit, M.S.W. refused a recently-terminated client’s husband’s demand to give back the client’s mother’s extremely valuable collection of antique crystal figurines. The husband took Keepit to small claims court and argued that his wife was distraught and vulnerable and wasn’t capable of making competent decisions. Mr. Keepit asserted that he was under no obligation to return a client’s gift, and that if the husband wanted redress he should sue his own wife.
The first two cases resulted in successful legal action against the therapists. However, Mr. Keepit got away with his ill-gained booty.The next two examples illustrate the cases of therapists who were trying to do something positive, but their actions were ultimately not helpful to the clients and caused the therapists considerable grief as well.
Joy Ride, Ph.D. offered to take Royce Turbo, her car-obsessed client, for a spin in her brand new sports car. She could envision no consequences and thought a little outing just this one time would strengthen the therapeutic alliance. The brief experience confused Mr. Turbo, who asked if they could drive all the way to the beach next time. When Dr. Ride pulled back, Turbo terminated therapy and accused Dr. Ride of wanting only his money so that she could pay for her expensive new car.
Tryin Tohelp, Ph.D., wanted to assist his financially shaky client who had both a troubled marriage and characteristics of an antisocial personality disorder. He decided not to disclose the Diagnostic and Statistical Manual’s Axis II diagnosis of a personality disorder, or the “V code” of marital problems because the client’s insurance carrier frequently declined to pay for treatment of these latter conditions.
Rationalization often operates under subtle and seemingly harmless circumstances, sometimes in order to justify inaction or convenience. Sometimes the “tipping point” – the act that spilled over into unethical territory – took a while in coming as the therapist slowly slid down a slippery slope. For example, sexual exploitation of a client is often the culmination of seemingly innocent flirtations. Therapists need to remain alert because we can all fall prey to talking ourselves into or out of doing something based on reasoning that is less than honest and clearheaded. Beware whenever you hear yourself thinking, “It’s just a minor thing,” “This time it’s different,” “Everyone does it,” “No one will get hurt,” “I can still be objective,” “Nobody else will care,” or “Just this one time.”
A fairly substantial percentage of ethics violators appear to be mental health professionals who usually conduct themselves in a principled and competent manner and who, under normal circumstances, show sufficient sensitivity to ethical dilemmas. However, circumstances can converge to displace one's usual awareness with temporary blindness, sometimes due to an inconvenient situation or distraction. Sometimes, as the result of immediate situational demands, therapists commit acts with unintended consequences.
Skid Greenspace, M.S.W, prided himself on continuing to use anything that had remaining function before recycling it. Mr. Greenspace was chagrined when a client pointed out that the scratch paper he left in the waiting room for children to draw on had confidential client treatment notes on the backside.
Broma Seltzer, a fragile client, made a frantic call asking to see her therapist, Delta Flyaway, L.M.H.C., right away. Ms. Flyaway was already running late to catch a plane for a long-anticipated trip to Europe. She told Ms. Seltzer that she would have her backup therapist make contact immediately. Ms. Flyaway became distracted by yet another call and left for the airport without contacting her backup. A week later, while skiing in the Swiss Alps, Ms. Flyaway suddenly remembered the call for backup that she had failed to make.
Kip Spontaneous was frustrated with several of his clients for various reasons and wrote on his Facebook page, “I hate being a therapist today. My clients are crazy-making.” This spontaneous outburst resulted in considerable fallout when a client’s friend happened to see it. The client stood outside the therapist’s office with a poster board on which the message was printed in huge letters to make sure that some of his other clients knew of the ill-conceived post. The psychologist lost six clients as a result.
Every mental health professional is vulnerable to membership in this “Oops!” category, and it is the most difficult type of infraction to predict or prevent. Thus, it is fitting that we turn now to a discussion of how any of us could find ourselves in an ethical predicament.
Carelessness, lack of awareness, insensitivity, inadequate knowledge or training, self-delusion, or some deficit in the therapist’s character are not the only conditions spawning ethically questionable actions. Alert, well-meaning, sensitive, mature, and adequately trained therapists functioning within their bounds of competence will also encounter ethical dilemmas that can result in vulnerability to charges of misconduct. Several common conditions that result in confronting an ethical situation are adapted here from Sieber’s (1982) classic scheme.
Sometimes an ethical issue is simply not predictable. For example, suppose that a conflict of interest does not become known until some time has passed after taking on a client. The client may turn out to be the therapist’s mother’s boss. An agitated client could discover a therapist’s home address and unexpectedly show up at the front door, which is opened by the therapist’s 9-year-old daughter. Crisis situations may present ethical challenges, and these, too, are usually unforeseen.
A therapist may understand an ethical problem, but not expect it to arise. Or, a therapist might underestimate the magnitude of the problem or decide that taking safeguards would prove unnecessary or too costly. For example, a therapist treating a couple may not attend sufficiently to the possible confidentiality dilemmas that could develop if a divorce occurs and one parent later attempts to subpoena the treatment records for use in a custody dispute. Potential ethical problems may never materialize, but, if they do, the therapist may be held responsible for not taking reasonable precautions. If there is a complaint, ethics committees and licensing boards may judge the therapist’s actions in hindsight as to whether the problem should have been perceived and avoided.
Even when a potential ethical problem can be foreseen, there may be no apparent way to avoid it. In some circumstances, at least one party will become upset or feel betrayed, but no feasible options exist to prevent the distress. For example, to protect the welfare of a client, a therapist may recognize no other course of action except to disclose information obtained in confidence. In another situation, a therapist may intervene on behalf of a client who claims to have experienced abuse, and other family members may become distraught and feel wronged.
In a variation of the anticipated dilemma, a problem could be seen as possibly arising, but ambiguous features cloud the choice of what action to take. We cannot always predict the consequences of available alternatives as we attempt to make a decision about how best to confront an ethical problem. The use of some innovative or controversial therapeutic techniques, for example, becomes problematic because the risks, if any, are simply unknown.
An ethical problem may arise whenever relevant guidelines or laws prove inadequate, nonexistent, ambiguous, or contradictory. The general or nonspecific nature of ethics codes and other regulations can create considerable confusion. The revision of ethics codes is a long and arduous process. In the meantime, new issues arise, such as social media and other technological advances and their potential for ethical pitfalls.
An ethical problem may present itself whenever discrepancies exist among the demands of laws, government policies, employers, and ethical principles that simultaneously jeopardize the welfare of client. In individual situations, therapists may feel torn among those who pay for their services or to whom they owe a favor, taxpayers or other third-party payers, colleagues, employers, or employees. These thorny dilemmas cause considerable distress, because a single choice must often be made from among several legitimate loyalties. Someone, or some entity, may not feel well served as a result. It often becomes difficult – if not impossible – to protect the rights and fulfill the legitimate needs of every involved constituency simultaneously.
When making ethical decisions, a thorny dilemma arises when one moral principle conflicts with another. Which one takes precedence? Principles, as described at the beginning of this course, are not prioritized. Clashes between ethical principles occur more regularly than you might think. For example, you might consider holding back a truthful response because the client would likely be upset or harmed by it. Or the divulging of information to help one person may involve breaking another’s confidence.
When an ethical conflict arises the best possible outcome becomes far more likely if certain conditions are established. These include:
Fortunately, most of the time one does not need to rush into a decision before meeting the conditions listed above. Either nothing will happen until these conditions can be satisfied, or the problematic act has already occurred but the ensuing damage will not materialize right away.
Do professional ethics codes inform us about how precisely to deal with individual ethical conflicts and dilemmas? Unfortunately, they do not. A thorough knowledge of relevant codes, accompanied by a sincere motivation to follow them, does not completely insulate therapists from questionable conduct. Professional ethics codes consist primarily of general, prescriptive guideposts with inherent gaps when it comes to deciding what specific action to take. Indeed, ethics codes were never intended to cover every conceivable problematic act. Furthermore, it seems unlikely that the creation of a comprehensive set of guidelines is even possible, thereby leaving it to ethics boards to determine the appropriateness of any given action in a specific context.
Therefore, we suggest that all mental health professionals internalize a decision-making strategy to assist in coping with ethical matters as they arise. We expect that such a process will maximize the chances of an ethically sound result, although we also readily acknowledge that this does not always happen. Some outcomes will remain unsettled no matter how hard one tries to resolve them. However, therapists who can document a sustained, reasoned effort to deal with the dilemma will have a distinct advantage should their decisions and actions ever be challenged.
We must stress that the application of ethical decision-making strategies does not actually make a decision. However, a systematic examination of the situation will likely have a powerful influence on a final determination.
People differ in their abilities to perceive that something they might do – or are already doing – could directly or indirectly affect the welfare of others (Rest, 1982). As we have already noted, violators of ethics codes can judge a situation inaccurately, for reasons such as ignorance or denial, and thus fail to undertake any decision-making process at all before acting.
Even when an incident is perceived to have ethical ramifications, a knee-jerk reaction is unlikely to lead to the best response. Despite the popularity of the “snap judgment superiority” as promulgated by popular works such as Malcolm Gladwell’s Blink, more recent research indicates that it pays to actively plan a response when a decision with potentially devastating consequences is involved (Newell, Lagnado, & Shanks, 2007). Taking the time to document, reflect on other factors that might be impacting on your decision and consult with another appropriate person is far more likely to produce a desirable result. Whereas one should undertake decision-making deliberately, the actual process can range from a few minutes to days or weeks. (We discuss a necessity to make swift decisions under emergency or other urgent conditions in the next section.)
Our suggested model, first published in 1985, was among the first to guide mental health professionals through the decision-making process. It has been updated here as new perspectives and data became available.
1. Determine whether the matter truly involves ethics. First, the situation must involve an ethical issue germane to your profession and its professional image. The distinction between the merely unorthodox or poor professional etiquette and unethical behavior may be clouded, particularly if one feels emotionally involved or under attack. Sometimes a claim of, “That’s unethical!” more accurately translates as, “I’m so upset by your rudeness that it must violate some rule!”
A helpful starting point is to focus on identifying the general moral or ethical principle applicable to the situation at hand. As we have already noted, overarching ethical principles such as respect for autonomy, non-maleficence (doing no harm), justice, according dignity, and caring toward others rank among those often cited as crucial for the evaluation of ethical concerns. Readers will find elements of these principles reflected in most ethics codes, although sometimes one will take precedence over another. For example, respect for client autonomy ranks below responsibility for a client threatening to harm another party or talking seriously about suicide. The ethical matter in question can often be linked to a specific element of a relevant ethics code, policy, or law, which makes this phase easier to complete.
2. Strive to discover all the available facts before proceeding. As Rogerson et al. (2012) remind us, sound ethical decisions are unlikely if we have incomplete or inaccurate information. The authors point out that, for example, the fundamental attribution error (attributing the behavior of others to their stable personality characteristic rather than to any situational variables while judging ourselves based on a given situation) may lead to misinterpretations. Or, we may make pre-judgments and fail to consider disconfirming data that could have provided a more accurate assessment.Detert, Trevino, & Sweitzer (2008) outline cognitive processes that can deactivate moral self-regulatory processes helping us to understand why individuals may engage in unethical behavior without apparent guilt or self-censure. For example, a cynical individual with a weak ability to empathize may, without awareness, commit an ethical infraction. When we served on the APA Ethics Committee, we saw examples of this phenomenon. One psychologist, for example, was furious with the committee for its objection to his practice of insisting that his clients pay for 15 sessions in advance. “That way I know they’ll show up,” was his defense. When the Committee asked why he thought his clients would all need 15 sessions, he replied, “Everyone needs at least 15 sessions. These are crazy times.”
Even after collecting data, the solution still may not become clear, and uncovered contradictions may cause more confusion than before the decision-making process started. Nevertheless, collecting relevant information constitutes a critical step that must be taken conscientiously. A disregard for extant policy or relevant ethical obligations may result in unwanted consequences for you or for a colleague.
Early in the process, you should also collect information from other involved parties as is appropriate. Sometimes this step reveals that a simple misunderstanding led to an improper interpretation, or the new data may reveal the matter to be more grave than first suspected.
Confidentiality rights must be assessed and protected throughout the process. In some cases, confidentiality issues may preclude taking any further steps.
3. Consult existing guidelines that might apply as a possible mechanism for resolution. Be prepared to do some homework by finding the resources that represent the moral responsibilities of mental health providers. Ethics codes and policy statements from relevant professional associations, federal law, or local and state laws (including those regulating the profession), research evidence (including case studies that may apply to the particular situation), and general ethics writings are among the materials that one might find helpful.
It is imperative for all mental health professionals to stay well informed about the most relevant ethics codes representing their respective professions. However, it is also wise to stay aware of the provisions of the codes promulgated by their sister professions because of the high probability of interacting with colleagues with different training backgrounds. The ethics codes of the following organizations can be found online:
American Psychological Association (2002, amended 2010) http://www.apa.org/ethics/code/index.aspx;
American Counseling Association (2014) http://www.counseling.org/resources/aca-code-of-ethics.pdf;
National Association of Social Workers (2008) http://www.socialworkers.org/pubs/code/code.asp;
American Association of Marriage and Family Therapy (2012) http://www.aamft.org/imis15/Content/Legal_Ethics/Code_of_Ethics.aspx; and
American Psychiatric Association (2010) http://www.psychiatry.org/practice/ethics/resources-standards
4. Pause to consider, as best as possible, all factors that might influence the decision you will make. An extremely common reason for poor ethical decisions arises from the inability to assess the matter objectively because of prejudices, biases, blind spots, or personal needs that distort the perception of the dilemma (Hadjistavropoulos & Malloy, 2000; Lincoln & Holmes, 2010; Tjeltveit & Gottlieb, 2010; Rogerson et al. 2012). We recommend pausing to gain an awareness of any inflexible mindsets that could be affecting your judgment. Avoid undue influence by irrelevant variables, such as an individual’s personal appearance, political affiliation, or social status. We also recommend searching out any financial ramifications (or other factors that work to your personal advantage), in order to ensure that these do not blur anyone’s vision, including your own.
Except in those instances when the issues appear clear-cut, salient, and specifically defined by established guidelines, mental health professionals may well have differing opinions regarding the best decision. Personality styles and primary guiding moral or religious principles can significantly influence the ethical decision-making process. Other personal characteristics influencing decisions include criteria used to assign innocence, blame, and responsibility; personal goals (including level of emotional involvement); a need to avoid censure; a need to control or for power; and the level of risk one is willing to undertake to get involved. Divergent decisions could also be reflected in judgments about the reprehensibility of a particular act. For example, no bright line demarcates the appropriate level of personal involvement with a client. Indeed, we have observed marked discrepancies about the seriousness of an alleged violation in actual ethics committee deliberations.
Consideration of any culturally relevant variables becomes important. If such factors as the degree of expected confidentiality, gift-giving traditions, bartering practices, geographic locale, placement of professional boundaries, gender, age, ethnicity, or culturally based expressive behaviors exhibited during therapy sessions play a part in an ethical matter, an inappropriate decision might result if culturally-based variables are not considered in the mix. Many proscribed acts are unethical no matter what the culturally relevant variables may be, but other instances can be influenced one way or the other depending on the cultural context.5. Consult with a trusted colleague. Because ethical decision-making involves a complicated process influenced by our own perceptions and values, we can usually benefit by seeking input from others. We suggest choosing consultants known in advance to have a strong commitment to the profession and a keen sensitivity to ethical matters. Choose a confidant with a forthright manner, and not an individual over whom you have advantaged status; otherwise, you may hear only what she thinks you want to hear.
We have heard of confidants who gave flawed advice, even causing the person seeking it to commit an ethical infraction. For example, a therapist asked a colleague whether he should agree to treat a rape victim, given that he had no relevant experience or training related to victims of sexual violence. They colleague allegedly replied, “Sure, how else are you going to learn?” In another incident, a poorly selected consultant advised a newly licensed counselor to “trust his gut” when it came to associating with clients outside of the office. His barely begun career came to an abrupt halt when, shortly thereafter, his status as a business partner of his sociopathic client became public. This client, a convicted con artist many times over, left the counselor open to prosecution. The counselor’s pleas of ignorance persuaded neither the court nor the licensing board. Bottom line – if you doubt a confidant’s advice, seek a second opinion.
6. Evaluate the rights, responsibilities, and vulnerability of all affected parties.These evaluations should include, if relevant, any involved institution and perhaps even the general public. All too frequently, a flawed decision results from failing to take into account a stakeholder’s right to confidentiality, informed consent, or evaluative feedback.
7. Generate alternative decisions.This process should take place without focusing on the feasibility of each option, and may even include alternatives otherwise considered too risky, too expensive, or even inappropriate. The possibility of not making a decision at this time and the choice to do nothing at all should both be considered also. Establishing an array of options allows the occasional finding that an alternative initially considered less attractive may be the best and most feasible choice after all.
8. Enumerate the consequences of making each decision.Whenever relevant, attempt to identify the potential consequences of a decision. These include psychological and social costs; short-term, ongoing, and long-term effects; the time and effort necessary to implement the decision; any resource limitations; other risks, including the violation of individual rights; and any benefits. Consider any evidence that the various consequences or benefits resulting from each decision will actually occur. The ability to document this phase may also prove useful should others later question the rationale for your final decision and resulting action.
9. Make the decision.If the above phases have been completed conscientiously – perhaps with the ongoing support of a consultant – a full informational display should now be available. Happily, a decision that also feels like the right thing to do may well become obvious at this point. Even so, many moral and just decisions do not always protect every involved person from some form of injury. Therefore, if anyone could suffer harm, pause to consider any actions that could minimize the damage. For example, if a therapist suspects that an out-of-control adult client might harm his child, the therapist may be legally required to file a report with the state’s child protection agency. Sometimes, a more positive outcome can occur with parental engagement rather than alienation, as depicted in the next case.
Robyn Resque, M.S.W., had treated Betty Boozer, an alcoholic single mother of two, for 18 months. Boozer had remained sober for more than a year, and had made sincere efforts to attend effectively to her children, now ages six and eight. One day, she appeared for a therapy session intoxicated. She had just learned that she faced a layoff from her job at a local business that had filed for bankruptcy. She felt embarrassed and depressed that she had broken her sobriety, and mentioned that she had lost her temper and beaten the children with a belt before coming to therapy.
In most states, Ms. Resque would be obligated to breach Ms. Boozer’s confidentiality by filing a report of suspected child abuse with child protection authorities. Doing so would protect the children, conform to state law, and constitute ethically acceptable behavior. Ms. Resque could, however, go a step further by attempting to engage Ms. Boozer in collaborating in filing the report, and by attempting to engage the authorities in assisting the family while Ms. Boozer strives to restore her sobriety and find alternative employment. The first course of action addresses ethical necessity. The second alternative involves considerably more effort and advocacy, but also could yield a better outcome all around.
Ideally, information about the decision should be shared with all affected parties, or at least with some subset of representatives if a larger population is involved. Sometimes these people cannot be contacted, are unable to participate, or cannot give consent due to age or physical, mental, or other limitations. In such cases, additional responsibilities to protect their welfare apply. Special advocates or other safeguards may become necessary in complex situations.
Some potential decision options can be quickly dismissed because they involve flagrant violations of relevant governing policies or someone’s rights, or because the risks far outweigh the potential benefits. Sometimes, several decisions appear equally feasible or correct. Alternatively, the best decision may not be feasible due to other factors, such as resource limitations, and require adopting a less preferable option. However, in our experience the right decision usually clearly presents itself, and it is time to proceed to the next, and perhaps most difficult step.
[We would note at this point that in some cases, your role will extend only to presenting the assembled information, because those affected have the right to make the final decision themselves. Sometimes when this happens, therapists experience a personal dilemma. Whereas we are morally obligated to make decisions in the best interests of those with whom we work, clients may choose to make decisions we would not have made on their behalf.]
10. Implement the decision. Mental health professions will remain strong and respected only to the extent that their members willingly take appropriate actions in response to ethical dilemmas. This often demands moral backbone and courage. It is at this point that the decision-making process comes to fruition, and the decision-maker must actually do something. This becomes the most difficult step, even if the decision and course of action seem perfectly clear. According to Rest (1982), “executing and implementing a plan of action involves figuring out the sequence of concrete actions, working around impediments and unexpected difficulties, overcoming fatigue and frustration, resisting distractions and other allurements, and keeping sight of the eventual goal” (p. 34).
The ideal resolution results when a decision can be made prior to the commission of an ethical infraction that would otherwise have untoward consequences. Often enough, however, the decision occurs in response to an already ongoing, problematic situation. Sometimes, the appropriate action involves simply ceasing and desisting from a practice that, after careful analysis,seems ethically risky even if no harm has yet occurred. Sometimes the best course of action is the recognition that one lacks some specific competencies and should now undertake continuing education or seek supervision. Often the implementation will involve the need to do something differently going forward, while making an attempt to ameliorate any damage now. Remediation attempts can range from making an apology to conducting an additional intervention to providing services or resources to those who were wronged. On occasion, the implementation will involve contacting an ethics committee or a licensing board to determine the appropriate resolution.
Unfortunately, the implementation phase also becomes a point at which this entire process can derail. Research tells us that most therapists are entirely capable of formulating what they should do. However, they will more likely respond to their own values and practicalities when determining what they actually will do, which is less than they know they should do (Bernard & Jara, 1986; Wilkins, McGuire, Abbott, & Blau, 1990); Rogerson et al, 2012). Tenbrunsel and Messick (2004) use the term “ethical fading” to describe the tendency to move the ethical or moral implications of implementing a decision into the background.
Sometimes there is little time to think before acting. Frantic phone calls from clients or their families, clients’ threats of harm to themselves or someone else, unexpected client behavior or demands, and alarming revelations during a therapy session are not rare occurrences. As a result, ethical dilemmas demanding an immediate response can and do arise. With no time to prepare a carefully reasoned decision using a procedure such as the one we have presented, therapists may feel understandably anxious and be prone to react in a less-than-satisfactory manner.
Mental health providers rank high among the professionals vulnerable to ethical and legal quandaries when making decisions and acting under crisis conditions (Hanson, Kerkhoff, & Bush, 2005). At some point, most therapists will face a serious situation requiring ethical decision-making and action during less than optimal conditions.
The cases below involve instances wherein something terrible is, or appears to be, in progress.
A client expressed considerable anger toward a boss who had recently threatened to fire him. During a psychological assessment, the client described his boss to the therapist as “an exploiter of the working class who deserved to be exterminated.” The client detailed a clear plan to perform the “execution” himself with a hunting knife he kept in the trunk of his car.
A mother brought her 10-year-old daughter to therapy because the child was becoming unusually reserved and withdrawn. The mother could offer no explanation for this abrupt change in her daughter’s demeanor. When the mother left the room, the child revealed that for the past three months her stepfather had entered her room after everyone else was asleep. He touched her body and requested that she fondle his genitals. The stepfather had warned the girl not to tell her mother or brothers because, if she did, the police would break up the family and it would be her fault.
Half way through a therapy session an angry husband pulled a gun from his jacket and shot at his wife, who promptly pulled a gun from her purse and shot back.
Involving the appropriate authorities would be acceptable in all of the above cases, despite the fact that, in the process, reporting might violate a confidence. The client’s boss appears to be in danger of bodily harm or even death, and the child may be experiencing ongoing harm. In the last case—and we swear this incident actually occurred—the warring spouses recovered from their wounds, and the police credited the therapist's crisis intervention skills that resulted in both clients placing their guns into the therapist's custody.
Sometimes crises do not involve immediate danger, but do necessitate immediate action.
A marriage and family counselor took a call from the 13-year-old daughter of a couple he was seeing. The girl sobbed, “I just called to say good-bye because I am running away from home,” and hung up.
Because the child is legally a minor, the therapist should inform the parents at once. The authorities might also become involved if the child proves difficult to locate.
Despite many warning signs, a crisis may not clearly exist. The next cases present ambiguous situations. The therapists’ suspicions could prove unfounded, and yet ignoring them could lead to disastrous consequences. How would you react to the next three situations?
A client who had expressed suicidal ideation in the past showed uncommonly flat affect during a therapy session. The therapist knew that the client had experienced recent stressors, and she became concerned that his apathy and apparent peacefulness might indicate a resolve to kill himself rather than a sign of improvement. The client vehemently denied any intent regarding self-harm. Fifteen minutes before the scheduled end of the session, the client stood up and calmly stated that he had to be somewhere else.
A therapist was awakened in her home at midnight by a loud pounding on her front door and someone yelling her name. She recognized the voice as that of one of her clients.
A therapist knew that tensions existed in the home of his elderly client who lives with her son and his wife, but became particularly concerned because the client has been rapidly losing weight. He asked the client about a bruise on her arm, and, after fumbling with her words, the client claimed she fell in the shower. The therapist doubted the bruise could have occurred in that way, but the client insisted that her living situation has improved. She promised to see a physician about her weight loss.
As each of the above cases demonstrates, crises requiring a decision that is bound to have ethical ramifications occur most often when an element of ongoing harm or immediate danger appears to be present. As seasoned clinicians know, uncommonly flat affect in a client at risk for suicide could indicate that the client has made a decision to resolve his pain by exercising the “ultimate solution.” As for the midnight wake-up, clients who stalk their therapists are not uncommon, and an estimate of the risk of such stalkers becoming aggressive is as high as 25% (Kaplan, 2006). Finally, elder abuse is not rare, and the vulnerable victim may be too intimidated to report it. Yet none of these cases is clear-cut.
Regardless of the nature of the actual or impending crisis, therapists are in the unenviable position of having to make a number of delicate decisions at a time when they, themselves, may feel anxious. Do both ethical and legal perspectives require maintaining confidentiality? If a disclosure appears warranted or mandated, who should be drawn into the matter? A client’s family? A state agency or emergency response team? The police? What details can one appropriately disclose? What is an acceptable variation in the degree of acceptable involvement with a client during a crisis?
We have argued consistently that therapists usually serve the consumers of their services best when they hold to appropriate professional roles. However, crises may call for temporary exceptions to this advice. The most ethical response under conditions of possible calamity—especially those involving matters of life and death—might conceivably involve ministering to distraught family members, breaking a confidence that would have remained secure under usual circumstances, showing more patience or engaging in more than the usual non-erotic touching, or even actively searching for the whereabouts of clients or their significant others. In one of the cases above, this may be one of those rare occasions when the therapist might consider jumping in his car and driving to the family home in the hopes of finding that the minor child has not yet run away.
Because of their very general nature, ethics codes will often offer little help in dealing with crises. The ethics code of the American Psychological Association (2010), for example, allows divulging information shared in confidence only as mandated or permitted by law. Statutes, regulations, or case law in many states allow disclosure when a client or others require protection from harm. Yet, if a client says, “I get so frustrated with my mother that I swear one of these days I will wring her neck,” has the remark crossed a sufficient threat threshold? Prediction of the actual level of immediate danger is not an exact science, but mental health professionals can be held accountable for their inaction and misjudgments.
Mental health professionals are, on occasion, themselves the target of a potential crisis. It is rare for a therapist to be physically harmed or killed by a client, but it does happen.
Some clients wait until their situations reach urgent proportions before consulting mental health professionals. In such instances, therapists may have to make critical judgments with potentially significant consequences about people with whom they have not yet formed a professional relationship or about whom they have yet to gather sufficient information. This next case illustrates this predicament:
During the first five minutes of the initial therapy session, a highly agitated woman claimed that a male neighbor was abusing her 26 year-old daughter by forcing her into “sexual slavery.” She rambled on, alleging bizarre sex acts that the neighbor regularly perpetrated on her daughter. She restated several times her conviction that the neighbor posed an immediate threat to her daughter’s life.
Does the mother’s story seem credible? After all, the therapist does not really know her. Does her agitation arise from actual events, or perhaps from a misunderstanding of consenting adults’ particular sexual proclivities? Could the mother’s concerns reflect a delusional state of mind? Why has she not brought her daughter with her? Where is the daughter now? Without answers to these questions, an optimal course of action is difficult to discern. The careful therapist can obviously listen with an empathic diagnostic ear, but cannot rush to judgment.
Assessing and responding to a client who may pose a risk of suicide carries a heavy and stress-provoking responsibility. Becoming well versed in the clues suggesting a risk of suicide should be an essential part of all psychotherapists’ training. These indicators include a verbal statement of intent, suicidal ideation, a history of past attempts, a precipitating event, deterioration in social or vocational functioning, a plan of action, intense affect, and expressed feelings of hopelessness and despair (Bongar, 1992; Hendin, Maltsberger, Lipschitz, et al., 2001; Hendin, Maltsberger, Haas, et al., 2004; Pope & Vasquez, 2005). Depending on the situation, some therapists may struggle with the ethics of suicide itself, as when a client has a terminal illness and experiences constant and severe pain.
According to several surveys, nearly one-quarter to one-half of therapists sampled lost a client through suicide. An important step therapists should take in working with potentially suicidal clients is carefully documenting all concerns and decisions. Such records will prove critical to a later defense should a therapist be sued, and the quality of such documentation may determine whether a defense attorney will take the case (Simpson & Stacey, 2004). Lawsuits against mental health professionals remain fairly rare (though on the rise), yet client suicide accounts for a significant proportion of them. The wise therapist will become familiar with the legal aspects of suicide in advance of being forced to learn them (see Baerger, 2001; Feldman, Moritz, Benjamin, et al., 2005; Gross, 2005; Gutheil, 2004; Packman, Pennuto, Bongar, et al., 2004; Remley, 2004; VandeCreek & Knapp, 2000; Weiner, 2005).
Clients with certain diagnoses, such as borderline personality disorder, seem exceptionally prone to crises because of emotional lability, impulsivity, and tenuous relationship histories. The high incidence of child abuse in our society suggests that most therapists will also have to deal with challenging family crises and the associated legal reporting mandates. Being prepared for what to expect and what to do in such circumstances alleviates the tension to some extent, and maximizes the chances for the best outcome (Kalichman, 1999; Zellman & Fair, 2002).
Although crisis management techniques are well beyond the scope of this course, we conclude this section by offering suggestions for preventive action in anticipation of making decisions under an intense time constraint or in emergency circumstances.
1. Know the emergency resources available in your community. Keep the names, numbers, and descriptions of community services in your local area in an easy-to-access location. The prudent therapist will also check the quality of the resources; sometimes promotional materials promise more than agencies actually deliver. Some are known to be slow or disorganized, ineffective, or even inhumane in actual crisis situations. This list should be updated at least once every year because well-meaning and enthusiastic community support services are sometimes short-lived. Some lose their funding and disband, new ones are established, and others undergo reorganizations that improve or downgrade the quality of services. If such emergency resources are used during a crisis, follow up on the quality of their performance and carefully monitor the client’s progress.
2. Form or join an alliance of colleagues in your community, with each person agreeing to be available for consultation when emergencies arise. Ideally, a mental health professional with experience in crisis care should be included in this group. Keep these names and numbers in your easy-access emergency resource file.
3. Know the laws and policies in your state or locale relating to matters that are likely to accompany crisis events. These include mandated reporting statutes (specifying the conditions under which information obtained in confidence must be reported to authorities) and commitment procedures. Before action becomes necessary, seek clarification on any sections of the law or policies that seem unclear. Frantic searches through files or frenetic phone calls to colleagues or attorneys are poor substitutes for preexisting knowledge.
4. Locate an attorney in your community who is knowledgeable about matters that have legal implications relevant to your practice. Keep that phone number in your emergency resource file.
5. Actively seek out learning experiences that will sharpen your knowledge about the kinds of crises that may arise in your professional practice. Take a continuing education class in crisis counseling if your formal training was deficient in this area. Taking courses in first aid and CPR might also be considered, just in case.
6. Conscientiously define your own areas of competence, then practice only within these confines. Although competence is an ethical issue in and of itself, practicing within the bounds of your competence provides an additional advantage during emergencies. The ability to function admirably during crises is often related to the level of expertise and experience with a particular clientele population or diagnostic group. Early on, refer clients who exceed your training and expertise to appropriate practitioners. When in doubt, consult with a senior colleague experienced in the relevant domains.
7. Carefully monitor the relationship between yourself and those with whom a close and trusting alliance has been built. Therapeutic miscalculations can result in intense client-therapist dynamics leading to unanticipated outcomes. The mishandling of transference by therapists has been identified as a cause of client crises. Gaining information about clients’ spiritual beliefs early on is also advised. Those undergoing a severe loss or other difficult life situation may also experience a spiritual crisis, and the therapist who understands a deeper meaning of a client’s despair is better positioned to respond effectively (Cunningham, 2000).
8. Never rely solely on your memory. Carefully document any crisis event, including the decisions you made and your rationale for making them. Detailed records will greatly assist you, and possibly your clients, should the event later require a formal review.
We have discussed crises and emergencies that happen to clients and their families. However, therapists can also experience calamities with little time to make adjustments for their clients and other professional commitments. The therapist who, for example, falls acutely ill must deal with revised session scheduling, how much to disclose to clients, and how clients should be referred if it becomes necessary to interrupt services (Kahn, 2003). Juggling unwelcome revisions may become even more difficult depending on the reason for making them.
The client felt increasingly irritated as her counselor, Di Verted, L.M.H.C., became unresponsive and distracted during the session. The client finally snorted, “I feel like you are not paying any attention to what I am trying to tell you, and it upsets me because my husband forgot my birthday again, and you don’t seem to care.” Ms. Verted apologized and haltingly disclosed that her three year-old granddaughter had drowned in the family swimming pool a few days before. The stunned client expressed sympathy, got up, and left.
The counselor did not handle her understandable personal grief in terms of how it might affect her client. The client felt ignored, and then was forced to deal with mixed feelings about complaining about what was, by contrast, a trivial matter. The client was also perhaps more drawn into her therapist’s personal life than felt comfortable to her. Ms. Verted needed more time before resuming her practice. She might have considered canceling appointments or referring urgent cases to a back-up therapist, explaining to her clients that she needed some time to deal with “a pressing family matter.” In the situation described above, the therapist might have considered sending the client a note apologizing for not recognizing her need for more personal time and for any discomfort the situation caused.
This course is mostly about the ethical obligations of mental health professionals in their own work with clients. However, we also have some responsibility to watch out for each other. Unethical activity often persists, totally unchecked, unless someone takes notice and intervenes. Observing or learning of an ethically questionable act constitutes the front-line opportunity for a corrective intervention. Action can be taken directly by confronting the colleague, or indirectly in the form of advising clients or others on how to proceed with concerns about another mental health professional’s actions. Alternatively, one can refer a case to an appropriate ethics committee or a state licensing board.
Because less serious forms of reported unethical behavior may not be pursued in formal venues, informal peer monitoring creates the best chance to intervene and prevent or correct the questionable behavior of colleagues for three reasons:
We understand that confronting another person for a distasteful reason raises a range of emotions: anxiety, fear of an unknown response and outcome, and so on. The urge to flee from such responsibility is, sadly, also understandable. In group practice, treatment centers, or research settings, one might feel reluctant to appear disloyal by complaining about a colleague. Conflicting feelings between a perceived duty to take action and wanting to maintain a protective stance towards a colleague are a common source of reticence to get involved. It is also tempting to rationalize that that someone else will deal with it (“bystander apathy”) or that the matter is not serious enough for concern. It is all too easy to procrastinate until the matter no longer seems relevant, especially if the evidence seems the least bit ambiguous, as it often is. Another source of resistance is a fear of retaliation, especially if the individual already seems menacing or is of a higher professional status. Knowledge of the often-publicized fate of whistleblowers ending up as targeted themselves may often explain why observers choose to remain silent.
However, most cases receiving media attention involve high-profile reporting to outside agencies. We know less about the gentler, behind-the-scenes interventions that mental health colleagues undertake to play their part in maintaining the public’s trust in their professions. One of the very attractive features of informal peer monitoring is that when it works out well, two goals can be met simultaneously – a problem is solved, and a colleague may have been saved from scrutiny by a more formal (and onerous) correctional forum. Our own recent research on responses to observations of scientific misconduct suggests that such direct interventions are often successful (Keith-Spiegel, Koocher, & Sieber, 2010).
We must also note that the organizational culture in which one works – be it a community clinic, managed care organization, hospital or educational institution – plays a significant role in determining how an intervention will play out. Conflicts are unlikely to arise when the integrity of the employer parallels ethical guidelines, and employees feel confident that their decisions will be supported up the line. Dilemmas can prove problematic, however, when an employer’s policy does not support or seems contradictory to general moral principles, professional ethics codes, and one’s own moral commitments.
A counselor in a community agency complained to the agency manager that Lucy Lips, Ph.D., often divulged intimate details about her clients, using their real names, in the coffee lounge. The manager replied, “Don’t be so critical. We all work here and what these people don’t know won’t hurt them.”
The “bad barrels” argument holds that characteristics of an organization’s culture can inhibit ethical behavior, even among individuals with otherwise high moral standards (Trevino & Youngblood, 1990). Such characteristics include support for, and encouragement of, unethical behavior by management, widespread and unchecked unethical actions by colleagues, unjust organizational policies, and intense pressure to perform. Such characteristics cause painful conflicts for mental health professionals who hold high ethical and professional standards for themselves.
Ironically, therapists sometimes divulge their ethical infractions to one of their peers, sometimes without any awareness of having done so. More commonly, colleagues come for advice before a contemplated action occurs. More often than not, gaining your approval of the contemplated act is the primary motive for soliciting you as a confidant. In such situations, you have been presented with an exceptional opportunity to take part in upholding the integrity of the profession. You can set your colleague straight.
Ethical violations often involve colleagues whose conduct and professional judgment are affected by addiction, marital discord, physical difficulties or, more often, emotional problems (Katsavdakis, Gabbard, & Athey, 2004). According to a classic survey undertaken by the APA Task Force on Distressed Psychologists, almost 70% of the sample personally knew of therapists experiencing serious emotional difficulties. However, only about a third of them were believed to have made substantive attempts to help themselves (reported in VandenBos & Duthie, 1986). We estimate, from our own experiences sitting on ethics committees, that about half of the therapists with sustained complaints appear to have some personal turmoil or emotional condition that very likely contributed to the commission of an ethical violation.
In cases where a colleague appears generally incompetent, informal intervention will not resolve the problem. Such individuals rarely have insight into their shortcomings and can cause considerable harm to clients. However, if the incompetence seems restricted to a single technique or application that could benefit from either remediation or discontinuation, informal intervention remains a viable option.
Mental health professionals may be asked by a colleague or a client to assist in confronting an alleged violator, but the requester insists on concealing his or her identity. Often, such people fear reprisal or feel inadequate to defend themselves. Occasionally, a third person critical to pursuing the matter is unavailable or unwilling to become involved or to be identified. These situations pose extremely frustrating predicaments. Approaching colleagues with charges issued by unseen accusers violates the essence of due process. Furthermore, alleged violators often know (or think they know) their accusers’ identities anyway.
When the alleged unethical behaviors are extremely serious, possibly putting
others in harm’s way, and when the fearful but otherwise credible individuals
making the charges adamantly insist on remaining anonymous, therapists may not
feel comfortable ignoring the situation. However, there may be nothing
else that can be done. Sometimes, the option to do nothing may not exist, such
as with adherence to a state’s mandatory reporting laws. However, for other
reporting situations not required by law, there may be no options for resolutions
if confidentiality issues cannot be resolved.
A new client told Ima Current, Ph.D., that he had adverse experiences with his previous therapist. He claimed that Dr. Weary Brusque would sit for most of the hour saying nothing or browsing through a magazine or doing paperwork while the client spoke. When Brusque did occasionally respond, the client claimed he simply barked quick orders, such as, “Just cut off that relationship.” Dr. Current was acquainted with Dr. Brusque and thought him extremely odd. She wanted to attempt to discuss the matter with Dr. Brusque, but when she offered to intervene, the client became frantic and remained resolute in his refusal to be identified.
Dr. Current is stuck. She cannot completely discount the remote possibility that Dr. Brusque had attempted to apply some strategic or paradoxical principles with this particular client. She can, however, certainly educate the client about behavior normally expected of professionals and possibly help him gain strength to later follow through with a complaint, if that should become the client’s wish.
1. Before going ahead, make sure that you identify the relevant ethical principle or law that applies to the suspected breach of professional ethics. If no violation of law, relevant policy, or ethical responsibility has occurred, then the matter may lie outside the domain of ethics. Perhaps the colleague has an offensive personal style that feels unpleasant but does not rise to the level of ethical misconduct. Perhaps the colleague holds personal views that seem generally unpopular or widely divergent from your own. In such instances, you have the right, of course, to express your feelings to your colleague, but you should not construe doing so as engaging in a professional duty.
2. Assess the strength of the evidence that an ethical violation has occurred. Ethical infractions, particularly the most serious ones, seldom involve acts committed openly before a host of dispassionate witnesses. With few exceptions, such as plagiarism or the inappropriate advertising of professional services, no tangible exhibits corroborate that an unethical event ever occurred.
A starting point for this assessment involves categorizing the source of your information into one of five categories:
- direct observation of a colleague engaging in unethical behavior;
- knowing or unknowing direct disclosure by the colleague that he has committed (or is about to commit) an ethical violation;
- direct observation of a colleague’s suspicious, but not clearly interpretable, behavior;
- receipt of a credible secondhand report of unethical conduct; or
- casual gossip about a colleague’s unethical behavior.
If you observed unethical behavior, have clear evidence, or the colleague disclosed an unethical act, you have a professional responsibility to proceed in some way. Having a suspicion of unethical behavior without direct evidence, however, is likely to occur more often. Proceeding in this case may take more tact and feel more precarious, but if you have good communication with the colleague, we suggest carefully moving forward.
If you do not have direct knowledge, ask yourself about the credibility of your source of information. Reports by clients about previous treatment relationships can be difficult to evaluate, requiring clinical skills to assess the likelihood of accuracy based on factors such as the degree of psychopathology (Overstreet, 2001). If the information came by casual gossip, proceed with considerable caution. The motivations of those passing on the story, coupled with the exaggeration and distortion that always hangs heavy on “grapevines,” could cause a colleague unfair damage. If no way exists to obtain any substantial, verifiable facts, you may choose to ignore the information or, as a professional courtesy, inform your colleague of the scuttlebutt. If the colleague is guilty of what the idle hearsay suggests, this may have a beneficial effect. However, we recognize that this constitutes risky business and may prove effective only if you feel reasonably confident that you can anticipate the colleague’s reactions.
If you find yourself approached by a credible person who claims firsthand knowledge and seeks assistance to pursue the matter, we suggest providing as much help as you can. Because we advise mental health professionals to consult with colleagues before taking any action, it seems only fitting that you should reciprocate by reacting receptively when others approach you. You will likely be able to assist the person with a plan of action that will not include your direct involvement. On the other hand, if you feel that you cannot comment confidently about the dilemma, you might offer a referral. If you do agree to become actively engaged, make certain that you have proper permission to reveal any relevant identities and that your information is as complete as possible.
3. Get in close touch with your own motivations to engage in (or to avoid) a confrontation with a colleague. If you are (or perceive yourself to be) directly victimized by the conduct of a colleague, you will probably feel more disposed to getting involved and more likely to approach the matter without sufficient preparation. In addition to any fears, anger, biases, or other emotional reactions, do you perceive that the colleague’s alleged conduct—either as it stands or if it continues—could undermine the integrity of the profession or harm one or more of the consumers served by the colleague? If your answer is affirmative, then some sort of proactive stance is warranted. However, if you recognize that your emotional involvement or vulnerability (e.g., the colleague is your supervisor) creates an extreme hazard that will likely preclude a satisfactory outcome, you may wish to consider passing the intervention task to another party. In such cases, be sure to first settle any confidentiality issues.
4. We strongly recommend consultation with a trusted colleague who has demonstrated sensitivity to ethical issues, even if only to assure yourself that you are on the right track. “Fresh eyes” have a way of clarifying ambiguities, biases,and gaps in knowledge and ensuring coverage of all of the bases.
5. Avoid the easy outs. You may well find yourself tempted to engage in one or two covert acts as alternatives to confronting a colleague directly. The first involves casually passing the information along to others in an effort to warn them. Although informing others may provide a sense that duty has been fulfilled, this step will more likely only serve to diffuse responsibility. Idle talk certainly cannot guarantee the offending colleague will shape up or that improved public protection will follow.
The second temptation involves engaging in more direct, but anonymous, action, such as sending an unsigned note or relevant document (e.g., a copy of an ethics code with one or more sections circled in red). This approach also does not guarantee constructive results. The reaction to an anonymous charge may prove counterproductive, only assisting an offender in perfecting non-detection. A certain amount of paranoia may result, adding suspiciousness to the colleague’s character.
Another problem with both of these surreptitious approaches is that you might have gotten it wrong. The presumed violator may have been misjudged. To gossip or become a “mystery accuser” whom an innocent individual cannot identify imposes unfair stress and harm to the reputation of a colleague. Such tactics, if unwarranted, would constitute a moral failure on your part.
6. If you decide to go ahead with a direct meeting, schedule it in advance, although not in a menacing manner. For example, do not say, “A matter has come to my attention about you that causes me grave concern. What are you doing a week from next Thursday?” Rather, indicate to your colleague that you would like to speak privately and schedule a face-to-face meeting at your colleague’s earliest convenience. An office setting would normally be more appropriate than a home or restaurant, even if the colleague feels like a friend. We do not recommend attempting to handle such matters on the phone unless geographical barriers preclude a direct meeting. Letters create a record but do not allow for back-and-forth interaction and the observation of body language and contemporaneous emotion. We do not recommend e-mail for the same reasons, as well as the additional concern that electronic communications may allow unauthorized others to gain access.
7. Set the tone for a constructive and educative session. Do not take on the role of accuser, judge, jury, and penance dispenser. The session will probably progress best if you view yourself as having an alliance with the colleague. Such a partnership would not proceed in the usual sense of consensus and loyalty, but rather as a collaborative effort between colleagues attempting to solve a problem together. Remember, what you think you know and what is actual fact may be two different things.
8. When entering the confrontation phase, remain calm and self-confident. The colleague may display considerable emotion. Remain as nonthreatening as possible. Even though it may feel like a safe shield, avoid a rigidly moralistic demeanor. Most people find righteous indignation obnoxious and it may thus prove non-productive. We suggest soothing language, such as expressing confusion and seeking clarification. It might go something like, “I met a young woman who, on learning that I was a therapist, told me that she was your client and that the two of you were going to start dating. I thought we should talk about it.” Things are not always as they seem. Social comparison research has shown that people tend to view others as less ethical than themselves and as less ethical than they actually are (Halbesleben, Buckley, & Sauer, 2004). It will always prove wise to allow an explanation at the outset. For example, you may learn that the young woman was a client of your colleague, but only briefly and several years earlier. Such responses may not render the matter entirely moot, but the discussion would likely proceed far differently than had you stormed into the meeting spouting accusations knowing only one version of the story about which you made a mistaken assumption.
9. Describe your ethical obligation, noting the relevant moral or ethics code principles that prompted your intervention. Do not play detective by attempting to trap your colleague through leading questions or withholding any relevant information that you are authorized to share. Such tactics lead only to defensiveness and resentment, thus diminishing the possibility of a favorable outcome.
10. Allow the colleague ample time to explain and defend her position in as much detail as required. The colleague may become flustered and repetitive. Be patient.
11. If you are intervening on behalf of another, you will first have to disclose why you are there and offer any other caveats. You might say something like, “I, myself, have no direct knowledge of what I want to discuss with you, but I have agreed to speak with you on behalf of two of your (named) supervisees.” Your role in such instances may involve arranging another meeting with all of the parties present and possibly serving as mediator during such a meeting.
12. If the colleague becomes abusive or threatening, attempt to steer the person to a more constructive state. Although many people need a chance to vent feelings, they may settle down if the confronting person remains steady and refrains from becoming offensive in return. It is important that the person feels that they have been heard. If a negative reaction continues, it may be appropriate to say something calming, such as, “I see you are very upset right now. I would like you to think about what I have presented and, if you would consider talking more about it, please contact me within a week.” If a return call does not follow, consider other forms of action. This could involve including another appropriate person or pressing formal charges. It would probably prove wise to have another consultation with a trusted colleague at this point. You should inform the suspected offender, in person or in a formal note, of your next step if you plan to take more formal action.
We conclude by being forthright about conditions under which attempting an informal resolution with a colleague may not be a sound option. In some jurisdictions, you may have a legal obligation to report certain types of misconduct to the authorities. Such requirements preclude informal options. Other possible contraindications include:
We know of rare instances of threatened physical harm, retaliation, or legal action for harassment and slander against therapists who attempted to deal directly with the ethical misconduct of their colleagues.
When informal intervention does not appear to be an appropriate action, yet the colleague’s behavior has caused harm to others, especially if the behavior is likely to be repeated, we strongly encourage pursuing an appropriate means of addressing the matter. This could involve reporting the incident to one’s supervisor, the ethics committee of a professional organization to which the individual belongs, or a licensing board.
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