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 terms “therapist” or “mental health professional” 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 mental health professionals to gain 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.
Human service practitioners will have no choice but to make decisions with possible ethical consequences at some point in their career. The decision could be about your own conduct or about that of another. Some decisions will be easy because the guidelines are clear and the matter itself is inappropriate but no harm will likely result. Others may be more difficult because the guidelines or circumstances are unclear and the wrong decision could carry consequences for others or yourself. Every now and again an issue of monstrous proportions may surface that affects you directly. For example, a client unexpectedly commits suicide or threatens or sues you, or a colleague damages your reputation. You may confront a situation that offers no choice but to make decisions with ethical implications under ambiguous circumstances.
Your own life may feel out of control (e.g., messy divorce, severe economic downturn, or addiction). Confusion, pressure, frustration, anxiety, conflicting loyalties, insufficient information, and the tendency to rationalize are common responses to ethical challenges at these times. Such reactions complicate matters and greatly elevate the chances of errors in decision-making. Intense stressors can result in an inability to make sound judgments (Advisory Committee on Colleague Assistance, 2014).
Even when our lives seem fine, ethical dilemmas can materialize in many ways, often abruptly when we least expect them. Of course, most therapists 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.
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. (Note 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.
Earlier work, including some of our own, focused heavily on step-by-step prescriptions for arriving at a decision most likely to lead to the “best“ ethical outcome. More recent writings stress how factors such as emotions, personal vulnerabilities, personality, and situational contexts influence how we make decisions, including ethical ones. Newer work also stresses the insufficiency of cognitive strategies to determine how decisions are made and how many nonrational factors affect our decisions (e.g., Rogerson, Gottleib, Handelsman, et al., 2011; Tjeltveit & Gottlieb, 2010). As we emphasize throughout this lesson, an early recognition of personal and situational risks can prevent many potential ethical problems from materializing or from escalating to the point of causing harm.
We do not wish to frighten readers, but we must communicate why ethical decision-making is more critical than ever to you as a practitioner. Not that long ago complaints were handled in confidential forums. Few avenues existed for the general public to discover the misbehavior of mental health professionals. Clients had few avenues for speaking out when they believed they had been wronged. In short, those who faced ethical sanctions were largely hidden from public scrutiny. Violators more easily dodged widespread humiliation and perhaps escaped long-term damage to their careers. All that has changed.
More likely than not, the identities of those who incur a formal ethical violation are now available for public viewing on the Internet. Many professionals and state licensing boards publish the names of those who have been disciplined (sometimes including the entire record). Sites are devoted exclusively to “outing” those mental health clinicians who have been found guilty of ethical improprieties, and some sites offer retroactive accounts going back 20 years or more. Sometimes the information the public can access gives excruciating detail and sometimes only the numerical designation of the violated principle is offered, leaving the exact nature of the unethical act up to the reader’s imagination. Regardless, “cyber scarlet letters” are assigned permanently. In addition, unhappy and disgruntled clients have access to a host of popular review sites that offer relative anonymity. Guilty and the merely misunderstood or completely innocent can receive devastating social media criticism or “one star” reviews that can negatively impact careers. In response, a lucrative and pricey “reputation repair” industry has sprung up, but it is very difficult to get a negative review removed unless the site’s content policy has been violated (Chamberlin, 2014). Sometimes the best one can do is to attempt to smother it by attracting more positive reviews.
Finally, as reports of ethical violators become easily accessible, public trust in the mental health professions erodes. A supplement by the U.S. Center of Disease Control (Reeves, Strine, Pratt, Thompson, Ahluwalia, Dhingra, et al., 2013) reports that mental illnesses account for a larger proportion of disability than any other illness grouping, including heart disease and cancer. Approximately 25% of adults have a mental illness and nearly half of adults will develop at least one mental condition during their lifetime, with anxiety and mood disorders accounting for the most common diagnoses. Up to 20% of children and adolescents have a mental disorder in any given year, with mood disorders and attention-deficit/hyperactivity being the most common diagnoses. A desperate need for competent and ethical mental health professionals is obvious, but if potential consumers have a negative image of mental health professionals they may refrain from seeking needed help.
This course will not provide answers to every ethical dilemma, nor can it advise on every circumstance in which an ethical dilemma arises. Rather we strive 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.
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 is very young and new to this country. She is proving difficult to engage. She was brought in by her American-born husband because she seems secretive. She mostly sits sullenly looking down into her lap, answering your questions using the fewest possible words. When she does look up, her expression is disturbing. She does divulge that she is very unhappy. You find her flashing eyes, her odd clothing, and her foreign accent somewhat intimidating. Actually, she scares you a little. It has even crossed your mind that she could be a sympathizer to an unfriendly group.
Are you overreacting? Would you terminate her? 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? Do you have a reasonable understanding of her native culture? Could your continued treatment of her have any chance of being effective?
Your high-spirited client, an ambitious realtor, enters your office, pulls a bottle and two shot glasses from her purse. She quickly pours drinks while announcing that she just sold a three million dollar home. Before you can respond, she bounces over, puts her arms around you and plants a kiss on your lips.
So, what are you going to do? Her arms are already around you, so what do you do with them? Should you just move on and share a drink, or is that a bad idea as well? Might she be seductive? Or is she only in a very good mood today? Can you tell the difference?
Is The Session Over Yet?
After 5 months, despite your efforts to remain objective and compassionate, you dread seeing this client. He refers to women, including his girlfriend, as “bitches.” He burps constantly and has an annoying habit of scratching his forehead every few minutes. He also calls you by your first name, which you have not invited him to do. Your dislike for him is increased after every session despite the fact that he seems to be improving in the areas for which he sought counseling.
Did you let this fester for too long? Can you do anything to alter your negative feelings? Should 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 appreciation for your 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 move her forward? Can this be accomplished without leaving the client feeling abandoned?
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 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. 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 not sure if you remember correctly, but early on she may have divulged that she owns a gun.
Is your client just releasing tension, 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 somewhat 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 each one played out. The “Scary Woman,” turned out to be a shy and frightened woman who wanted desperately to return to her family in her country of origin. The newly licensed therapist's own cultural ignorance and fear-based judgments led to a misguided decision. He called the husband to try to get more information about why she was so unhappy. The husband seemed irritated and hung up. The client never returned, and the therapist soon read in the local newspaper that she had been badly beaten by her husband and may not survive.
“Let’s Party” was the spark that eventually led to a sexual relationship followed by the client charging abandonment when the therapist broke it off. This therapist eventually lost his license.
“Is This Session Over yet?” ended poorly. The therapist, who had sandbagged his feeling towards the client he disliked exploded into a rage when the client pushed his buttons one too many times. The therapist then insisted he leave the office and told him to never return. The client contacted an ethics committee and posted a devastating online review, claiming the therapist had “uncontrollable anger issues and may be dangerous.”
The client in “Letting Go” continued therapy for another 5 months, then lost her feelings of enchantment towards the therapist after entering into a relationship with a controlling man who insisted she quit therapy because it was “not good for her.” The client ended up telling everyone in the small town that the therapist never helped her despite being in treatment for so long.
“All in the Family” destroyed the sibling relationship. When the disgruntled sister believed her daughter was not improving, she accused her sister (the therapist) of being interested only in the $150 per session fee.
In the actual “Wild Eyes” case, the therapist felt ambivalent about what he should do, It was getting dark out and he and was running late for a birthday dinner with his wife and children. He decided against following after her to talk things over, warning the boyfriend, or intervening in any other way based, as he later would tell a licensing board, on her “occasional bursts of “drama.” The client did shoot her boyfriend 6 times, causing substantial nonfatal injuries.
It seems fitting to quickly review underlying values and virtues that should guide ethical decision-making. These same elements are expressed in the ethics codes of all major mental health professions.
Although we may all strive to behave correctly and do good, a gap often exists between the ideal outcome and what can realistically be accomplished. We acknowledge upfront 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 keen ethical and self-awareness.Below are the core principles we believe should serve as an overall guide to the behavior of mental health professionals:
The stereotype of the “unethical mental health professional” is outright unsavory. At times, some therapists willfully, even maliciously, decide to engage in acts they know to be in violation of ethical and legal standards. Or sometimes we can just scratch our heads and ask ourselves, “What was the therapist thinking?” Below are a few actual examples:
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 psychologist used the services of a sex worker, but had insufficient cash to pay her fee. He left his laptop computer containing over 600 unencrypted client files from his employing agency as collateral while he went to find an ATM. When he returned 15 minutes later, the prostitute and the laptop were gone. The psychologist reported the theft without mention of the associated sexual activity, but eventually replaced his initial false account with the correct one. The laptop was recovered from a pawn shop. Nevertheless, the psychologist lost his job, and his license to practice was suspended pending further investigation.
Thankfully, such extreme cases are exceedingly rare and suggest at the very least an inadequate moral foundation. In our experience, the more prevailing portrait of the therapist 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.
1. The Unaware or Misinformed. 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. Sometimes the violation is minor and due to inexperience, but even seasoned therapists can lose touch with the professional standards governing their practice. It is of critical importance to keep up with the ever-changing landscape of professional practice. Ethics committees, licensing boards, and the courts do not consider ignorance an adequate defense.
When questioned by an ethics committee about a sexual affair with a client he had terminated only 3 months earlier, the therapist wrongly asserted that the ethics code of the American Psychological Association specifically allows sex with former clients.
2. The Incompetent or Undertrained The misconduct of mental health professionals can arise from an incapacity to perform the services being rendered as a result of inadequate training, lack of skill, or both. Sometimes emotional disturbances or substance abuse 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 sophisticated techniques or specialized 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. When the supervisor asked the therapist to detail her background, in psychodiagnostic testing she admitted having virtually no training or experience in these specific assessments, but was doing some reading on the topics and believed she was “picking up speed” as she went along.
3. The Insensitive. 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 individuals or groups. Often, such insensitivity precludes recognizing that an ethical issue even exists.
A therapist was usually late for therapy sessions. When a single mother of four young children complained how she didn’t like waiting for up to an hour because it threw off her schedule, he responded, “You don’t have a job, so what difference does it make?”
4. The Exploitive. 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.
The young client was attractive and appreciative. The therapist was going through a difficult divorce. When the therapist suggested they become more than client/therapist, the client felt flattered. They started by having lunch after every appointment, then dinners, and finally retreats to a local motel. The sexual activity was not as exciting as she expected it to be. She felt disillusioned and guilty about having sex with a still-married man, quit therapy, and contacted a licensing board.
5. The Irresponsible. Irresponsibility can result from laziness, stress, lack of awareness, or other reasons that divert attention from professional responsibilities. 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.
As a client’s symptoms became increasingly severe, the therapist felt uncomfortable treating her. He informed the client that he could no longer counsel her and she would need to find another therapist. When the client asked for an explanation, the therapist only replied, “I have my reasons.”
6. The Vengeful. Cases of mental health professionals who have sought revenge on a colleague, a client, or others who they perceive as having done them wrong are not common and seldom make their way to ethics committees, licensing boards, or to the courts. However, some outraged mental health professionals have allowed their emotions to supersede professional judgment, and charges of defamation have been upheld. 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, such as sending angry emails. Impulsively vengeful therapists often feel remorseful and foolish later and frequently apologize for their loss of control. Unfortunately, damage may have already occurred because the impact of such outbursts cannot always be fully rectified.
A mental health professional working in a research university gathered strong circumstantial evidence that his colleague and professional rival stole research notes from her lab. The researcher was later seen releasing her colleague’s laboratory rats in the university’s botanical garden.
7. The Self-Serving Rationalizers. 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). Rationalization often operates under subtle and seemingly harmless circumstances, sometimes in order to justify inaction or convenience. The work of Merritt, Effron, & Monin (2010) revealed that people can engage in what they call “moral self-licensing.” Past good deeds can liberate us to commit acts that are immoral, unethical, or otherwise problematic, behaviors we would otherwise avoid for fear of feeling or appearing to be immoral. Another intriguing finding with decision-making ramifications is how the time of day influences moral judgments. Kouchaki and Smith (2013) report that study participants engaged in less cheating and lying on a series of tasks in the morning than on the same tasks in the afternoon, perhaps because fatigue lowers our “ethical standard thresholds.” 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.
A therapist volunteered two mornings a week at a local women’s shelter. She also visited her elderly mother in a nursing home 50 miles away every Saturday. When a new client claiming to be in the “high end computer business” offered to give her a high-end computer and all the accessories, she graciously accepted while telling herself, “I deserve this.” The client turned out to be a deeply troubled thief. When apprehended several weeks later the client claimed that he had a partner and, as proof, reported that one of the stolen items was in her office.
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.
8. Therapists without Boundaries. Role-blending accounts for a large proportion of the most inappropriate or mindless decisions that therapists make. Boundaries become especially thin in the presence of self-serving circumstances and, if not perceived and reversed in time, cross a line. While recognizing that it is impossible to avoid all boundary crossings and that not all are unethical or harmful (and some may even be helpful), therapists who are unaware, rationalizing, or malintentioned can inflict considerable harm to those with whom they work. Whether this is the result of ignorance, self-absorption, avarice, neediness, or a mental condition is not always clear.
A therapist saw his clients as friends and often took them to dinner, gave them gifts, and enjoyed telling them his personal life stories. When a wealthy client refused the therapist’s request for a business favor because, as the client put it, “that would jeopardize my relationship with my boss,” the therapist berated him for his selfishness and accused him of taking advantage by accepting dinners and gifts.
9. The Burned-out, Vulnerable, or Otherwise Impaired. 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.
A therapist became frustrated with the lack of progress in many of his clients. He quit taking any notes, resulting in his inability to keep track of what transpired during previous sessions. At home, he was caring for his ailing mother while also trying to keep two rebellious teenagers from getting into trouble. One client quit and complained to an ethics committee that the therapist did not seem to know anything about her issues, and sometimes even called her by the wrong name, despite having been her client for 9 sessions.
10. Therapists Who Momentarily Slip. 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. For example, confidential information may slip out. Sometimes, as the result of immediate situational demands, therapists commit acts with unintended consequences, such as revealing too much about their own personal life that ends up backfiring. 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.
A client in acute distress called his therapist to ask for an appointment as soon as possible. The therapist scheduled the client for 6 p.m., right after her last session. The regularly scheduled client left at 5:45 and the now-hungry therapist engaged in her usual routine and went right home. The client arrived to find no one in the office, scrawled a note and shoved it under the door that read, “No one, not even you cares.” The Client made a suicide attempt later that evening.
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; Knapp, Younggren, VandeCreek, Harris, & Martin, 2013; 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 a risk management, perspective 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 a very strong risk-management perspective might also choose to 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 too many mental health professionals hide out in a safe zone?
Of course, mental health professionals should pay attention when a client’s behavior suggests that transferences 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 and 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.
Part of vigilance is attending to red flags. Not every item in Table 1 (adapted from Keith-Spiegel, 2014) is necessarily unethical or leads to an unethical outcome. For example, it is possible for bartering to work out in a way that satisfies the client and avoids the potential risks of exploitation or contraindication. Therapists are human and may find themselves sexually attracted to clients. The ethical issue will be how those feelings are dealt with. However, whenever one of these flags waves, one should pause to evaluate the next step.
Table 1 - Red Flags: Proceed with Caution
Wishing For a Different Relationship from Client/Therapist
|Rationalizing the Acceptability of a Contemplated Boundary Crossing or Deviations from Standard Practice|
|Concerns about Personal Ambition and Financial Gain|
|Needs to Enhance One’s Own Self-esteem|
Expecting the Client to Fulfill your Personal or Social Needs
Fear of being Rejected or Client Terminating Therapy for Financial or Other Reasons
Negative Feelings Toward a Client
Signs that the Client is the More Powerful Individual in the Relationship
Personal Life Contamination of Professional Performance
General Red Flags
Table 2 is designed to help assess whether blending roles should even be considered. We adapt from the ideas of many others as well as our own observations and research. Most risks can be evaluated along a continuum as opposed to the dichotomous scheme we present here, and each situation has its own idiosyncrasies requiring assessment before acting. However, if a clear-headed reflection tends toward the “more risky” column, we advise considerable caution before crossing a boundary.
Table 2: Evaluating Additional Roles with Clients
Basic Considerations Regarding Added Role Dimensions
|Unclear whether an added role would be wise||Clear indications favoring an added role|
|Current level of client’s dependency needs||High||Low|
|Blending is necessary or indicated||No||Yes|
|Low or unknown||High|
|Likelihood of client confusion||High||Very Low|
|Potential for conflict-of-interest||High||Absent|
|Conflicted / no time specifiable||Mutual / Satisfactory|
|Considerable||Very small; negligible|
|Beginning practitioner||At least one year of active, independent practice|
|Not likely||Very likely|
Alert, well-meaning, sensitive, mature, and adequately trained therapists functioning within their bounds of competence will 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.
Unforeseen Dilemmas. 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. (These will be further discussed in an upcoming section.)
Inadequate Anticipation. A therapist may understand a potential 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.
Unavoidable Dilemmas. 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.
Unclear Dilemmas. In a variation of the inadequately 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 an innovative or controversial therapeutic techniques, for example, becomes problematic because the risks, if any, are simply unknown.
Inadequate Sources of Guidance. 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.
Loyalty Conflicts. 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 constituent simultaneously.
Conflicting Ethical Principles. When making ethical decisions, a thorny dilemma arises when one moral principle conflicts with another. Which one takes precedence? The values listed 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: having sufficient time for the systematic collection of all the pertinent information necessary to plan the appropriate strategies, consultation, intervention, and follow-up; properly identifying the person(s) or entity(ies) to whom one owes primary allegiance; taking the opportunity to involve all relevant parties; operating under low stress and with a mindset that maximizes objectivity and self-awareness; and being able to maintain an ongoing evaluation that allows for midcourse corrections or other changes to satisfactorily resolve the dilemma (adapted from Babad and Salomon (1978).
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 any ensuing damage will not materialize right away.
Because professional ethics codes are general proscriptive guidelines that cannot inform us of how to deal with specific ethical dilemmas and their associated variables, 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. Sometimes outcomes will remain unsettled no matter how hard one tries to resolve them. However, therapists who can document a sustained effort to deal with the dilemma, including well-reasoned accounts of their decision-making rationale, will have a distinct advantage should their 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 your 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 (2007) Blink, 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. The overarching ethical issue 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 might 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 can sometimes 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 appropriate. Sometimes this step reveals a simple misunderstanding that 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 decision-making 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 you 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/psychiatrists/practice/ethics
4. Pause to consider, as best as possible, all factors that might influence the decision you will make. As we have been stressing throughout, 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 clients. 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. It is helpful to learn the fundamental values of cultures and religious orientations other than one’s own (see Houser, Wilczenski and Ham,2006) while avoiding the assumption that a specific client is going to reflect the same world view. Unwarranted and possibly poor decisions could follow from believing everyone from a certain culture or group is pretty much alike.
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. 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 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.
A therapist treated an alcoholic single mother of two, for 18 months. The client had remained sober for more than a year, and had made sincere efforts to attend effectively to her children, now ages 6 and 8. 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, the therapist would be obligated to breach the client'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. The therapist could, however, go a step
further by attempting to engage the client in collaborating in filing the report,
and by attempting to engage the authorities in assisting the family while the client 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.
Callahan (2009) notes that behavioral emergencies and crises are often described as interchangeable, and yet distinguishing the two has relevance for how decisions are made. A behavioral emergency requires an immediate response and intervention to avoid possible harm to the client or someone else. Behavioral emergencies include suicidal or violent behavior or interpersonal victimization. The client’s status must be evaluated, followed by an intervention and a plan to move forward. Interventions can range from the simple, such as nonjudgmental listening, to ordering inpatient hospitalization. Crises, on the other hand should be reserved for an external event that causes a loss of psychological equilibrium leading to an individual’s difficulty with coping. These may range from more commonplace events causing anxiety or stress to trauma resulting from a life or death situation. In these types of crises the individual may reach out for, or at least welcome, assistance.
Behavioral emergencies often involve little time to reflect 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. It is even possible that the anxiety may encourage decisions that are self-serving, protective, or even unethical (Kouchaki & Desai, 2015).
Mental health providers rank high among the professionals vulnerable to ethical and legal quandaries when making decisions and acting under behavioral emergency conditions (Hanson, Kerkhoff, & Bush, 2005). These conditions pertain when therapists are concerned about a client’s condition (especially if information is incomplete), or when the best course of action is unclear, or when the situation is emotionally charged, when time is of the essence, and when stakes are high should a negative outcome result (Kleespies, 2014). Both coping and decision-making skills must be brought to bear (Sweeny, 2008).
The cases below involve instances wherein something terrible is, or appears to be, in progress.
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 the above cases, despite the fact that, in the process, reporting might violate a confidence. In the second 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 behavioral emergencies 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 two 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.
As both cases demonstrate, an incident 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).
Regardless of the nature of the actual or impending emergency, 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, behavioral emergencies and 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. The case of the child about to run away from home provides an example 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 girl has not yet left home.
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 rare 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 & Sullivan, 2013; 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. (Kleespies, 2014).
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 or behavioral emergency 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 therapist 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.” The therapist 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 therapist 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. The therapist 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 therapists in their own work with clients. However, mental health professions remain strong when its members take action when the unethical behavior of others is observed. Unethical activity often persists, totally unchecked, unless someone takes notice and intervenes. Action can be taken directly by confronting the colleague and perhaps working though a solution, 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 incidents 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: (1) colleagues have specialized knowledge about expectations of members in the field, (2) colleagues are in an advantageous position to observe or hear about unethical behaviors among peers, and (3) colleagues may be able to prevent ethical infractions from ever materializing.
Many questionable acts will not be repeated once the colleague understands or receives insight into why an act was wrong. However, when a colleague willfully and knowingly engages in professionally irresponsible or unethical behavior, intervention becomes more demanding, uncomfortable, and worrisome. This takes personal courage; we will attempt to assist you with the process at the end of this lesson.
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. 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 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, Gabbet al., 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 his therapist that he had adverse experiences with his previous therapist. He claimed that the previous therapist would sit for most of the hour saying nothing or browsing through a magazine or doing paperwork while the client spoke. When the previous therapist did occasionally respond, the client claimed he simply barked quick orders, such as, “Just cut off that relationship.” The current therapist was acquainted with the client’s previous therapist and thought him extremely odd. She wanted to attempt to discuss the matter with him, but when she offered to intervene, the client became frantic and remained resolute in his refusal to be identified.
The current therapist feels stuck. She cannot completely discount the remote possibility that the client’s previous therapist had attempted to apply some type of strategic or paradoxical intervention 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:
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 his or 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 emotional or defensive in return. It is important that the person feels that he or she has 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 other appropriate means of addressing the matter.
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