AVOIDING COMMON ETHICAL DIFFICULTIES: HOW TO ENHANCE ETHICAL AWARENESS WITH SOME PRACTICAL SUGGESTIONS: PART II

Below are ideas about how practitioners may avert common ethical dilemmas. Previously published in THE SPECIALIST (07/2018 - published by ABPP) and on the IPA Website BLOG (02/2019) were some thoughts about UNDERSTANDING WHAT CONSTITUTES A MULTIPLE RELATIONSHIP and IDENTIFY YOUR CLIENT AND YOUR ROLE.

1. RESPECT AUTONOMY

Psychologists need to provide clients with information needed to give informed consent at the beginning of treatment. When details are not given, difficult situations may arise. For example, when psychologists fail to explain their duty to report abuse and neglect to an adolescent client before psychotherapy begins, they may be unsure what to do if abuse is later revealed that the client does not want reported. Points to discuss with the client include: + Limits of confidentiality, such as mandatory reporting. + Nature and extent of the clinician’s record-keeping. + The clinician’s expertise, experience, education and training as well as areas where the psychotherapist lacks training. + Estimated length of psychotherapy. + Alternative treatment or service approaches. + Fees and billing practices. + Whom to contact in case of emergency. + Client’s right to terminate sessions and any financial obligations, if that occurs. + Services the psychologist will provide, and those not offered. If individuals are not competent to make decisions for themselves, then the person who is giving permission must have access to that same information. Moreover, a signed consent form does not substitute for the informing process, which should occur first, and that includes situations where informed consent is implied, such as in an employee evaluation.

2. KNOW THE DIFFERENCE BETWEEN ABANDONMENT AND TERMINATION

Psychologists may discontinue treatment when clients: + Are not benefiting from psychotherapy. + May be harmed by the treatment. + No longer need psychotherapy. + Threaten the psychotherapist, themselves or others. Psychologists should provide pre-termination treatment and suggest alternative providers. This may not be possible in all cases, such as if a client abruptly stops attending sessions. Such pre-termination discussion may include explaining the benefits of the new service and why the current treatment is no longer helpful, addressing feelings of separation by emphasizing the transfer is not a personal rejection and identifying practical issues in transferring the client, such as making financial arrangements with a new provider before ending treatment. Involve the client in the plan. Empower them to feel confident and competent. Help the client understand that the transition is a constructive step toward achieving their goals. By contrast, abandonment occurs when a psychologist inappropriately ends treatment, such as halting needed psychotherapy with no notice.

3. STAY WITH THE EVIDENCE

When you give an expert opinion, or conduct an assessment, base your evaluation only on the data available. For example, psychologists in child custody cases should be certain they are not biased in favor of the parent who is more financially secure. The best approach is to stay mindful about what one knows, what one does not know and what have been the sources of information. Some suggestions include: + Know the referral question(s) and choose assessment tools to validly answer question(s). This means psychologists need to read and understand test manuals. For example, personality tests appropriate for clinical use are not necessarily appropriate for employment selection. + Do not rely on third-party reports to formulate assessments and avoid giving an opinion of any person not directly evaluated. + Make certain the assessment is thorough. Do not give an expert opinion without consulting all sources available. For example, a psychologist conducting a custody evaluation fails to check with child protection services and therefore does not learn that one parent is being investigated for child neglect, a fact that may have changed the opinion of the psychologist. + Discuss the limitations of one’s work and make statements about the certainty of the findings. It is equally important to offer any plausible alternative hypothesis that would account for the data. In court cases, where the facts may be disputed, one may describe the contradictions between the two parties and then make a set of recommendations based on each party’s side of the story, leaving it to the court to decide the truth. + Ensure that tests were developed for the target population and that they are culturally appropriate. If not, make the proper adjustments and note the limitations of those adaptations in the findings.

4. SUPERVISORY RESPONSIBILITIES

Supervising psychologists should continually assess the competence of those they supervise and make certain they are doing what is appropriate. If a document is sent under the supervisor’s name, the supervisor is responsible. A client is not going to sue the receptionist/secretary, or the supervisee, but will sue the supervisor. Supervisors should also: + Establish timely and specific processes for providing feedback, and provide information about these processes at the beginning of supervision. + Outline the nature and structure of the supervisory relationship, in writing, before supervision begins. Include the responsibilities of both parties, the nature and frequency of the supervision and other key aspects of the supervisory relationship. + Document their experience with the supervisee, including supervision dates, discussions and other relevant facts. Such information will help if ethical dilemmas arise later. + Explain to clients that the psychotherapist is in training and give clients the name of the supervisor. Note that billing may be under a supervisor’s name, not the supervisee, so that clients do not accidentally report billing problems when there are none. + Avoid delegating work to people who have multiple relationships with the client that would likely lead to harm or the supervisee’s loss of objectivity. For example, avoid using a non-English speaking person’s spouse as a translator. 

Below is a summary of an interesting and insightful article from the MONITOR ON PSYCHOLOGY, April, 2019, pages 70-73.  It is written by Chris Palmer (Staff Writer for the MONITOR) and is titled, HOW TO MENTOR ETHICALLY.

1. PREPARE

• Before becoming a mentor, consider the time, energy and emotional capital that you will need to support a trainee’s academic and professional growth. 
• Mentoring can take many forms, including helping students choose coursework, overseeing research projects, providing emotional support and helping trainees build networks and find jobs.
• Even experienced mentors have to be honest with themselves about the limits of their mentoring capabilities.  

2.  MANAGE EXPECTATIONS

• Be clear with yourself and your potential mentee about the parameters of the relationship. 
• Clarify how long the mentorship will last, how often you will meet, the amount of time you are prepared to offer and what is expected from the relationship.

3.  BE INCLUSIVE 

• It is ethically imperative to mentor diverse students, not just those who are similar to yourself.
• Cross-gender, cross-race and cross-sexual orientation mentoring relationships can be effective and productive.
• To reach out, attend conferences hosted by diverse organizations.
• Find ways to reach-out to the shy and/or underperforming students.

4.  PROTECT MENTEE’S PRIVACY 

• Create an atmosphere where a mentee feels safe to divulge fears, concerns and failures.
• Remain mindful that mentor-mentee communications are not privileged in a legal sense, nor confidential in the sense of psychologist-client communications. 
• A mentor has a responsibility to register serious concerns about a mentee’s competence, both with the mentee and with clinical training leaders, if in such a setting.
• Ongoing discussions with your mentee about how you plan to protect privacy, while also insuring that competence concerns are addressed, may help mitigate any surprises for the mentee.

5.  MAKE SURE THE MENTEE GETS DESERVED CREDIT 

• If mentoring a dissertation or a thesis, the student should be the first author.
• If a mentee has a wonderful idea and the mentor is taking credit or writing a paper about the idea without including the student, it is potentially exploitative. 
• Even when mentors give their hard-working proteges all the credit they deserve, there is a danger that mentees may be exploited in terms of the amount of work they are assigned.

6.  MAINTAIN BOUNDARIES

• Avoid blurring the boundaries of the relationship and having it morph into the inappropriately personal.
• Avoid being a mentee’s friend, therapist or sexual partner.
• Warning signs for mentors include finding themselves thinking about and looking for opportunities to spend more time with the mentee and making very personal disclosures. 
• Be careful not to abruptly withdraw and leave the mentee wondering if they did something wrong. 
• Do not burden or confuse the mentee by sharing any feelings of personal attraction. 
• Seek consultation with a trusted colleague, discuss appropriate options for keeping the mentorship professional and helpful for the mentee or, if necessary, devise a process for gracefully transferring the mentee to a different mentor.

7.  MINIMIZE MULTIPLE ROLES

• A power differential may be problematic if the mentor also serves as an advisor, supervisor and/or classroom instructor. The mentor should ensure that other professionals fulfill these important roles in the education of a mentee.
• Mentors have an obligation to avoid engaging in multiple relationships that could impair their objectivity and thereby risk exploitation or harm to their mentees.

 8.  ADVOCATE BUT EVALUATE

• You do not want to overlook opportunities for development of the mentee if your mentee is experiencing problems.
• Mentors need to take seriously their responsibility to vet and prepare mentees for the sake of current and future clients and agencies for which they may be employed in the future. 
• Intentional ethical mentoring requires self-awareness and a focus on the best interests of the mentee. 
• Modeling ethical behavior in the context of a personal developmental relationship may pay dividends by inspiring mentees to care for the ethical commitments and aspirations of their profession.

 

 

IPA ethics committee is comprised of five clinical psychologists and the Executive Director of IPA. The committee meets on a monthly basis. Since the last reporting period there has been one inquiry regarding an ethical issue.  The committee over the last two months has primarily been involved in creating its presentation at the annual convention on ethics. In addition there is an Ethical Hip Tip on management of obsolete electronic files that should be available to membership in the near future. The Ethics Committee when not preparing for the annual convention and reviewing ethical calls is the process of updating its policies and procedures.

AVOIDING COMMON ETHICAL DIFFICULTIES: HOW TO ENHANCE ETHICAL AWARENESS WITH SOME PRACTICAL SUGGESTIONS 

By being aware of foreseeable potential conflicts, and discussing them frankly with colleagues and clients, practitioners may evade misunderstandings, hurt feelings and difficult situations that lead to hearings before licensing/ethics boards, lawsuits, suspension/revocation of license, loss of professional membership or other dire consequences.   

Incorporate ethics by asking, “How may I be even better in my practice?”  Good ethical practice is good professional practice, which is good risk management practice.  When in ethical quandaries, it is often because one unwittingly slid too far down a slippery slope, a result of ignorance about ethical obligations or thinking one could deal with a situation that spiraled out-of-control.

Many problems are situations that develop gradually, moving step-by-step beyond what were once initially firm professional boundaries.  Although each step seemed harmless at the time, many practitioners later realize that they have landed themselves in deep trouble.

Below are ways practitioners may avert two common ethical dilemmas.

UNDERSTAND WHAT CONSTITUTES A MULTIPLE RELATIONSHIP 

Is it ethical to volunteer at your daughter’s softball team fund-raiser, if you know a client is going to be present?  Should you purchase a vehicle from a client who owns the only dealership in your small, rural town?  Should you ask an intern to drive you to the airport?  A central question in any multiple relationship situation is, “Whose needs are being met?”  Whenever the answer pertains to the needs of the psychologist, it is a time when the psychologist needs to take great care and obtain a consultation.

According to the APA Ethics Code, psychologists should avoid relationships that could reasonably impair, exploit or harm performance.  Multiple relationships without such effects may not necessarily be unethical.  When weighing the pros and cons in situations, think about three factors:

• POWER.  How much of a power differential is there between the psychologist and the other person?
• DURATION.  Will contact be brief, continuous or episodic over a long time?  Before entering into a dual relationship psychologists should consider whether, for example, a client could return for additional services.
•   TERMINATION.  Has the therapeutic relationship been permanently terminated with mutual understanding by the client?  If a psychologists treats clients with a chronic mental illness, treatment could stop and start for years, thus precluding some relationships that may be all right otherwise.

It is only an ethical problem when there is reason to predict a foreseeable risk and the psychologist fails to see it, ignores it and/or goes forth anyway.  If psychologists find, despite their efforts, a potentially harmful multiple relationship has arisen, they are ethically mandated to take steps to resolve it in the best interest of the person or group while complying with the Ethics Code.

Never permissible are sexual relationships with current clients.  While sexual relationships with previous clients are not automatic violations if they occur more than two years after termination of psychotherapy, psychologists need to be mindful of the harm that may come from a sexual involvement with a client no matter when it occurs. 

 IDENTIFY YOUR CLIENT AND YOUR ROLE 

When practicing psychologists work with organizations or groups of individuals, they should understand from the beginning who they were hired to help and what is expected of them.  Dilemmas arise in a variety of situations:

+ In couples psychotherapy when, for example, one partner wants a better marriage but the other wants a “painless” divorce.  Psychologists should clarify, at the beginning, that they will not decide whether the couple should stay together or offer subsequent expert opinions during a divorce suit.

+ In court, when it is unclear whether the psychologist is serving as an expert witness or an advocate for one side.  Court-appointed evaluators should express well-balanced, objective opinions, while advocates are often psychologists for one party and who have had little, if any, direct contact with the other party.  Because they are unable to provide an objective evaluation, psychologists who are psychotherapists for one of the parties should not serve as expert witness.

+ When psychologists provide services to a person or entity at the request of a third party, such as a parent requesting psychotherapy for their child, or a Police Department requesting an evaluation of an Officer.  A psychologist may have one legal client, but several ethical clients.  In each case it is crucial to know who is being served and what is the role of the psychologist in providing that service.

How may psychologists avoid role-related dilemmas?  Knowing who is the client, your role, being transparent about what it is that you do, and being mindful about the professional boundaries that arise, are good guideposts to effective practice.  That means psychologists should, at the outset, have frank discussions with all parties involved about the relationship they will have with each person or organization.  For example, are they hired by a business to enhance worker productivity or are they to help individual workers with mental health problems?

Other things to cover include confidentiality limits, what specific services will be provided to which people and how the psychologist and others could use the services or information obtained.  If one is reasonable and straightforward with people, you will be in good stead most of the time   Treat them the way you would want to be treated in a similar situation, find out what their expectations are and clarify those expectations.

The most effective strategy that a psychologist may take to minimize exposure to ethical and legal problems is to strive to be mindful, compassionate, wise, genuine and honest.  

Barney Greenspan is a Diplomate in three specialties (Clinical Psychology; Clinical Child & Adolescent Psychology; & Psychoanalysis); Fellow in six divisions of APA (Clinical; Psychotherapy; Psychoanalysis; State, Provincial & Territorial Affairs; Independent Practice; & Clinical Child & Adolescent Psychology); Chair, ABPP Ethics Committee; Member, APA Ethics Committee; & President, Idaho Psychological Association.

This article was previously published in THE SPECIALIST by ABPP, 07/12/2018.