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ETHICAL DECISION MAKING IN UNIVERSITY AND COLLEGE COUNSELING CENTERS Ted Stachowiak, PhD, ABPP Presented at the Texas University and College Counseling.

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Presentation on theme: "ETHICAL DECISION MAKING IN UNIVERSITY AND COLLEGE COUNSELING CENTERS Ted Stachowiak, PhD, ABPP Presented at the Texas University and College Counseling."— Presentation transcript:

1 ETHICAL DECISION MAKING IN UNIVERSITY AND COLLEGE COUNSELING CENTERS Ted Stachowiak, PhD, ABPP Presented at the Texas University and College Counseling Centers Conference, Austin, TX, February 6,

2 Outline  Moral reasoning  Professional vs. personal distinction  Nonrational processes in decision making  Ethical risk factors common to counseling centers  When does a person become a “client”  Impact of client characteristics on ethical decision making  Overcoming vulnerabilities and developing resilience  Conflicts between client and institutional welfare  Ethical Leadership  Audience generated questions 2

3 Ethical Dilemma  Good, but contradictory ethical reasons for taking conflicting and incompatible courses of action  Welfare of the client versus the welfare of others and/or other groups 3

4 Example: Personal Friendships  Michael has several friends including Roger and Daniel. Roger has recently met and started dating a wonderful lady named Phyllis. He is convinced this is a long term relationship. Unknown to Roger, Michael observed them at a restaurant several days ago and realized Phyllis is the wife of his other friend Daniel.  Michael is deciding whether to tell Roger that Phyllis is married when he receives a call from Daniel. Daniel suspects his wife is having an affair and since they and Michael share many friends and contacts, he asks if Michael has heard anything regarding an affair.  To whom does Michael owe greater friendship to in this situation? No matter who he tells, he is going to end up hurting one, if not both friends. Does he remain silent and hope his knowledge is never discovered? 4

5 Mental Health Professionals  Have an obligation to:  Think wisely about what it means to:  Benefit others  Avoid harming others  Act towards others in a consistently ethical manner 5

6 What is Ethics?  Ethics refers to well-founded standards of right and wrong that prescribe what humans ought to do, usually in terms of rights, obligations, benefits to society, fairness, or specific virtues.  Ethics refers to the study and development of one's ethical standards 6

7 The Basic Questions of Ethics  What should we do?  How shall we live?  These questions are related to moral philosophy  However, the concepts of what should we do and how shall we live predate humans 7

8 The Solution!....Partially  Develop and adhere to a code of ethics 8

9 Kitchener, K. S. (1984, September). Intuition, Critical Evaluation and Ethical Principles: The Foundation for Ethical Decisions in Counseling Psychology. The Counseling Psychologist 9

10 Case 1  Under pressure to succeed, a first-year student in a counseling psychology graduate program has cheated on a final paper in a required class. The professor believes that the student has academic potential and recognizes that exposing the student’s cheating would lead to expulsion from the program and affect the student’s plans to pursue a career in psychology. 10

11 Case 1 (cont.)  On the other hand, the professor is aware that the student will be under pressure every day of his career, and may be similarly tempted to resort to unethical behavior. The professor is also aware that she has a responsibility to protect the public from professionals who resort to dishonesty in times of stress. 11

12 Intuitive Level - Moral Reasoning  Beliefs, knowledge, and assumptions we come to about what we “ought and ought not” to do  Experiences  Knowledge of professional ethical code  “Immediate” moral feelings  Moral good sense, conscience  Susceptible to situational circumstances (ordinary moral standards don’t apply to “me”)  Kitchener, K.S., (1984, September). Intuition, critical evaluation and ethical principles: The foundation for ethical decisions in counseling psychology. The Counseling Psychologist, 12,

13  Intuitive level of moral reasoning is not enough  We can convince ourselves that in our particular situation, ordinary moral standards do not apply  In very unusual cases we may not have an ordinary sense of which direction to take 13

14 TSBEP Sanctions  Improper dual relationship  Failure to report legal action  Personal problems with potential to impair competency  Sexual misconduct with patients – felony conviction  Failed to timely respond to patient’s written records request  Conducted evaluations without the requisite competency  Failed to adequately document joint session between spouses  Misrepresentation of services  Failed to control storage of records  Failed to obtain mandatory CE  Engaged in dual relationship with patient (social, therapeutic)  Failed to provide records as required by law 14

15 TSBEP Sanctions (cont.)  Sexual misconduct  Failed to establish professional boundaries regarding multiple related clients, did not properly terminate services  Failure to maintain record of treatment of client as required for continuity of care  Failed to properly identify self as supervisee and failed to identify supervisor  Advertised an unlicensed individual as a psychologist on here website  Improper relationship with former client  Practiced without a license, exemption, or competency; failed to specify scope and limitations of an evaluation; and forge a supervisor’s name to a report  Sexual relationship with patient, impairment  Improper sexual conduct, dual relationship  Failed to maintain records of psychological services  Failure to timely report arrest 15

16 Critical-Evaluative Level -Moral Reasoning  C. Ethical Theory  B. Principles  Beneficience and Nonmalficience  Fidelity and Responsibility  Integrity  Justice  Respect for People’s Rights and Dignity  A. Rules, Professional Codes, Laws 16

17 Ethical Rules  First line of ethical justification  Contradictory and ambiguous guidelines  May come under more than one set of rules  Reflect what most of the profession can agree upon, rather than “ideal” behaviors  Ethical codes may be too narrow or too broad 17

18 Ethical Principles  Beneficence and Nonmalficence  Fidelity and Responsibility  Integrity  Justice  Respect for People’s Rights and Dignity 18

19 Ethical Principles - Aspirational  Are not absolute, but are always morally relevant and give us consistent advice about what to consider  Provide a framework within which to critically consider ethical issues  One principle might weigh more heavily in certain circumstances 19

20 Ethical Principles  Can be applied across many situations when ethical codes are silent or conflict  Provide a more general justification for ethical codes and may illuminate inconsistencies within the code itself  Move us beyond believing we have fulfilled our ethical responsibility if we have not broken a specific rule in our professional code 20

21 21

22  One night, while drinking with friends at a bar, Dr. R sees two of his long-term clients sitting a few feet away. Even though he knows his clients are there, he becomes very intoxicated, to the point of slurred speech.  Is his behavior subject to the ethics code?  Would it be subject to the ethics code if one of the clients had an alcohol abuse problem?  What if Dr. R was head of the local treatment facility?  What if the same incident was repeated a number of times? 22

23 Voluntary Professional Constraints  Membership in a professional organization  “The Ethics Code applies only to psychologists’ activities that are part of their scientific, educational, or professional roles as psychologists...These activities shall be distinguished from the purely private conduct of psychologists.”  American Psychological Association. (2010). Ethical principles of psychologists and code of conduct, p

24 NBCC Code of Ethics  NCCs recognize that their behavior reflects on the integrity of the profession as a whole, and thus, they avoid actions which can reasonably be expected to damage trust.  24

25 ACA Code of Ethics  Professional counselors behave in an ethical and legal manner. They are aware that client welfare and trust in the profession depend on a high level of professional conduct.  American Counseling Association. (2014) Code of Ethics, 18 –

26 NASW Code of Ethics  The following ethical standards are relevant to the professional activities of all social workers.  26

27 American Psychiatric Association  The requirement that the physician conduct himself/herself with propriety in his or her profession and in all actions of his or her life is especially important in the case of the psychiatrist because the patient tends to model his or her behavior after that of his or her psychiatrist by identification.  American Psychiatric Association. (2013). The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, p. 4 27

28 “Off the Clock”  We can engage in:  Exploitative relationships  Sexual and multiple relationships  Demeaning behavior  Racism  Violating personal confidences  Abusiveness to family, friends  Lying  Cheating  Stealing  Discrimination 28

29 We can be scoundrels! 29

30 …..well, mostly!  We can be expelled from APA for a felony conviction even if the felony is unrelated to our professional role  Personal behaviors can be disciplined even though not actionable under Ethical Standards  The Ethics Code does not mention legal violations 30

31 The Boundary (Between Personal and Professional)  Deeply rooted in culture  A right to a personal life with minimal constraints from individuals, organizations, or government  Bill of Rights  Autonomous self  Separation of roles  “Don’t fence me in” 31

32 Boundary Blurring/Crossing  Impairment – debilitating intrusion of personal issues into professional roles  Disciplinary processes to determine consequences  Education/CEs  Therapy/Supervision  Sanctions 32

33 Justice William O. Douglas  The right be let alone is indeed the beginning of all freedom 33

34 Autonomy – Informed Consent  Evidence of the influence, value, and expression of free choice for the individual, whenever possible  Role theory assumes that individuals can carry out different roles  One set of obligations/activities can be defined and contrasted with another set 34

35 Professional-Personal Blurring Example  Decision to hire a candidate  Influenced by  Department needs  Qualifications  Personal chemistry  Opinions of close colleagues  Personal feelings 35

36 Personal or Professional?  Enthusiastic reference letter  Probably is a mix of personal and professional  We probably operate in the gray area often 36

37 When the Personal and Professional Merge  Can become contentious  Pre 1977 ethical code  Under what circumstances psychologists should be able to have sexual relationships with former or even current clients 37

38 What is Personal? Professional?  2010 Ethics Code – “These activities shall be distinguished from purely private conduct of psychologists, which is not within the purview of the Ethics Code.”  Section 2.06 “Personal Problems and Conflicts”  The perceptions of others may be a factor (Can we really leave our professional identity at the office?) 38

39 Case 2  One night, while drinking with friends at a bar, Dr. X, a psychologist, sees two long term clients a few feet away. He becomes very intoxicated, to the point of slurred speech.  Does this situation come under the code of conduct?  What if one of the clients had an alcohol abuse problem?  What if Dr. X ran the local treatment facility?  What if this happened several times? 39

40 Case 3  Dr. Y, psychologist and professor, is a player- manager for a softball team and invited Lois, her doctoral student, to play on the team. On the field and in front of others, Dr. Y repeatedly belittles Lois’s athletic skills, and minimizes Lois’s play time. In her role as doctoral advisor, Dr. Y is supportive and fair.  Is Dr. Y’s on field behavior subject to the code? 40

41  Standard 3.04 admonishes psychologists against harming students and others with whom they work  Might Dr. Y’s on field behavior impact Lois off the field in their teacher-student relationship? 41

42 Feminist Psychology  “The personal is political”  Political issues (e.g., social justice) are seen to come under the psychological umbrella  Personal values and personal identity are inextricably interwoven with the idea of professional values and ethics  One’s identify as a psychologist is irrevocably bound up with one’s personal commitments 42

43 Virtue Ethics  Emphasis on character  The kind of person someone is in personal life drives how that person thinks and what that person does in professional life  Effectiveness in professional functioning  Ability to self reflect (interpersonal and personal dynamics and their source) 43

44 Are Personal and Professional Inseparable?  Is personal skill (self-reflection) implicitly a professional skill? 44

45 The Personal vs. Professional Boundary Questions  What Standard of the Code of Conduct might I be violating if I engage in this specific behavior?  VS.  What values/principles do I follow, whether in my personal or professional life? 45

46 The Importance of Perceptions 1. Does the behavior, on its face, seem at least partially professional? 2. Is there a high probability that clients will be directly, significantly, and negatively impacted? 3. Is the behavior under discussion linked to a role played by psychologists? 4. Has a client expressed confusion about whether the behavior is personal or professional? 46

47 5. Is there a high probability that the action will be viewed or discovered by clients currently receiving services? 6. Does the action threaten the credibility of the psychologist or the field of psychology? 7. Given the opportunity, did the psychologist fail to clarify that the action was personal? 8. Was the behavior repeated, especially if the answer to one of the first four questions was “yes?” 47

48 Implications of a Fuzzy Boundary  Character must play a role in selecting and training future mental health practitioners  Truthfulness  Personal responsibility  Integrity  Just staying out of trouble by obeying the “standards” is not enough  The antidote to self-deception is self-reflection and self-knowledge, and an opportunity to safely consult with trusted colleagues 48

49 Role Play Technique – Texas Style 49

50 50

51 Ethical Decision Making  Ethical knowledge does not necessarily lead to ethical behavior  Multiple personal and interpersonal processes affect the decision maker  Automatic processes and intuition may play a bigger role than has been acknowledged 51

52 Decision Making Models  Predicated upon a normative ideal of rationality and critical evaluation  Nonrational thoughts are typically viewed as impurities  Nonrational (intuitive) processes are an inherent and inevitable component of any cognitive endeavor 52

53 Subjective Reactions  We encourage therapists to pay attention to their subjective (intuitive) reactions to clients and use those reactions for interventions  Similarly, in considering courses of action for ethical decision making, being unaware of or disregarding “intuition” or subjective reations can lead to misguided decisions. 53

54 Research on Decision Making  Clinicians report what should be done using ethical guidelines  However, they are not always willing to implement their decisions  Actual behaviors are influenced by personal values and practical considerations  Personal and situational features of a dilemma affect its resolution 54

55 The Dichotomy…  …between ethical knowledge and ethical behavior  One theory…  Behavior results primarily from intuitive judgments  Knowledge consists of reasoning “after the fact.” 55

56 Intention vs. Outcome  Which matters more?  For example, if competent therapists, intending to help their clients, initiate interventions that cause unanticipated harm, have they behaved ethically (because they had good intentions) or unethically (because harm resulted)? 56

57  Mark, an older doctoral student, was full of remorse when he came to his initial appointment at the counseling center. After asking and receiving assurance that their conversations would be confidential, Mark disclosed that, two months earlier, he had murdered his mother out of compassion for her discomfort. She was 73 years old and suffered from advanced Alzheimer's disease. Mark could not stand to see his mother in such a state, so he gave her sleeping pills and staged a bathtub drowning that resulted in a ruling of accidental death by the medical examiner.  What is the counselor’s ethical/legal duty, if any? 57

58 Confidentiality  J9gu8 J9gu8 58

59 Decision Making and Judgment  Decisions are not based on the objective state of the world  Decisions are based on the subjective experience of the world  Human capacity for rationality is finite, leading to certain tendencies and biases 59

60 Example  After contemplating the effects of losing a lucrative grant, a researcher may be tempted toward more professionally risky unethical practices – such as “cherry picking” data and even falsifying results – in order to avert the termination of a project the researcher believes to have considerable potential benefits for society. 60

61 Heuristics  A heuristic is a mental shortcut that allows people to solve problems and make judgments quickly and efficiently. These rule-of-thumb strategies shorten decision- making time and allow people to function without constantly stopping to think about the next course of action. While heuristics are helpful in many situations, they can also lead to biases. 61

62 Availability  People approximate frequency on the basis of how easily something comes to mind, but more memorable events are not necessarily more frequent. 62

63 Representativeness  People estimate the likelihood of an event by how similar it is to a conceptual prototype 63

64  Dr. R was interviewing a client who expressed great appreciation of him as a therapist but then became suddenly angry when she learned that an expected appointment time was not available. This one sample of behavior, which he interpreted as idealization and vilification, led Dr. R to conclude that the client had borderline personality disorder, and this decision influenced how he conceptualized his subsequent treatment decisions. 64

65 Anchoring  Describes the common human tendency to rely too heavily on the first piece of information offered (the "anchor") when making decisions. 65

66 Confirmation Bias  Believing a colleague generally to be an ethical clinician may unduly influence the evaluation of specific troublesome behaviors. 66

67 Confirmation Bias  _X8AA _X8AA  8au-YU 8au-YU 67

68 Blind Spot Bias  People perceive biases in others while denying them in themselves  Better –than-average for positive traits.  Less-than-average" for negative traits. 68

69 Self-Serving Bias  Positive event - You had a particularly good session with a client and you attribute it to your own awesomeness! (internal attribution)  Negative event - You had a particularly unproductive session with a client and you attribute it to some client characteristic – resistance, unwillingness to take responsibility, etc. (external attribution). 69

70 Self-Serving Bias  The heart of “conflict of interest”  External interests – clinician accepting a very rare item (gift) that he/she has been looking for from a client who is engaging in questionable business activities  Internal interests ( social or even sexual misconduct with clients or students  In it to win: The Jack Abramoff Story 70

71 Self-Serving Bias 71

72 Affective  Therapists might act on the basis of affective responses to a student, patient, or colleague rather than on a dispassionate examination of objective merits.  The use of the affect heuristic is consistent with findings that considerations such as personal loyalty may be more salient than ethical principles in making decisions 72

73 Avoidance of Discomfort  When confronted with a conflict-laden dilemma, therapists may choose an objectively worse, but less discomforting, course of action.  They may delay the decision and thereby exacerbate the consequences. Conversely, avoidance of ambivalence may lead to premature discontinuation of deliberation, hasty decisions, and equally adverse outcomes. 73

74 Complacency  Individuals tend to make decisions that are justified by subjective reasons. When planning a course of action, this tendency leads to imagined sequences of events, inadequate adjustments for the unknown or unexpected, and staggering overconfidence. 74

75 Moral Equilibrium  Moral compensation  Moral license 75

76 Moral Equilibrium  moral-equilibrium moral-equilibrium 76

77 Fundamental Moral Unit – Culturally Influenced  The individual  Relationships between people  Aggregate good 77

78 Multiple Relationships  A 10-year review of complaints before the APA Ethics Committee showed that boundary issues are the most common source of complaints against psychologists (Bennett et al., 2006), and such problems occur among academics as well as practitioner psychologists (see Ei & Bowen, 2002).  Slippery Slope – Incrementalism 78

79 Incrementalism  ncrementalism ncrementalism 79

80 Rationalization  VoOo VoOo  0heWs 0heWs 80

81 Framing 81  aming aming

82 Overconfidence 82  verconfidence-bias verconfidence-bias  3i0uA 3i0uA

83 Training and Supervision 83

84  Awareness of the pitfalls and errors of ethical reasoning can be supplemented with positively framed considerations as a matter of professional development.  Intuitive and affective responses can guide behavior to ensure better decisions without conscious awareness, particularly in complex circumstances. 84

85  Helping supervisees become aware of their own contributions to ethical reasoning, on the basis of their own values, motivations, and virtues can lead to a more comprehensive, supportive, and effective training experience. 85

86  Supervisors can work to increase supervisees’ awareness of those occasions when their emotions might work in their favor and become critical elements in ethical reasoning 86

87 87

88 88

89 Common CC Issues  Protecting access to electronic files  Client advocacy and institutional rules  Definition of what constitutes the “file” with electronic recording  Reporting sexual abuse  Remote access to electronic client files  Use of  Demanding clients and clients’ rights  Responding to potential conflicts between client an institutional welfare 89

90 Access to Electronic Files  A doctoral graduate student in psychology was working part time in the counseling center. The counseling center has a policy of restricting access to the files of clients who have some type of relationship with a client. At the time that the graduate student was employed as a counselor, several clients of the counseling center who were also graduate students in psychology were being seen in the center. It was discovered that the doctoral student staff member had accessed the files of several but not all of these clients. Not all of the clients had been restricted from the doctoral student.  What are the ethical issues involved? What action would you recommend to the Director?  90

91 Client Advocacy and Institutional Rules  A client of the counseling center was being treated for anxiety. The university has a prohibition against pet animals in the residence halls. The client disclosed in counseling that her goldfish were effective in helping her to reduce anxiety and remain calm. The client asked the counselor to write a letter in support of her being able to have her goldfish in her on campus room. The counselor provided a letter that explained the potential anxiety-reducing impact that animals have been shown to have, including goldfish. The letter did not make a recommendation about whether or not the client should be allowed to have the goldfish. About a month later the counseling center the Director handed the counselor a copy of the letter that he had earlier written on behalf of the client wanting goldfish in room, confirming that the counselor had written it. The Director had been given the copy by a University attorney, along with the instruction to tell the counselor to never do anything like that again without having it okayed by the attorney’s office. The reason behind the instruction was that University was in the midst of a class-action lawsuit brought by students in regards to having pets in dorms and it would not look good for the university if the opposing attorney obtained a copy. The Director agreed with the university attorney but the counselor disagreed.  The counselor consulted APA Ethical Guidelines, which states to do what is appropriately beneficial for a client although it may disagree with the larger agency's wish. The counselor consulted with his personal attorney, who gave the opinion that the university attorney had not only acted unethically, but had put herself at risk of inappropriately meddling with possible evidence.  What are the ethical issues involved? What is your opinion of how the counselor handled the situation? 91

92 Defining What Constitutes a Client File  Documentation of services provided  Client written/electronic communications  Information received from others about the client  Treatment records from other providers 92

93 Reporting Sexual Abuse  A therapist in a counseling center is providing aftercare treatment for a student who was recently in inpatient treatment for substance abuse. During the first session the client reveals that a mental health counselor at the treatment facility paid to have sex with another patient, who is a prostitute. The mental health staff counselor works in another department in the treatment facility and, according to the therapist’s client, the (prostitute) patient is not aware that one of her customers is a mental health counselor in another part of that facility.   The therapist does not know the mental health counselor well, but has provided some consultation for the mental health counselor in the past. The therapist does not dwell on the situation with the client. However, after the session, the therapist feels uneasy about what the client revealed.   Are there any ethical obligations of the therapist who hears this information?   What are potential ethical pitfalls in this scenario?   What, if anything, should the therapist do? 93

94 Safeguarding Information  Remote access to client files  Unencrypted s 94

95 Client’s Right to Access File  Lucy, a 2 nd year student in the College of Law, is a current client who has been particularly demanding and difficult to work with. You've now seen her seven times and have alternated between being occasionally encouraged but often wondering if it might be better to refer her to another agency or professional who could work with her on an extended basis. (Your counseling center is short term but has no predetermined session limit.)  Lucy has just phoned you and demanded to see her client file, saying something like "I know my rights! And I want to see what sort of things you been putting in my university record!" Before hanging up she indicated she was leaving shortly and would be at the counseling center in 45 minutes to review the file.  You immediately look through Lucy's file and find a case note that describes her as an "erratic and explosive individual, with a long history of interpersonal conflicts, who may well qualify for a diagnosis of borderline personality disorder." "O my goodness" you think... "This is going to be difficult..."  Who are the stakeholders in this situation and what might their perspectives be? What ethical and legal issues need to be immediately considered? How should the counselor respond to Lucy when she arrives in 45 minutes? And in light of relevant ethical principles vs. legal standards, what policies and procedures would you recommend a counseling center have in place to deal with situations like this? 95

96 High Service Demands 96

97 Responding to Potential Conflicts Between Client and Institutional Welfare.  Title IX reporting requirements  Reporting anonymously  Tell Somebody Report 97

98 Janie is a freshman living on campus. She came to the counseling center for a crisis, and you are the counselor on crisis duty. She told you that two weeks ago she was sexually assaulted by the boyfriend (Tom) of her best friend, Lori. All three live on campus. She cried deeply as she described an assault in which she feared for her life. A month ago Lori confided to Janie that Tom had physically and sexually her. You talked to Janie about reporting the assault to the Title IX officer. Janie said no way would she do that because she was quite sure Tom would retaliate on both her and Lori, and it would be just her word against his. He is a popular upperclassman. She did not seek treatment or file a police report because she was intoxicated. She said Tom stated he would “take care of” her if she told anyone. She came to the counseling center because she knew the counseling center would protect her confidentiality. From what Janie disclosed, and given that Tom has assaulted women twice in one month, you are quite sure that Tom is going to assault another woman soon. 98

99 What is a Criminal Proceeding?  Texas Health & Safety Code § (a)(7)  A professional may disclose information in any criminal proceeding, as otherwise provided by law  “It is my legal opinion that a reasonable interpretation of the term criminal proceeding as used in Texas Health & Safety Code § includes any and all phases between official accusation to final disposition of a criminal case.”  J.M. Brown, Assistant General Counsel, Texas A&M University System, Office of General Counsel (personal communication, February 11, 2010) 99

100 When Does a Prospective Client Become a Client?  Not much in the literature  Potentially profound implications  If no professional relationship, then no multiple relationship  Students access counseling services in many ways  Registration  In person  Telephone  Online  Crisis  Triage  Telephone  In person 100

101 When Does a Professional Relationship with a Psychologist Begin? An Empirical Investigation Smith, J. A., Pomerantz, A. M., Pettibone, J/ C., & Segrist, D.J. (2012). When does a professional relationship begin? An empirical study. Ethics & Behavior, 22(3),

102 Scenarios – Has the student attained “client status?” Student contacts the counseling center and asks for referral information for a private practitioner Student wants to be seen at the counseling center, but your assessment is that the student’s needs are outside of the center’s “role and scope” and is referred out “Revolving door” students – referred out but they manage the system and get another appointment or come in for crisis – multiple times Student schedules an initial appointment but doesn’t show and never reschedules – student provided personal information online (e.g., CCAPS) 102

103 What constitutes the professional therapist-client relationship?  If no professional relationship…  No multiple relationship  No liability …..usually 103

104  Duties increase as the therapy relationship evolves  “As contact with a potential client increases in frequency, so too does the duty of care.”  Younggren, J.N., & Davis D. D. (2012). Ethical issues in the beginning and end of therapy. In S. J. Knapp (Ed.) APA handbook of ethics in psychology: Vol 1 Moral foundations and common themes (pp Washington, DC: American Psychological Association. Doi: /

105  Even when interacting with a person not yet a client, a therapist still has an obligation to take some action on that person’s behalf rather than simply ignoring or refusing him or her  Failure to act in a manner commensurate with the duty of care, even in the very early stages of professional interaction, could be viewed by some as a form of abandonment.  Duty of care does not necessarily translate into a duty to treat. 105

106 Participants  109 psychologists from APA Division of Psychologist in Independent Practice  Mean age – 61.6 (SD = 9.5)  Male = 66%. Female = 44%  Average number of clients seen per week during the past year = 24.3 (SD = 12.6) 106

107 Participants’ Ethnicity  Caucasian/White = 66.3%  African American/Black = 25.9%  Hispanic/Latino/a = 3.6%  Multiracial, Asian Pacific Islander, and Other = less than 1.0% each 107

108 Professional Relationship  5 minute phone call ending with referral  20 minute phone call ending with referral  60 minute interview ending with referral  60 minute interview followed by a second 60 minute interview 108

109 Vignette A  In search of a psychotherapist, Sally calls Dr. Jones to set up an initial appointment. During their phone conversation, Sally gives a brief description of the problems she's been having. Dr. Jones explains to Sally that he feels that she would be better suited with a different therapist who specializes in the treatment Sally needs. After giving Sally a few names and phone numbers of the therapists in the area specializing in this type of treatment, the conversation is over. The phone call lasted approximately 5 minutes. 109

110 Vignette B  In search of a psychotherapist, Mary calls Dr. Smith to set up an initial appointment. During their phone conversation, Mary gives a brief description of the problems she's been having. Dr. Smith explains to Mary that he feels that she would be better suited with a different therapist who specializes in the treatment Mary needs. After giving Mary a few names and phone numbers of the therapists in the area specializing in this type of treatment, the conversation is over. The phone call lasted approximately 20 minutes. 110

111 Vignette C  In search of a psychotherapist, Melissa comes in for an initial interview with Dr. Morgan to discuss her need for treatment. During the interview, Melissa gives a brief description of the problems she's been having. Dr. Morgan explains to Melissa that he feels that she would be better suited with a different therapist who specializes in the treatment Melissa needs. After giving Melissa a few names and phone numbers of the therapists in the area specializing in this type of treatment, the interview is over and Melissa has no additional contact with Dr. Morgan. The interview lasted approximately 60 minutes 111

112 Vignette D  In search of a psychotherapist, Alice comes in for an initial interview with Dr. Witt to discuss her need for treatment. During the interview, Alice gives a brief description of the problems she's been having. Dr. Witt explains that she feels she can help Alice, as the treatment she needs is a specialty of hers. The interview lasts approximately 60 minutes. The following week, Alice comes in for another session with Dr. Witt. 112

113 Questions Asked of Participants 1. Has a professional relationship been established between [the prospective client] and the psychotherapist? 2. Has [the prospective client] become a client of [the psychotherapist]? 3. Would it be ethical for [the psychotherapist] to begin dating [the prospective client]? 4. Would it be ethical for [the psychotherapist] to form any social or business relationship(s) with [the prospective client]? 113

114 Professional Relationship? Scale 1 = Definitely, 7 = Definitely Not  5 minute phone call ending with referral = 4.8  20 minute phone call ending with referral = 4.6  60 minute in-person initial interview ending with referral = 3.2  60 minute in-person initial interview with return appointment =

115 Client Status? Scale 1 = Definitely, 7 = Definitely Not  5 minute phone call ending with referral = 6.8  20 minute phone call ending with referral = 6.8  60 minute in-person initial interview ending with referral = 5.9  60 minute in-person initial interview with return appointment =

116 Ok to Have a Dating Relationship? Scale 1 = Definitely, 7 = Definitely Not  5 minute phone call ending with referral = 4.4  20 minute phone call ending with referral = 3.9  60 minute in-person initial interview ending with referral = 5.0  60 minute in-person initial interview with return appointment =

117 OK to Have a Social or Business Relationship? Scale 1 = Definitely, 7 = Definitely Not  5 minute phone call ending with referral = 4.4  20 minute phone call ending with referral = 3.5  60 minute in-person initial interview ending with referral = 4.8  60 minute in-person initial interview with return appointment =

118 Findings  5 minute and 20 minute phone calls elicited midrange (maybe) responses regarding a professional relationship, but leaning toward no professional relationship  Professional Relationship and Client Status are seen as distinct, with a Professional Relationship somewhat easier to attain 118

119 Findings (cont.)  60 minute in-person interview followed by a second session produced definitive responses that a professional relationship had been established and the prospective client had become a client 119

120 Findings (cont.)  60 minute in-person interview + second session seems to have cemented that a professional relationship had been established, the prospective client was in fact a client, and that extratherapeutic involvement would be unethical.  Some psychologists may find it ethically acceptable to have an extratherapeutic relationship with a person who is thought to be a client with whom the psychotherapist is engaged in a professional relationship. 120

121 Missed Initial Appointment  John is a junior at a university majoring in Business. During the past semester, he was developed misgivings about his major, and has decided that the only reason he majored in business is because of his family’s influence. He decides he wants to get career counseling and learns that he can register online for an appointment. He goes online and completes the information requested, which includes current and past suicidal ideation/behavior, his use of alcohol and other substances, and also information about his family’s mental health history. He scheduled an appointment and receives confirmation that his initial appointment will be with Ann (LPC). He overslept the morning of his appointment. On the way to the counseling center, he is pulled over by police for speeding. He uses his cell phone to call the counseling center to cancel his appointment and states he will call later to reschedule. Two weeks go by and John has not called to reschedule his appointment.  Is John a “client” of the counseling center?  If “yes,” why? If “no,” why? 121

122 The Influence of Client Characteristics on Psychologists’ Ethical Beliefs  Pomerantz, A. M., & Pettibone, C. J. (2005). The influence of client characteristics on psychologists’ ethical beliefs: An empirical investigation. Journal of Clinical Psychology 61(4),

123 Ethical Decision and Client Characteristics  Ethical decisions often lead to actions done to someone  Models of decision making often imply that a decision happens in the abstract  Characteristics of the someone, as perceived by the decision maker, can have a powerful impact on the process of ethical decision making  Pomerantz, A.M., & Pettibone, J.C. (2005). The influence of client characteristics on psychologists’ ethical beliefs: An empirical investigation. Journal of Clinical Psychology, 61,

124 Participants  350 psychologist were randomly selected from licensed Missouri psychologists  102 surveys were used (34.6% return rate)  Equal number of females and males  Mean age = 51.9 (SD 10.3)  Mean years of experience = 18.7 (SD 11.1) 124

125 Questionnaire Variables  “Client” Age = 28 or 58 years  Sex = Male or Female  Diagnostic Severity  Major Depressive Disorder, Single Episode, Mild  Major Depressive Disorder, Recurrent, Severe Without Psychotic Features 125

126 Factors Explored  Assertive or Discomforting Actions  Nonsexual Dual Relationships 126

127 Assertive or Discomforting Therapist Behaviors  Therapists consider their behavior to be more ethical when directed at:  Younger males versus older males  Older females versus younger females  Therapists may view older males with more respect and authority, but not older females  Older males and younger females are populations with higher rates of suicide  To the extent that therapists are sensitive to client vulnerability, they may be less likely to engage in such behaviors 127

128 An Important Question  Would I make the same ethical decision if the person(s) toward whom the decision is directed had different characteristics?  A small body of empirical research indicates that psychologists’ decisions about what is ethical do in fact depend on characteristics of the recipient of that decision 128

129 APA Ethical Code – Standard 10.08(b)  Ethicality of sexual intimacies may depend on former client characteristics  Personal history  Current mental status  Potential adverse impact 129

130 APA Ethical Code – Standard 5.05  Ethicality of soliciting testimonials depends upon whether the client is “vulnerable to undue influence” 130

131 APA Ethical Code – Standard 6.03  Implies that the ethicality of withholding records for nonpayment depends on whether the client’s current state necessitates “emergency” treatment as opposed, presumably, to nonemergency treatment. 131

132 APA Ethical Code – Standard 6.05  Ethicality of bartering depends upon whether the barter is “not clinically contraindicated” 132

133 Client Characteristics Potentially Affecting Treatment Decisions  No insurance or ability to self pay  No transportation  Difficult to be with  Longer term issues than typical for your center but pleasant  Unkempt  Difficult to understand because of language 133

134 Client Disposition  Liz has recently completed a two session extended intake at your counseling center. She is a 23 year old, single, Latina with a significant history of psychological problems and several treatment experiences that, in her words, "usually haven't helped much." She matriculated five years ago but to date has completed about two years of coursework. Despite inconsistent attendance she has accumulated a GPA of 3.45 and reports majoring in psychology in part "to better understand how I keep screwing myself up." She also indicates that her mother, who recently obtained U.S. citizenship, keeps pressing her to "settle down, marry, and have kids like you should have done in the first place."  In checking the agencies records you note that she has been a client on two prior occasions, the most recent being about one year ago. The various intake reports and case notes indicate that since entering high school she has worked briefly with two private practitioners associated with a low-fee community center (a social worker and a year later a psychiatrist) as well as been referred to a comprehensive community mental health agency. Various diagnoses are cited in the record including major depression, bipolar disorder, and panic disorder with agoraphobia. There are also indications that on occasions she has used alcohol excessively (e.g., more than 3 drinks per day usually on weekends) and also sometimes smoked marijuana "because it helps me feel better." On her just completed OQ-45 she reports having suicidal thoughts "sometimes" and "rarely" having thoughts of harming others.  Three years ago Liz saw a counseling center intern for six sessions but never showed up for her seventh session. A year ago agency staff decided to refer her to an experienced local therapist who specializes in doing longer-term therapy with clients suffering "chronic psychological dysfunction" and even helped her arrange for the initial appointment. During the recent intake Liz reported discontinuing seeing the therapist after three visits, saying "he was an old guy that I just couldn't relate to and, besides, we couldn't afford his fees. I thought I was on my mother's insurance, but it turned out I wasn't." She then went on to say "Please don't refer me out again; I won't go! I like your counselors, and I think they can help me like none of these others have done."  You're about to lead an agency team meeting charged with making disposition decisions about clients who have recently completed the intake process. Note that your agency has a 12-session counseling policy that most staff members support unequivocally. What factors about Liz's situation should the group take into account? What ethical and moral concerns are relevant to her situation? And how should the agency respond to Liz's request for help? 134

135 Overcoming Vulnerabilities and Developing Resilience  Tjeltveit, A. C., & Gottlied, M. C. (2010). Avoiding the road to ethical disaster: Overcoming vulnerabilities and developing resilience. Psychotherapy: Theory, Research, Practice, Training, 47(1), 98 –

136 Knowing Versus Doing  37% of psychologists would not report a colleague sexually involved with a client, although they knew they should  80% knew that “working when too stressed to be effective” is unethical, but 53% acknowledged doing so, 4.4% “fairly often” 136

137 Assumptions  Personal feelings, motivations, and values are power shapers of our ethical lives  Unawareness leads to vulnerability  Awareness leads to enhanced decision making 137

138 Assumptions (cont.)  Prevention efforts are too narrowly focused on didactic instruction and can lead to a myth  “…learning ethical standards, principles, and guidelines, along with examples of how they have been applied, translates into ethical practice”  The lines between clinical, ethical, and legal are often blurred  The need for ethical decisions can arise very quickly (anyone willing to share an example?) 138

139 Primary Prevention  “…doing something now to prevent or forestall something unpleasant or undesirable from happening in the future, or  doing something now that will increase desirable outcomes.”  Includes addressing the emotions and personal values of the therapist well in advance 139

140 Resilience 1. Specific skills that can be marshaled when faced with difficult situations in which there are strong temptations to transgress. 2. Relatively stable personal characteristics that help cope with and overcome adversity in optimally ethical ways. 3. Emanates from social relationships and support networks 4. Multidimensional – ability to respond well to the above three. 140

141 Vulnerabilities  Areas of our lives that are not well protected from ethical lapses 141

142 General Vulnerabilities  Prone to errors in judgment when fatigued or stressed  Stressful nature of our work or stress in our personal lives can quickly create exposure to ethical risks 142

143 Idiosyncratic Vulnerabilities  Particular personal histories, personalities, habits, character structure  Victimization, trauma, discrimination, racism  Life has gone well - empathic failure – difficult to understand those who have experienced great difficulties  Long history of manipulating others for personal gain while rationalizing actions as beneficent 143

144 Prevention Requires Intellectual and Emotional Honesty  Ability to explore the full range of emotions that we actually experience, especially those that are not easy to own, or don’t seem socially acceptable or politically correct  Some may be at odds with stereotypes of what “good” therapists should feel  Countertransference 144

145 Factors Affecting Resilience and Vulnerability: DOVE  Desire  Opportunity  Values  Education  These can be range from being a protective strength to being a significant risk factor 145

146 Desire to Help  At the core of our professional identities  As resilience, can sustain effort even in the face of adversity  As vulnerability, “There’s no one thing that has gotten (psychologists) therapists into [ethical] trouble than the desire to be helpful.  Example – the well intentioned boundary violation – can reduce treatment effectiveness, harm clients, or lead to being manipulated 146

147 Desire to Help (cont.)  Imposing solutions on clients (violation of autonomy)  Allow unpaid bills to accumulate for clients having financial difficulties  For social justice, agreeing to testify on behalf of a client beyond one’s area of competence  Desire to Help may be a therapist’s greatest resilience and most significant vulnerability 147

148 A Powerful Opportunity  Resilience - the opportunity to contribute to knowledge, provide services to clients, teach, advance social policy, foster change in clients, i.e., make the world a better place  Vulnerability – self-deception, self-serving bias – power and trust are abused because of feelings and intuitions that interfere with sound decisions 148

149 A Powerful Opportunity (cont.)  May be wise for a therapist to routinely avoid treating clients who pose personal difficulties  A distressed therapist  Difficult to focus on key questions  Conduct a thorough assessment  Think clearly about the implications of treating a client  Summon the emotional energy to decline to treat and refer  Therapist may be faced with a difficult client at a time when least capable of doing so 149

150 Values  Core values as professionals are intertwined with personal values from our individual experiences  Resilience – lead therapists in positive directions and accomplish worthwhile goals  Promote consistency in work and behavior and enhance personal identity 150

151 Values (cont.)  Vulnerability – Therapists act on their values in misguided, rigid, or self-serving ways 151

152 Education  Resilience – involves lifelong, multidimensional learning that improves professional learning  In personal lives, when loves ones are ill or have problems, therapists use their education and knowledge to help  As educated citizens, therapists contribute to the community and, in return, draw strength from their participation 152

153 Education (cont.)  Self-care refers not merely to avoiding impairment and ethical violations, but also to avoiding ethical mediocrity and moving toward excellence.  Engaging in self-sustaining behaviors 153

154 Education (cont.)  Vulnerability - professionals who complete their training without the emotional ed­ ucation and awareness needed to avoid self- deception  Therapists com­placently rely on their graduate training and fail to continue their learning process. 154

155 Education (cont.)  Vulnerability – Education is viewed as an intellectual activity only, leaving little room for nurturing emotional intelligence 155

156 Applying the DOVE Factors: An Example  Background  As a child and adolescent, Evangelina Cruz, PhD, had experienced both victimization and discrimination. She developed a desire to help others at a very young age, had been reared with strong values regarding education, and saw becoming a psychotherapist as the way to achieve her goal of helping others and making a difference. She worked hard in school. Despite economic obstacles, she was accepted at a prestigious university, and subsequently a professional preparation program of equal rank, one that had a strong emphasis on multiculturalism and feminism. It was just what she had hoped for. Cruz was an outstanding student and won a coveted internship at a large urban mental health center that specialized in treating trauma victims and torture survivors. This position allowed her to develop expertise in treatment approaches for women with posttraumatic stress disorder (PTSD). Her scholarly writing and public advocacy won her a number of early career awards and the respect of her col­leagues who saw her as a dedicated and self- sacrificing professional who was a strong advocate for her clients. These experiences deepened her personal values and increased her desire to help the disempowered, exactly what her professional education would now provide her the opportunity to do. 156

157 The Case  Shortly after entering independent practice, Cruz was consulted by Angie Immel, who presented with moderately severe symptoms of acute anxiety and depression she claimed were the result of sexual harassment by her boss, Alex Morse. She said that Morse began pursuing her from the time she started working for him. When she rejected his initial overtures, she reported, his advances increased, and he began making inappropriate and highly sexualized remarks whenever he could do so in private. Immel said that she tolerated this behavior and had not become symptomatic until Morse began to touch her; then she became afraid.   Immel said she complained to the human resources department on numerous occasions, but nothing had been done because, according to her, Morse was best friends with and the golfing partner of the human resources director. Immel also made oblique references to filing an Equal Employment Opportunity Commission complaint and a subsequent law suit, but Cruz did not fully appreciate what Immel meant by these references. Cruz assumed she would not be involved in the legal process, and she and Immel never discussed it. She saw the legal issues as unrelated to her work and chose to maintain focus on the distress of her client. At the same time, she supported Immel’s efforts based on her own belief that a corporate giant had exploited Immel.  157

158 The Case (cont.)  Cruz treated Immel with cognitive-behavioral therapy, but she did not respond as well as Cruz expected. In part, Cruz’s efforts were frustrated because at every session Immel asked her to document the aversive incidents that occurred during the previous week. Cruz informed Immel that this recording of events was both unnecessary for and interfering with her treatment, but Immel persisted, and Cruz deferred to the wishes of her client. Although the treatment was not going very well, Cruz persevered.   One day, she received a telephone call from Blanca Knox, Immel’s attorney, who informed her that she would be calling her to testify as an expert witness in a sexual harassment case against Morse and his company. Cruz first resisted Knox’s request because she knew the data she had were limited and that she could not directly address the legal question regarding what caused Immel’s condition. But Knox was persistent, telling her that her testimony was vital to the case and that, without it, Immel would surely lose. Eventually, in her desire to advocate for her client, Cruz relented and testified that Immel suffered from PTSD that was the direct result of Morse’s behavior.   Shortly after the trial, at which Morse and his company were not held liable, Cruz received notice that a complaint had been filed against her with the state board of psychology for offering testimony that was beyond the boundaries of her competence. Cruz found herself confused, frightened, overwhelmed, and completely unappreciated and misunderstood. She became outraged and came to view the complaint as another example of oppression of the disadvantaged. 158

159 Analysis  As a psychotherapist, Cruz brought many strengths to her work. She had a strong desire to help others based on her values and personal experience, and she acquired the opportunity to do so through her education and training. Her background motivated her, and her accomplishments reinforced her; she was on course for a successful and rewarding career. By analyzing the DOVE factors, we can see how the resilience produced by those strengths became vulnerabilities when she began treating Immel.   The first vulnerability for her was that, although she may have been well trained clinically, her education regarding the legal system was lacking. Being ignorant of the legal process created a vulnerability for her that could have been easily avoided had she learned even a little about it and the role that experts play in it (see Foote & Goodman-Delahunty, 2005). Her ignorance of the legal system may have been due to deficiencies in her training, but it may also have been due in part to her value of helping the disadvantaged. This value may have contributed to her too quickly viewing Immel as a victim who had been exploited by oppressive forces, rather than taking the time to consider alternative hypotheses. A third factor that may have contributed to Cruz’s situation was her desire to help. Such feelings may have led her to trust her client and not question her motives. Her desire may have become a more serious vulnerability when Immel did not improve and in fact made what appeared to be unreasonable demands on her. Finally, when Knox called her, Cruz found that she had the opportunity to help Immel in an unanticipated way that could bring her client great benefit. Unfortunately, many dimensions of Cruz’s resilience became vulnerabilities in this example. They impelled her forward, caused her to lose control of the treatment process, and became obstacles to the necessary self- examination that could have helped her avoid such an unpleasant outcome. 159

160 Ethical Leadership  Humane Orientation  Justice Orientation  Responsibility and Sustainability Orientation  Moderation Orientation  Eisenbeiss, S.A. (2012). Re-thinking ethical leadership: An interdisciplinary integrative approach. The Leadership Quarterly, 23, 791–

161 Humane Orientation  Treat others with dignity and respect  Recognize rights of others  Have concern about the well being of another 161

162 Justice Orientation  Fair and consistent decisions  Not biased by third party interest  Respect for diversity  Non discriminatory treatment 162

163 Responsibility and Sustainability Orientation  Longer term views of the organization  Interconnectedness  More indefinite and distal targets (the common good) 163

164 Moderation Orientation  Temperance and humility  Strong professional will with personal modesty  Controlled narcissistic tendencies  Able to hear expressions of doubt  Able to hear contradiction 164

165 Consequences of Leaders with the Four Orientations  Absence of drama  Leadership is predictable, dependable  Trust in leadership increases  Followers strive to emulate the four orientations with clients and interactions with colleagues  Attention to and a desire for ethical behavior becomes infused into the organization  Genuine self pride and job satisfaction increases  Preventive staff voluntary self disclosure, “I am not sure if this is an issue, but.....” 165

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