Infusing Ethical and Multicultural Competencies Into Internship Training: A Participatory Workshop APPIC Conference Portland, Oregon April 17, 2009 Erica H. Wise, Ph.D. Department of Psychology UNC Chapel Hill

APPIC Overview 1. Being an ethical role model for our trainees 2. Ethical and multicultural considerations in supervision and training 3. Effective strategies for developing ethical and multicultural competencies at the internship level

APPIC Serving as an Ethical Role Model o Be familiar with ethical and legal standards o Attend ethics and multicultural workshops o Be familiar with practice guidelines (e.g. Ethics Code, LGBTQ, Multicultural) o Regularly consult with colleagues o Promote ethical and multicultural discourse in your agency

APPIC General Ethical Considerations in Supervision and Training o Be familiar with guidelines and standards related to supervision and training o Incorporate these principles into the your training program o Create an atmosphere that fosters discourse about ethics, multicultural considerations and practice

Professional Self-Regulation Risk management Risk management Aspirational Ethics Aspirational Ethics 5

APPIC Philosophical Underpinnings There are two philosophical world views that are commonly drawn from in the study of moral and ethical reasoning: o Deontological o The Moral Imperative o Choices and behavior are inherently right or wrong o Teleological o Utilitarianism or Pragmatism o Choices and behaviors are judged by outcome

APPIC Sources of Guidance for the Practice of Psychology o APA Ethics Code o HIPAA and other federal regulations o Psychology Practice Act in your state o Your agency or institution o Guidelines and best practices documents

APPIC Ethical Issues in Supervision Major Ethical Issues: o Competence and Client Welfare o Informed Consent o Confidentiality o Supervisee Rights o The Relationship Between Supervisor and Supervisee

APPIC Competence and Client Welfare

APPIC Delegation of Work to Others (excerpt) Psychologists who delegate work to…supervisees…take reasonable steps to…authorize only those responsibilities that such persons can be expected to perform competently on the basis of their education, training and experience…with the level of supervision being provided.

APPIC Informed Consent

APPIC Informed Consent to Therapy o Psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers. o When the therapist is a trainee and the legal responsibility for the treatment provided resides with the supervisor, the client/patient, as part of the informed consent procedure, is informed that the therapist is in training and is being supervised and is given the name of the supervisor.

10.02 Therapy Involving Couples or Families (a) When psychologists agree to provide services to several persons who have a relationship (1) which of the individuals are clients/patients and (2) the relationship the psychologist will have with each person. This clarification includes the psychologists role and the probable uses of the services provided or the information obtained. 13 APPIC 2009

What do psychologists say? Informed consent is a shared decision making process in which the professional communicates sufficient information to the other individual so that s/he may make an informed decision about participation in the professional relationship. Barnett, PPRP, APPIC 2009

Readability of NPP Forms? The Numbers Game, Washington Post, % of patient privacy forms were as easy to read as comics 1% were as easy to read as J.K. Rowlings Harry Potter and the Sorcerers Stone. 8% were as easy to read as H.G. Wellss The War of the Worlds 91% were as easy to read as professional medical literature or legal contracts 15 APPIC 2009

Etymology of Inform From the Latin Informare; in= causative preposition + formare= to make or to form; to form an idea To cause someone to form an idea 16 APPIC 2009

Etymology of Consent From the Latin comsentire com= with + sentire=to feel or to sense To feel together; to feel with; to be of one mind 17 APPIC 2009

Final Thoughts on Informed Consent To cause someone to form an idea To feel together; to feel with; to be of one mind How can the Informed Consent process truly serve more than a risk management function? Wise, PPRP, APPIC 2009

19 Confidentiality

CONFIDENTIALITY Done or communicated in confidence; told in secret Done or communicated in confidence; told in secret In the context of an intimate or trusting relationship In the context of an intimate or trusting relationship Latin: con = with; fidere = trust Latin: con = with; fidere = trust General Principle General Principle Balance between: public welfare and individual rights 20

CONFIDENTIALITY General Rule Mandated Exceptions Mandated Exceptions Permitted Exceptions Permitted Exceptions 21

APPIC Definition of Terms o Privacy o Confidentiality o Privilege

APPIC CONFIDENTIALITY General Rule o Mandated Exceptions o Permitted Exceptions

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

APPIC Limits of Confidentiality 4.02 Discussing the Limits of Confidentiality (a) Psychologists discuss with persons (including, to the extent feasible, persons who are legally incapable of giving informed consent and their legal representatives) and organizations with whom they establish a scientific or professional relationship (1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities. (See also Standard 3.10, Informed Consent.) (excerpt)

APPIC Disclosure With Consent 4.05 Disclosures (a) Psychologists may disclose confidential information with the appropriate consent of the organizational client, the individual client/patient, or another legally authorized person on behalf of the client/patient unless prohibited by law.

APPIC Disclosures Without Consent 4.05 (b) Psychologists disclose confidential information without the consent of the individual only as mandated by law, or where permitted by law for a valid purpose such as to (1) provide needed professional services; (2) obtain appropriate professional consultations; (3) protect the client/patient, psychologist, or others from harm; or (4) obtain payment for services from a client/patient, in which instance disclosure is limited to the minimum that is necessary to achieve the purpose. (See also Standard 6.04e, Fees and Financial Arrangements.)

APPIC Supervisee Rights

APPIC Descriptions of Education and Training Programs Psychologists responsible for education and training programs take reasonable steps to ensure that there is a current and accurate description of the program content (including participation in required course- or program-related counseling, psychotherapy, experiential groups, consulting projects, or community service), training goals and objectives, stipends and benefits, and requirements that must be met for satisfactory completion of the program. This information must be made readily available to all interested parties.

APPIC Student Disclosure of Personal Information Psychologists do not require students or supervisees to disclose personal information in course- or program- related activities, either orally or in writing, regarding sexual history, history of abuse and neglect, psychological treatment, and relationships with parents, peers, and spouses or significant others except if…

APPIC Student Disclosure of Personal Information o The program or training facility has clearly identified this requirement in its admissions and program materials or o The information is necessary to evaluate or obtain assistance for students whose personal problems could reasonably be judged to be preventing them from performing their training- or professionally related activities in a competent manner or posing a threat to the students or others.

APPIC Assessing Student and Supervisee Performance o In academic and supervisory relationships, psychologists establish a timely and specific process for providing feedback to students and supervisees. Information regarding the process is provided to the student at the beginning of supervision. o Psychologists evaluate students and supervisees on the basis of their actual performance on relevant and established program requirements.

APPIC The Relationship Between Supervisor and Supervisee

APPIC Multiple Relationships A multiple relationship occurs when a psychologist is in a professional role with a person and: o At the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or o Promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. o At the same time is in another role with the same person,

APPIC Multiple Relationships (excerpt) o A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologists objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. o Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.

APPIC Exploitative Relationships Psychologists do not exploit persons over whom they have supervisory, evaluative, or other authority such as clients/patients, students, supervisees, research participants, and employees.

APPIC Sexual Relationships With Students and Supervisees Psychologists do not engage in sexual relationships with students or supervisees who are in their department, agency, or training center or over whom psychologists have or are likely to have evaluative authority.

APPIC Psychologists in Training Exemptions Example from NC Psychology Practice Act (d) Nothing in this article shall be construed as limiting the activities, services, and use of title designating training status of a student, intern, fellow, or other trainee…preparing for the practice of psychology under the supervision and responsibility of a qualified psychologists…provided that such activities and services constitute a part of his or her course of study as a matriculated graduate student in psychology.

APPIC Developing Ethical Competencies in our Trainees… What are we trying to do?

APPIC ADPTC Competency Outline #7 Ethical Competencies During the practicum, the student will build on coursework in ethical practice, developing individual, practical knowledge of ethical practice, including linkage of the APA ethics code (APA, 2002) to behavior and decision making in actual clinical settings. In addition, students should increase and apply their understanding of legal standards (state and federal, e.g., HIPAA) and APA practice guidelines.

APPIC ADPTC CO Ethical Competencies More specifically, during practicum training the student will work to develop the following ethical competencies: Knowledge of ethical/professional codes, standards and guidelines; knowledge of statutes, rules, regulations and case law relevant to the practice of psychology. Knowledge of ethical/professional codes, standards and guidelines; knowledge of statutes, rules, regulations and case law relevant to the practice of psychology. Recognize and analyze ethical and legal issues across the range of professional activities in the practicum setting. Recognize and analyze ethical and legal issues across the range of professional activities in the practicum setting. Recognize and understand the ethical dimensions/features of his/her own attitudes and practice in the clinical setting. Recognize and understand the ethical dimensions/features of his/her own attitudes and practice in the clinical setting. Seek appropriate information and consultation when faced with ethical issues. Seek appropriate information and consultation when faced with ethical issues. Practice appropriate professional assertiveness related to ethical issues (e.g., by raising issues when they become apparent to the student). Evidence commitment to ethical practice. Practice appropriate professional assertiveness related to ethical issues (e.g., by raising issues when they become apparent to the student). Evidence commitment to ethical practice.

Competency Benchmarks Readiness for Internship Essential Component: Intermediate level knowledge and understanding of the APA Ethical Principles and Code of Conduct and other relevant ethical/ professional codes, standards and guidelines; laws, statutes, rules, regulations Behavioral Anchor: Behavioral Anchor: o Identifies ethical dilemmas effectively o Actively consults with supervisor to act upon ethical and legal aspects of practice o Addresses ethical and legal aspects within the case conceptualization o Discusses ethical implications of professional work o Recognizes and discusses limits of own ethical and legal knowledge APPIC

Competency Benchmarks Readiness for Entry to Practice Essential Component: Routine command and application of the APA Ethical Principles and Code of Conduct and other relevant and other ethical, legal and professional standards and guidelines of the profession Behavioral Anchor: Behavioral Anchor: o Spontaneously and reliably identifies complex ethical & legal issues, analyzes them accurately and proactively addresses them o Aware of potential conflicts in complex ethical and legal issues and seeks to prevent problems and unprofessional conduct o Aware of the obligation to confront peers and or organizations regarding ethical problems or issues and to deal proactively with conflict when addressing professional behavior with others APPIC

APPIC Strategies o Didactics and formal seminars o Integrate ethical and multicultural considerations into all agency activities o Supervision o Experiential learning o Socratic questioning

APPIC Supervision Considerations

APPIC Supervision Defined An intervention provided by a more senior member of a profession to a more junior member or members of that same profession (Bernard & Goodyear, 2004) (Bernard & Goodyear, 2004)

APPIC Supervision… o Is evaluative and extends over time o Enhances professional functioning of the junior person o Monitors quality of professional services to the client o Serves as a gatekeeper for the profession (Bernard & Goodyear, 2004) (Bernard & Goodyear, 2004)

APPIC Supervision as a Triadic System ClientSupervisee Supervisor

APPIC The Supervisory Dyad Supervisee Supervisor

APPIC A stronger supervisory relationship will facilitate increased trainee disclosure and enhanced examination of multicultural and ethical considerations

APPIC Empirical Evidence Suggests That With Improved Alliance Supervisees will: o Disclose more in supervision o Adhere to treatment better o Connect better to their client (Bernard & Goodyear, 2004)

APPIC How Supervisors Help Foster a Strong Alliance Create shared goals with supervisee Consider the process of evaluation o Criteria for evaluation (based on what?) o Formative versus Summative (when?) o Evaluation feedback and instruments (how?) Cultivate a safe, supportive atmosphere o Discuss multicultural issues o Address negative experiences/interactions

APPIC Strategies for developing ethical competencies in our trainees Strategies for developing ethical competencies in our trainees Early in training (practicum): o Supervisor initiative to focus on ethics o Incorporate ethics in a structured manner into supervision process o Intervene actively in ethical decision- making o Recognize individual differences in critical thinking in supervisees

APPIC Strategies for developing ethical competencies in our trainees Later in training (internship/postdoc): o Can recognize ethical dilemmas and to function more autonomously in ethical decision making o May still need assistance with complex ethical dilemmas o Inculcate value of life long learning related to ethical competency o Can identify context specific ethics in order to develop templates

APPIC Experiential Learning A model of ethical decision making using clinical supervision vignettes

APPIC Ethical Decision Making o Recognize a situation in which there is an ethical dilemma or in which there is potential for harm o Identify the underlying moral or ethical principle or dilemma o Consult available sources of guidance o Consult a knowledgeable colleague or expert o Consider sources of influence (internal/external) that might impact your judgment o Identify potential options and likely consequences o Decide on a course of action o Take it one step at a time* Adapted from Koocher, G.P. and Keith-Spiegel, P., Ethics in Psychology, 1998

APPIC Multicultural Ethical Vignettes An 18yo male comes in to your clinic to discuss the self-hate that he experiences because of his attraction to other males. He tells you that he is a fundamentalist Christian and has read on the internet about reparative therapies that are designed to make me normal. He requests this treatment and volunteers that he has no interest in learning to accept the unacceptable. An 18yo male comes in to your clinic to discuss the self-hate that he experiences because of his attraction to other males. He tells you that he is a fundamentalist Christian and has read on the internet about reparative therapies that are designed to make me normal. He requests this treatment and volunteers that he has no interest in learning to accept the unacceptable. A 23yo Latina female comes in to your clinic because she is feeling extreme conflict between her desire to continue in her Ph.D. program in biochemistry and her wish to be close to her extended family in California. They want her to come home and get to know a local male whose family is from the same small town in Mexico. She is lonely and struggles with intense guilt. A 23yo Latina female comes in to your clinic because she is feeling extreme conflict between her desire to continue in her Ph.D. program in biochemistry and her wish to be close to her extended family in California. They want her to come home and get to know a local male whose family is from the same small town in Mexico. She is lonely and struggles with intense guilt. A 24yo male Asian graduate student from Taiwan comes in to your clinic because he feels increasingly unhappy with his major in computer science. He tells you that his family expects him to be a computer science engineer; in fact, they would not have funded travel, living and tuition expenses for him to study anthropology about which he has an intellectual passion. A 24yo male Asian graduate student from Taiwan comes in to your clinic because he feels increasingly unhappy with his major in computer science. He tells you that his family expects him to be a computer science engineer; in fact, they would not have funded travel, living and tuition expenses for him to study anthropology about which he has an intellectual passion.

FB and the Concerned Intern An intern comes to you and confides their concern about a fellow intern who has a Facebook site that includes detailed personal information. Your agency has no explicit policy related to this issue. What if the interns FB site includes drinking photos from a recent spring break trip to Key West? What if the interns FB site includes drinking photos from a recent spring break trip to Key West? What if the interns FB site includes links to a site that features racist and/or LGBTQ targeted humor? What if the interns FB site includes links to a site that features racist and/or LGBTQ targeted humor? What if you work with high risk patients in your setting? What if you work with high risk patients in your setting? What if the concerned intern indicates that they dont want anyone to know that they raised the issue with you? What if the concerned intern indicates that they dont want anyone to know that they raised the issue with you? Do you have an ethical or legal obligation to act in this situation? Do you have an ethical or legal obligation to act in this situation? If you do decide to take action, what are the pros and cons of handling this situation privately versus publicly? If you do decide to take action, what are the pros and cons of handling this situation privately versus publicly? What would you do? What would you do? APPIC

Supervisor Concern You are an internship TD. An intern confides in you that one of her supervisors has been spending supervision time discussing his personal health problems. This supervisor has made deprecating remarks about the mostly lower SES clients who seek treatment in your setting. The intern tells you that she does not want you to stir things up by talking to the supervisor about her complaint and adds that she is the vulnerable party in this situation. How would you react to this disclosure from the intern? How would you respond to the intern? How would you respond to the intern? What are the ethical and legal issues considerations in this situation? What are the ethical and legal issues considerations in this situation? What are your obligations (if any)? What are your obligations (if any)? What would you do? What would you do? APPIC

APPIC Distressed Intern You have noticed that your supervisee Pat has seemed quieter than usual in supervision and in the training seminar. When you casually ask at the end of a supervision session how Pat is doing, Pat confides in you that Pats former partner has just ended a 6 year relationship that began when they were in college. Pat begins to sob with great intensity when describing the situation to you. Pat has been distraught and has even had thoughts of not wanting to live. Pat begs you not to tell the training committee because the humiliation would make things worse. In addition to being on call that day, you are already running late for a meeting, have several phone calls to return and a client waiting to be seen. What might you be feeling? What might you be feeling? What are your various obligations? What are your various obligations? What if you are aware that at least one of Pats clients is dealing with the painful ending of a romantic relationship? What if you are aware that at least one of Pats clients is dealing with the painful ending of a romantic relationship? What are the relevant ethical or legal obligations? What are the relevant ethical or legal obligations? What are some possible courses of action? What are some possible courses of action?

APPIC Staff Halloween Party The counseling center staff is planning their annual Halloween party. This is traditionally a time during which staff let loose; dress up in costumes and share good food and drinks. Some of the staff wants to invite the Interns so that they will feel more included in the staff and get to know every better. Some staff feel uncomfortable drinking and partying with students present. What are the relevant ethics considerations? What are the relevant ethics considerations? What are the potential benefits and risks? What are the potential benefits and risks? What would you advise the staff? What would you advise the staff?

Supervisor Competence You are supervising Joan who is an intern at your center. She took an advanced DBT case formulation seminar, completed an intensive DBT practicum and was a RA in a DBT lab in her doctoral program. She is very excited about applying this approach to a client who has presented to the outpatient clinic with a history of self injurious behavior. You have worked with such clients, but your only exposure to DBT was a weekend workshop that you participated in several hears ago. What would your thoughts and feelings be? Are you competent to supervise this treatment case? What are the legal and ethical issues? What are your options? What would you do? 62 APPIC 2009

63 Relationship Concern Earl is a recently separated staff member who is supervising Edith. Edith approaches Earl towards the end of the day with a request to discuss a client she is concerned about. Earl explains that he is busy the next hour, and he has an appointment later that evening and needs to leave on time in order to get dinner before his appointment. However, Edith is welcome to join him and discuss her concerns over dinner. Edith really wants to discuss her case but feels uncomfortable discussing the case over dinner. She is also concerned that her supervisor will think less of her if she isnt willing to do this. You are a staff member that works with Edith and she mentions the situation to you before responding to Earls invitation. What would your reaction be? What would your reaction be? Would you feel differently if the genders were reversed? Would you feel differently if the genders were reversed? What would be relevant ethical issues in this situation? What would be relevant ethical issues in this situation? What would your do? What would your do?