Distance is the Best Armor
Ethical Decision-making in Clinical Practice
John D. Gavazzi, Psy.D., ABPP
Donald Jennings, Ed.D
Objectives
Learn the most frequently asked questions of APA’s Ethics Committee.
Understand one model of ethical decision-making.Heighten awareness regarding multiple
relationships. Identify forensic issues related to the practice of
psychology.Recognize confidentiality issues in a variety of
settings
Ethics
Personal ethics
Higher moral principles
Ethical codes/principles
Ethics as law
Goals of the Ethical Codes
To educate and guide ethical decision-making
To provide a clear statement about what contributes to unethical behavior
Difficulties with ethics codes
There are approximately 100 enforceable standards
Codes do keep current (e.g., online psychotherapy)
Codes are not always clear and may contain conflicting information
Autonomy
It encompasses freedom of thought and action. Individuals are at liberty to behave as they chose.
- Determining goals in therapy
- Making decisions (e.g., marriage)
- Terminating treatment
Versus
Authoritarianism
Laissez-Faire
Beneficence
The principle of benefiting others and accepting the responsibility to do good underlies the profession.
- Providing the best treatment possible
- Refer when needed
Nonmaleficence
The principle is doing no harm.
- Not using an experimental technique as the first line of treatment
- Providing benefits, risks, and costs
Versus
Non-productive therapy
Iatrogenic effects of therapy
Fidelity
This principle refers to being faithful to commitments. Fidelity includes promise keeping, trustworthiness, and loyalty.
- Avoid conflicts of interests that could compromise therapy
- Therapeutic contract (e.g., session length, time, attention)
Versus
Divided Loyalties
Lack of informed consent
Risks
Ethics Committees
Licensing Board
Civil Litigation
Criminal Court
APA Ethics Office – FAQs
Release of records (subpoenas & raw test data to attorneys)
Multiple/sexual relationships between client- therapist Multiple relationship/sexual boundaries with supervision Abrupt termination (clinic restructuring, managed care) Forensic/custody matters Test security Confidentiality (breaches and issues between and within
institutions)
APA Ethics Cases
Felony Conviction
Loss of license
Sexual misconduct/Multiple relationships
Child Custody
Practicing outside area of competence
Malpractice Carriers
Sexual misconduct/Multiple relationships
Custody Evaluations
Practicing outside area of competence
State/Provincial Boards of Psychology
Unlicensed practice of psychology
Multiple relationships
Custody Evaluations
Practice outside area of competence
False representations (misleading advertising)
Ethical Decision-Making: A Problem-Solving Approach
1. Describe the parameters of the situation& define potential issues
2. Consult the guidelines (APA Ethics Code, State Licensing Law)
3. Generate the alternative decisions possible for each issue.
4. Enumerate the consequences of making each decision.
5. Consult with a colleague
6. Make the decision.
7. Document your decision-making process and any consultations that you obtained
Boundaries
Definitions,External Boundary Issues, & Internal Boundary Issues
Principles Related to Boundaries
Not all boundary crossings are problematic.
Some boundary crossings are always wrong and/or prohibited.
It is impossible to avoid all boundary crossings.
Evaluation of boundary crossings can be helped by the principles that underlie our ethics code.
External Boundary Issues
Working within limited or small social networks
Working in certain settingsForensic versus Clinical RolesSupervisors
Internal Boundary Issues
Non-therapeutic self-disclosurePsychological voyeurismIntrusive advocacyAllowing patients certain advantagesSelling products to patientsTouching and hugging
Helpful Tips
Psychologists should avoid dual-role and conflict-of-interest relationships.
Sexually intimate behavior with patients is a serious boundary violation with possible legal and ethical consequences.
Psychologists need to carefully monitor rationalizations when faced with multiple roles and seek assistance before blending roles.
Psychologists need to recognize their own feelings toward each patient and how these feelings may interfere with psychotherapy. Seek supervision or consultation if you are engaging in these behaviors.
Group Exercise
Boundaries
Forensic Issues
Responding to Subpoenas, Releasing Raw Data, Custody
Evaluations, &Forensic and Clinical Roles
Responding to Subpoenas
Subpoenas are a legal demand for information; authorized by a court and served by attorney.
Subpoenas can be issued without the knowledge of the patient.
Subpoenas should not be ignored
Responding to Subpoenas
Advise the patient and the patient’s attorney.
Obtain a written release of information.
If patient refuses, communicate the refusal in writing to the party requesting information.
Releasing Raw Data
Test scores, stimuli, and patient responses; not raw handwritten notes
Possible misuse of data (e.g., erroneous conclusions, responses taken out of context)
Raw data (stimuli, test questions) may become part of the public domain.
Raw data can be released to a qualified psychologist who is working with a non-psychologist professional (with appropriate release of information).
Custody Evaluations
Highly specialized and complex process
Refer to APA’s Guidelines for Child Custody Evaluations in Divorce Proceedings
PPA’s Child Custody Project Group
Need a high level of training, skills, and supervision to perform competently
Clinical vs. Forensic Roles
See Chart on last page of handout
Blending clinical and forensic roles must be avoided.
Be clear at the outset of the relationship what your role is and what your responsibilities are.
Group Exercise
Forensic Issues
Confidentiality
Privacy, Privilege, and Confidentiality
Privacy
A basic right granted by the 4th ammendment of the Constitution to decide how much of a person’s thoughts, feelings, or personal data should be shared with others.
Privilege
A legal term that prevents disclosing information in court or other legal proceedings because that information was gathered in a special relationship.
The patient has the privilege and can waive it.
Confidentiality
A professional standard of conduct that obliges the psychologist from discussing information with anyone.
Confidentiality is a cornerstone of psychotherapy.
Breaches of Confidence
Duty to Warn
Patient Welfare/Safety
Mandated child abuse
Helpful Tips
Psychologist knowledge of general principles and issues is crucial
Informed consent at the beginning of treatment is essential.
Prior to releasing any records or general information, a written release of information is usually necessary.
Helpful Tips
There is a “need to know” basis when releasing records. Record keeping becomes an issue.
Special considerations need to be made for rights of minors and legally incompetent individuals.
Group Exercise
Confidentiality
Wrap Up
Question & Answer
Evaluation Forms