Discussion Making Difficult Ethical Decisions

Chapter 3 The APA Ethics Code and Ethical Decision Making

The APA’s Ethics Code provides a set of aspirational principles and behavioral rules written broadly to apply to psychologists’ varied roles and the diverse contexts in which the science and practice of psychology are conducted. The five aspirational principles described in  Chapter 2  represent the core values of the discipline of psychology that guide members in recognizing in broad terms the moral rightness or wrongness of an act. As an articulation of the universal moral values intrinsic to the discipline, the aspirational principles are intended to inspire right actions but do not specify what those actions might be. The ethical standards that will be discussed in later chapters of this book are concerned with specific behaviors that reflect the application of these moral principles to the work of psychologists in specific settings and with specific populations. In their everyday activities, psychologists will find many instances in which familiarity with and adherence to specific Ethical Standards provide adequate foundation for ethical actions. There will also be many instances in which (a) the means by which to comply with a standard are not readily apparent, (b) two seemingly competing standards appear equally appropriate, (c) application of a single standard or set of standards appears consistent with one aspirational principle but inconsistent with another, or (d) a judgment is required to determine whether exemption criteria for a particular standard are met.

The Ethics Code is not a formula for solving these ethical challenges. Psychologists are not moral technocrats simply working their way through a decision tree of ethical rules. Rather, the Ethics Code provides psychologists with a set of aspirations and broad general rules of conduct that psychologists must interpret and apply as a function of the unique scientific and professional roles and relationships in which they are embedded. Successful application of the principles and standards of the Ethics Code involves a conception of psychologists as active moral agents committed to the good and just practice and science of psychology. Ethical decision making thus involves a commitment to applying the Ethics Code and other legal and professional standards to construct rather than simply discover solutions to ethical quandaries (APA, 2012f).

This chapter discusses the ethical attitudes and decision-making strategies that can help psychologists prepare for, identify, and resolve ethical challenges as they continuously emerge and evolve in the dynamic discipline of psychology. An opportunity to apply these strategies is provided in the cases at the end of each chapter and the 10 case studies presented in  Appendix A .

Ethical Commitment and Virtues

The development of a dynamic set of ethical standards for psychologists’ work-related conduct requires a personal commitment and lifelong effort to act ethically; to encourage ethical behavior by students, supervisees, employees, and colleagues; and to consult with others concerning ethical problems.

—APA (2010b, Preamble)

Ethical commitment refers to a strong desire to do what is right because it is right (Josephson Institute of Ethics, 1999). In psychology, this commitment reflects a moral disposition and emotional responsiveness that move psychologists to creatively apply the APA’s Ethics Code principles and standards to the unique ethical demands of the scientific or professional context.

The desire to do the right thing has often been associated with moral virtues or moral character, defined as a disposition to act and feel in accordance with moral principles, obligations, and ideals—a disposition that is neither principle bound nor situation specific (Beauchamp & Childress, 2001; MacIntyre, 1984). Virtues are dispositional habits acquired through social nurturance and professional education that provide psychologists with the motivation and skills necessary to apply the ideals and standards of the profession (see, e.g., Hauerwas, 1981; Jordan & Meara, 1990; May, 1984; National Academy of Sciences, 1995; Pellegrino, 1995). Fowers (2012) described virtues as the cognitive, emotional, dispositional, behavioral, and wisdom aspects of character strength, which motivates and enables us to act ethically out of an attachment to what is good.

Focal Virtues for Psychology

Virtue ethics can provide psychologists a more personal and therefore more effective foundation from which to approach ethical issues, and it helps offset an overreliance on conformity to rules that may be inconsistent with the aspirational principles of the discipline (Anderson & Handelsman, 2013; Kitchener & Anderson, 2011). Many moral dispositions have been proposed for the virtuous professional (Beauchamp & Childress, 2001; Keenan, 1995; MacIntyre, 1984; May, 1984). For disciplines such as psychology, in which codes of conduct dictate the general parameters but not the context-specific nature of ethical conduct, conscientiousness, discernment, and prudence are requisite virtues.

· A conscientious psychologist is motivated to do what is right because it is right, diligently tries to determine what is right, makes reasonable attempts to do the right thing, and is committed to lifelong professional growth.

· A discerning psychologist brings contextually and relationally sensitive insight, good judgment, and appropriately detached understanding to determine what is right.

· A prudent psychologist applies practical wisdom to ethical challenges, leading to right solutions that can be realized given the nature of the problem and the individuals involved.

The virtues considered most salient by members of a profession will vary with differences in role responsibilities. The asymmetrical power relationship and the client’s/patient’s vulnerability in the provision of mental health services requires virtues of benevolence, care, empathy, emotional self-restraint and monitoring, and compassion (Ivey, 2014). Prudence, discretion, and trustworthiness have been considered salient in scientific decision making. Scientists who willingly and consistently report procedures and findings accurately are enacting the virtue of honesty (Fowers, 2012). Fidelity, integrity, and wisdom are moral characteristics frequently associated with teaching and consultation. The Standards for Forensic Psychology (APA, 2013e) encourages forensic practitioners to act with reasonable diligence and promptness in managing their workloads so they can provide agreed upon and reasonably anticipated services across all work activities. The virtue of self-care enables psychologists to maintain appropriate competencies under stressful work conditions (see the  Hot Topic “The Ethical Component of Self-Care”  at the end of this chapter).

Openness to Others

“Openness to the other” has been identified as a core virtue for the practice of multiculturalism (Fowers & Davidov, 2006). Openness is characterized by a personal and professional commitment to applying a multicultural lens to our work motivated by a genuine interest in understanding others rather than reacting to a new wave of multicultural “shoulds” (Gallardo, Johnson, Parham, & Carter, 2009). It reflects a strong desire to understand how culture is relevant to the identification and resolution of ethical challenges in research and practice, to explore cultural differences, to respond to fluid definitions of group characteristics, to recognize the realities of institutional racism and other forms of discrimination on personal identity and life opportunities, and to creatively apply the profession’s ethical principles and standards to each cultural context (Aronson, 2006; Fisher, 2015; Fowers & Davidov, 2006; Hamilton & Mahalik, 2009; Neumark, 2009; Riggle, Rostosky, & Horne, 2010; Sue & Sue, 2003; Trimble, 2009; Trimble & Fisher, 2006).

Openness may also be a core virtue for practicing in the primary care interprofessional organizations created by the Affordable Care Act, where the psychologists’ role extends beyond providing patient services to include making contributions to integrated teams of health care professionals. Nash et al. (2013) have proposed a “primary care ethic” that reflects a guiding philosophy or set of values characterized by openness, appreciation, and willingness to engage as a psychologist in the interprofessional primary care environment. It reflects (a) a respect and appreciation for contributions by professionals from other disciplines; (b) a desire to integrate disciplinary perspectives; (c) a valuing of collaborative relationships and a willingness to cultivate and maintain them; and (d) a willingness to initiate clear, open, and constructive interprofessional communication.

Can Virtues Be Taught?

No course could automatically close the gap between knowing what is right and doing it.

—Pellegrino (1989, p. 492)

Some have argued that psychology professors cannot change graduate students’ moral character through classroom teaching and therefore ethics education should focus on understanding the Ethics Code rather than instilling moral dispositions to right action. Without question, however, senior members of the discipline, through teaching and through their own examples, can enhance the ability of students and young professionals to understand the centrality of ethical commitment to ethical practice. At the same time, the development of professional moral character is not to simply know about virtue but to become good (Scott, 2003). Beyond the intellectual virtues transmitted in the classroom and modeled through mentoring and supervision, excellence of character can be acquired through habitual practice (Begley, 2006). One such habit for the virtuous graduate student and seasoned psychologist is a commitment to lifelong learning and practice in the continued development of moral excellence.

Some moral dispositions can be understood as derivative of their corresponding principles (Beauchamp & Childress, 2001). Drawing on the five APA General Principles,  Table 3.1  lists corresponding virtues.

Ethical Awareness and Moral Principles

In the process of making decisions regarding their professional behavior, psychologists must consider this Ethics Code, in addition to applicable laws and psychology board regulations.

—APA (2010b, Introduction)

Lack of awareness or misunderstanding of an ethical standard is not itself a defense to a charge of unethical conduct.

—APA (2010b, Introduction)

Ethical commitment is just the first step in effective ethical decision making. Good intentions are insufficient if psychologists fail to identify the ethical situations to which they should be applied. Psychologists found to have violated Ethical Standards or licensure regulations have too often harmed others or damaged their own careers or the careers of others because of ethical ignorance. Conscientious psychologists understand that identification of situations requiring ethical attention depends on familiarity and understanding of the APA Ethics Code, relevant scientific and professional guidelines, laws and regulations applicable to their specific work-related activities, and an awareness of relational obligations embedded within each context.

Moral Principles and Ethical Awareness

To identify a situation as warranting ethical consideration, psychologists must be aware of the moral values of the discipline. Although the Ethics Code’s General Principles are not exhaustive, they do identify the major moral ideals of psychology as a field. Familiarity with the General Principles, however, is not sufficient for good ethical decision making. Psychologists also need the knowledge, motivation, and coping skills to detect when situations call for consideration of these principles and attempt to address these issues when and if possible before they arise (Crowley & Gottlieb, 2012; Tjeltveit & Gottlieb, 2010; see also the  Hot Topic “The Ethical Component of Self-Care”  at the end of this chapter).  Table 3.1  identifies types of ethical awareness corresponding to each General Principle.

Ethical Awareness and Ethical Theories

Ethical theories provide a moral framework to reflect on conflicting obligations. Unfortunately, ethical theories tend to emphasize one idea as the foundation for moral decision making, and illustrative problems are often reduced to that one idea. Given the complexity of moral reality, these frameworks are probably not mutually exclusive in their claims to moral truth (Steinbock, Arras, & London, 2003). However, awareness of the moral frameworks that might help address an ethical concern can also help clarify the values and available ethical choices (Beauchamp & Childress, 2001; Fisher, 1999; Kitchener, 1984).

Deception Research: A Case Example for the Application of Different Ethical Theories

Since Stanley Milgram (1963) published his well-known obedience experiments, the use of deception has become normative practice in some fields of psychological research and a frequent source of ethical debate (Baumrind, 1964, 1985; Fisher & Fyrberg, 1994). Researchers using deceptive techniques intentionally withhold information or misinform participants about the purpose of the study, the methodology, or roles of research confederates (Sieber, 1982). Deception is still widely practiced within experimental social psychology and in sexual health behavior and health care research (Kirschner et al., 2010; Miller, Gluck, & Wendler, 2008; Wong et al., 2012). By its very nature, the use of deception in research creates what Fisher (2005a) has termed the consent paradox: obtaining ‘informed consent’ under conditions in which participants are not truly informed.

On the one hand, intentionally deceiving participants about the nature and purpose of a study conflicts with Principle C: Integrity and Principle E: Respect for People’s Rights and Dignity and with enforceable standards requiring psychologists to obtain fully informed consent of research participants prior to study initiation (Standards 3.10, Informed Consent; 8.02, Informed Consent to Research; 9.03, Informed Consent in Assessments; 10.01, Informed Consent to Therapy).

On the other hand, the methodological rationale for the use of deception is that some psychological phenomena cannot be adequately understood if research participants are aware of the purpose of the study. Thus by approximating the naturalistic contexts in which everyday behaviors take place, deception research can reflect Principle A: Beneficence and Nonmaleficence and Principle B: Fidelity and Responsibility by enhancing the ability of psychologists to generate scientifically and socially useful knowledge that might not otherwise be obtained. For example, deception has been used to study the phenomenon of “bystander apathy effect,” the tendency for people in the presence of others to observe but not help a person who is a victim of an attack, medical emergency, or other dangerous condition (Latane & Darley, 1970). In such experiments, false emergency situations are staged without the knowledge of the research participants, whose reactions to the “emergency” are recorded and analyzed.

Standard 8.07, Deception in Research (as well as federal regulations governing participant protections) permits deception under limited conditions. However, its use remains ethically controversial. Below we present a case example of a deception study with discussion of how different ethical theories might lead to different conclusions about the moral acceptability of deceptive research. Readers should refer to  Chapter 11  for a more in-depth discussion of Standard 8.07, Deception in Research.

Case Example

The Gaffe Study (Gonzales, Pederson, Manning, & Wetter, 1990)

This experiment was conducted to examine whether undergraduate males and females differ in their explanations for an embarrassing incident and whether the severity of their mistake would influence their explanations. Undergraduate students were “invited” to help researchers develop a video for a future study on how people form impressions. Each student participated in a taped discussion with another student in which they either were interviewed or were the interviewer. They were not told the true purpose of the study or that the other “student” was actually a confederate of the research team. Participants were then told to place their belongings on a table. As they did so, the experimenter pulled a hidden string attached to a strategically placed cup of colored water, which spilled onto what appeared to be the confederate’s bag. For half the participants, only papers were in the tote bag (low-severity incident) while for the other half an expensive camera was in the tote bag (high-severity incident). Immediately after the cup spilled, the confederate exclaimed, “Oh no, my stuff!” followed by “What happened?” The experimenter had turned on the video so that participants’ nonverbal responses (e.g., hand to face, head shaking), instrumental behaviors (e.g., attempts to empty the bag), and verbal responses (e.g., “I’m sorry” or “I didn’t do it”) could be analyzed. See Fisher and Fyrberg (1994) to learn how introductory students evaluated the ethics of this study.

Ethical Theories

Deontology or Kantian Ethics

Deontology has been described as “absolutist,” “universal,” and “impersonal” (Kant, 1785/1959). It prioritizes absolute obligations over consequences. In this moral framework, ethical decision making is the rational act of applying universal principles to all situations irrespective of specific relationships, contexts, or consequences. This approach reflects Immanuel Kant’s conviction that ethical decisions cannot vary or be influenced by special circumstances or relationships. Rather, Kant stipulated that an ethical decision is only morally justified if a rational person believes the act resulting from the decision should be universally followed in all situations. This is called the categorical imperative. For Kant, respect for the worth of all persons was one such universal principle. A course of action that results in a person being used simply as a means for others’ gains would be ethically unacceptable.

With respect to deception in research, from a deontological perspective, since we would not believe it moral to intentionally deceive individuals across a variety of other contexts, neither the potential benefits to society nor the effectiveness of participant debriefing (informing participants about the true nature of the study after their participation is completed) for a particular deception study can morally justify intentionally deceiving persons about the purpose or nature of the study. Further, from a Kantian perspective, deception in research is not ethically permissible, since intentionally disguising the nature of the study for the goals of research violates the moral obligation to respect each participant’s intrinsic worth by undermining that individual’s right to make rational and autonomous informed consent decisions regarding participation (Fisher & Fyrberg, 1994).

Utilitarianism or Consequentialism

Utilitarian theory prioritizes the consequences (or utility) of an act over the application of universal principles (Mill, 1861/1957). From this perspective, an ethical decision is situation specific and must be governed by a risk–benefit calculus that determines which act will produce the greatest possible balance of good over bad consequences. An “act utilitarian” makes an ethical decision by evaluating the consequences of an act for a given situation. A “rule utilitarian” makes an ethical decision by evaluating whether following a general rule in all similar situations would create the greater good. Like deontology, utilitarianism is impersonal: It does not take into account interpersonal and relational features of ethical responsibility. From this perspective, psychologists’ obligations to those with whom they work can be superseded by an action that would produce a greater good for others.

A psychologist adhering to act utilitarianism might decide that the potential knowledge about social behavior during an embarrassing situation generated by this deception study could produce benefits for many members of society, thereby justifying the minimal risk of harm that the embarrassment might cause and the violation of autonomy rights based on the absence of true informed consent for only a few research participants. A rule utilitarian might decide against the use of deception in all research studies because the unknown benefits to society do not outweigh the potential harm to the discipline of psychology if society began to see it as an untrustworthy science.

Communitarianism

Communitarian theory assumes that right actions derive from community values, goals, traditions, and cooperative virtues. It considers the common good, community values and goals, and cooperative virtues as fundamental to ethical decision making (MacIntyre, 1989; Melchert, 2015; Walzer, 1983). Communitarianism is often contrasted with liberal individualism, an ethical theory that privileges the individual over the group and identifies individual autonomy, privacy, property, free speech, and freedom of religion as the cornerstones of a civil society, thus elevating individual over group rights (Beauchamp & Childress, 2001; Dworkin, 1977). Although all forms of communitarianism support ethical decisions that improve the health and welfare of members of the community, some forms value group welfare over individual rights and reject the deontological categorical imperative that ethical decisions have universal application across different communities.

Whereas utilitarianism asks whether a policy will produce the greatest good for all individuals in society, communitarianism asks whether a policy will promote the kind of community we want to live in (Steinbock et al., 2003). For example, from a communitarian perspective, the competent practice of psychology cannot be defined simply in terms of individual interpretations of ethical standards but rather must be consistently evaluated and affirmed through interdependent and communal dialogue and support among members of the field (Johnson, Barnett, Elman, Forrest, & Kaslow, 2013).

The challenge to a communitarian perspective is the question of which community values should be represented in ethical decision making. Drawing on the principle of justice, Fisher and her colleagues have argued that the values of a majority may not reflect the needs or values of a more vulnerable minority within a community. For this reason, scientific, intervention, or policy decisions made in response to majority values may result in or perpetuate health disparities and other inequities suffered by marginal groups (Fisher, 1999, 2011; Fisher et al., 2002; Fisher & Wallace, 2000). For example, sensitivity to “who is the community” is particularly important when psychologists are consulting with community “representatives” in the design and evaluation of social or educational programs. Restricting consultation to community leaders and program administrators may result in programs that fail to adequately serve the members most in need.

Research psychologists who believe deception research is ethically justified can be conceived as members of a scientific community of shared values that has traditionally assumed (a) the pursuit of knowledge is a universal good, (b) the results of deception research are intrinsically valuable, and (c) consideration for the practical consequences of research will inhibit scientific progress (Fisher, 1999; Sarason, 1984; Scarr, 1988). The historical salience of these shared values may be implicitly reflected, at least in part, in the acceptance of deception research in the APA Ethics Code (Standard 8.07, Deception in Research) and in current federal regulations (Department of Health and Human Services [DHHS], 2009). However, little is known about the extent to which the “community of research participants” shares the scientific community’s valuing of deception methods. The participant community may instead place greater value on their right to determine whether they will be exposed to specific research risks and benefits and on society’s need to perceive scientists as members of a trustworthy profession.

Relational Ethics

Relational ethics, originating out of feminist ethics or an ethics of care, sees a commitment to act on behalf of persons with whom one has a significant relationship as central to ethical decision making. This moral theory rejects the primacy of universal values of deontology and the cost–benefit calculus of utilitarianism in favor of relationally specific obligations (Baier, 1985; Brabeck, 2000; Fisher, 1999, 2000, 2004). It also rejects communitarianism’s emphasis on group norms and instead stresses the importance of the uniqueness of individuals embedded in relationships. Relational ethics focuses our attention on power imbalances and supports efforts to promote equality of power and opportunity for women and other marginalized groups (Brabeck & Brabeck, 2012; Sechzer & Rabinowitz, 2008). It underscores the value of understanding the point of view, needs, and expectations of clients/patients, research participants, and others as a means of enhancing psychologists’ own moral development and ethical decision making (Fisher, 2000; Noddings, 1984).

In relational ethics, responsiveness to research participants and psychologists’ awareness of their own boundaries, competencies, and obligations are the foundation of ethics-in-science decision-making (Fisher, 1999, 2002a, 2004, 2011). From a relational perspective, in the absence of dialogue with prospective participants, the psychologists designing the “Gaffe” study, by virtue of their training and institutional positions, may have overestimated the scientific validity and value of the study and underestimated undergraduates’ stress, discomfort, and sense of disempowerment during the study and following debriefing (Fisher & Fyrberg, 1994). Thus, relational ethics would view this study as a violation of investigators’ obligations of interpersonal trust to participants and as reinforcing power inequities by permitting faculty members to deprive undergraduates of information that might affect their decision to participate.

Ethical Absolutism, Ethical Relativism, and Ethical Contextualism

Psychologists with high levels of ethical commitment and awareness are often stymied by moral complexities that surface when individuals or cultural communities with whom they work hold values that are or appear to be distinctly different from the Ethics Code aspirational principles, contrary to evidence-based “right” clinical outcomes, or inconsistent with federal regulations and professional guidelines for protecting the rights and welfare of research participants. Such dilemmas can be framed in three different ways.

The first, termed “ethical absolutism,” adopts the universal perspective of the deontic position and rejects the influence of culture on the identification and resolution of ethical problems in a manner that can lead to a one-size-fits-all form of ethical problem solving. However, psychologists who adopt an absolutist stance misconceive the discipline of psychology as an impartial helping or scientific profession whose values and techniques are universally related to the essential humanity of those with whom we work (Fisher, 1999; Koenig & Richeson, 2010). For example, drawing on Principle C, Integrity, a psychologist who has learned that a child client has a genetic marker for a serious adult onset disorder may believe it is his ethical duty to share this information with the child, without considering other moral positions, including the child’s right to have one’s future options kept open until one is old enough to make one’s own life choices (Millum, 2014).

In sharp contrast, “ethical relativism,” often associated with some forms of utilitarianism and communitarianism, denies the existence of universal or common moral values characterizing the whole of human relationships, proposing instead that how ethical problems are identified and resolved is unique to each particular culture or community. This can result in confusing what “is” for what “ought” to be (Melchert, 2015). For example, this stance runs the risk of condoning client or organizational behaviors, beliefs, and attitudes that reflect systemic cultural injustices or cultural values such as racism, heterosexism, or misogyny that are iatrogenic to a client’s mental health or the well-being of employees or those whom organizations serve (Cassidy, 2013; Fisher, 2014; Knapp & VandeCreek, 2007).

Ethical contextualism, variously known as cross-cultural ethics or moral realism, blends the two approaches and assumes that moral principles such as beneficence, integrity, social justice, and respect for people’s rights and dignity are or should be universally valued across diverse contexts and cultures, but the expression of an ethical problem and the right actions to resolve it can be unique to the cultural context (Fisher, 1999, 2000, 2014; Korchin, 1980; Macklin, 1999; Melchert, 2015). This position is reflected in the Universal Declaration of Ethical Principles for Psychologists (International Union of Psychological Science, 2008), which includes an articulation of ethical contextualism in its recognition that these value principles may be expressed in different ways in different communities and cultures and that respect for different customs and beliefs should be limited only when they seriously contravene “the dignity of persons or peoples or causes serious harm to their well-being.” Consistent with the relational or feminist ethics framework, psychologists taking a contextual stance are motivated to understand how ethical values may be differentially expressed across different cultural contexts and to identify when group acceptance of a norm is inconsistent with a basic universal morality.

Case Example

Working With a Client With Racist Attitudes and Behaviors

Psychotherapists may wrestle with ethical principles guiding treatment of clients/patients with impulse control or cognitive or emotional disorders whose symptomology includes expressions of racist attitudes and behaviors. Consider the case of a client who has been suspended from work for continued harassment of and threats against his Hispanic coworkers.

Psychologists applying an ethical absolutist position might jump to the conclusion that since racism and intolerance are universally morally reprehensible, the client has no regard for right and wrong or the feelings of others and thus is suffering not only from possible impulse control disorders but also from the more character-based antisocial or paranoid personality disorder.

By contrast, those holding a relativist position might decide that the best approach would be to treat the mental health problem as distinct from the client’s prejudicial attitudes because of their belief that psychologists should be accepting of their clients’ socially constructed values.

Approaching this dilemma from an ethical contextual perspective, psychologists would base their treatment plan on the assumption that, given intolerant beliefs driving the client’s behavior are inconsistent with basic moral values, the crucial task for the psychologist is to understand the meaning and function of the racist attitudes and behaviors as they relate to the client’s mental health problems and address both the racism and mental health conditions during treatment.

Ethical Competence

Too often, psychologists approach ethics as an afterthought to assessment or treatment plans, research designs, course preparation, or groundwork for forensic or consulting activities. Ethical planning based on familiarity with ethical standards, professional guidelines, state and federal laws, and organizational and institutional policies should be seen as integral rather than tangential to psychologists’ work.

Ethical Planning

Ethical commitment and well-informed ethical planning will reduce but not eliminate ethical challenges that emerge during the course of psychologists’ work. Ideally, ethical competence should be “preventive.” A working understanding of ethical theories, Ethics Code principles and standards, scientific and professional guidelines, laws, and organizational policies should help psychologists anticipate situations that require ethical planning before a problem occurs.

Need to Know: “Why Good Students Go Bad”

Burkholder & Burkholder (2014) identified four ethical pitfalls that often lead students to commit ethical violations:

· Beliefs that the Ethics Code is optional or only applies to “bad” people

· Personal characteristics, such as mental health and substance abuse disorders, that distract from a focus on learning how to integrate ethics into professional activities

· Poor advisement or supervision or misguidance, leading to deficient preparation and training

· Overenthusiasm, pressure to achieve high grades, or rushing to complete training requirements that leads to a blurring of appropriate boundaries, taking inadequate steps to protect confidentiality, or taking other ethical shortcuts in science or practice

Need to Know: Ethical Competence and Ethical Planning

Obtaining the competencies necessary to recognize when a situation requires ethical decision making is a daunting task for graduate students, early career professionals, and seasoned professionals (Moffett, Becker, & Patton, 2014). To limit mistakes that can be made when facing unexpected ethical challenges, whenever psychologists begin new professional or scientific work, they should do the following:

· Evaluate their role responsibilities and ensure they have the competencies required to fulfill these roles

· Identify the potential psychological, social, or legal vulnerabilities of those with whom they will work

· Become familiar with commonly established ethical procedures for the type of activities in which they will be engaged, the populations with whom they will work, and the work setting

· Develop a plan to readily draw on the ethical standards, professional guidelines, organizational policies, and laws that should guide their decision making if unanticipated ethical situations arise and identify colleagues who can provide consultation

Competence and Ethical Decision Making

Ethical competence is also necessary to identify unanticipated situations that require ethical decision making. Ethical problems often arise when two or more principles or standards appear to be in conflict, when unexpected events occur, or in response to unforeseen reactions of those with whom a psychologist works. There is no ethical menu from which the right ethical actions can simply be selected. Many ethical challenges are unique in time, place, and persons involved. The very process of generating and evaluating alternative courses of action helps place in vivid relief the moral principles underlying such conflicts and stimulates creative strategies that may resolve or eliminate them.

Ethical decisions are neither singular nor static. They involve a series of steps, each of which will be determined by the consequences of previous steps. Evaluation of alternative ethical solutions should take a narrative approach that sequentially considers the potential risks and benefits of each action. Understanding of relevant laws and regulations as well as the nature of institutions, companies, or organizations in which the activities will take place is similarly essential for adequate evaluation of the reactions and restraints imposed by the specific ethical context.

Ethical Standards

Familiarity with the rules of conduct set forth in the Ethical Standards enables psychologists to take preventive measures to avoid the harms, injustices, and violations of individual rights that often lead to ethical complaints. For example, psychologists familiar with the standards on confidentiality and disclosure discussed in  Chapter 7  will take steps in advance to (a) develop appropriate procedures to protect the confidentiality of information obtained during their work-related activities; (b) appropriately inform research participants, clients/patients, organizational clients, and others in advance about the extent and limitations of confidentiality; and (c) develop specific plans and lists of appropriate professionals, agencies, and institutions to be used if disclosure of confidential information becomes necessary.

Guidelines

Good ethical planning also involves familiarity with guidelines for responsible practice and science. The APA and other professional and scientific organizations publish guidelines for responsible practice appropriate to particular psychological activities. Guidelines, unlike ethical standards, are essentially aspirational and unenforceable. As a result, compared with the enforceable Ethics Code standards, guidelines can include recommendations for and examples of responsible conduct with greater specificity to role, activity, and context. For example, Standard 2.01, Boundaries of Competence, requires psychologists to limit their services to populations and areas within their boundaries of competence, but as a general standard it does not specify what such competencies are in different work contexts. By contrast, guidelines such as those for multicultural education, training, research, practice, and organizational change (APA, 2003) describe the specific areas of training, education, or supervision that psychologists must have to perform their jobs competently. The Guidelines for the Evaluation of Dementia and Evaluation of Age-Related Cognitive Change (APA, 2012d) provide a list of necessary competencies, including memory changes associated with normative aging and the broad range of medical, pharmacological, and mental health disorders (e.g., depression) that can influence cognition in older adults. The crafters of guidelines developed by APA constituencies usually attempt to ensure that their recommendations are consistent with the most current APA Ethics Code. However, readers should be alert to instances in which the 2010 Ethics Code renders some guideline recommendations adopted prior to 2010 obsolete. Specific Guidelines are discussed throughout this book where their relevance to ethical standards can be applied. Continuously updated links to APA guidelines are provided at  http://study.sagepub.com/fisher4e .

Laws, Regulations, and Policies

Another important element of information gathering is identifying and understanding applicable laws, government regulations, and institutional and organizational policies that may dictate or limit specific courses of action necessary to resolve an ethical problem. There are state and federal laws and organizational policies governing patient privacy, mandated reporting for child abuse and neglect and elder abuse, research with humans and animals, conduct among military enlistees and officers, employment discrimination, conflicts of interest, billing, and treatment. For example, practicing psychologists need to be familiar with rules and procedures under the Health Insurance Portability and Accountability Act (HIPAA). Those working in schools must understand privacy rights protections under the Family Education Rights and Privacy Act (FERPA). Psychologists involved in forensically relevant activities must also be familiar with continuing evaluation of rules of evidence governing expert testimony, and research psychologists need to know the Department of Health and Human Services Part 46 Protection of Human Subjects. The relevance of these laws to the science and practice of psychology is discussed throughout this volume.

As discussed in  Chapter 2 , only a handful of Ethical Standards require psychologists to adhere to laws or institutional rules. However, choosing an ethical path that violates law, institutional rules, or company policy can have serious consequences for psychologists and others. Laws and policies should not dictate ethics, but familiarity with legal and organizational rules is essential for informed ethical decision making. When conflicts between ethics and law arise, psychologists consider the consequences of the decision for stakeholders, use practical wisdom to anticipate and take preventive actions for complications that can arise, and draw on professional virtues to help identify the moral principles most salient for meeting professional role obligations (Knapp, Gottlieb, Berman, & Handelsman, 2007).

Stakeholders

Ethical decision making requires sensitivity to and compassion for the views of the affected individuals. Discussions with stakeholders can clarify the multifaceted nature of an ethical problem, illuminate ethical principles that are in jeopardy of being violated or ignored, and alert psychologists to potential unintended consequences of specific action choices. In research, this means enhancing external validity and the generalizability of findings by understanding the realities of participants’ lives. To this end, psychologists draw on the perspectives of prospective participants to ensure that the research design and procedures reflect their values and merit their trust. Psychologists also consult with other community stakeholders to ensure reasonable steps are taken to avoid community harm that may arise following dissemination of research results (Fisher, 1999, 2004, 2015).

In assessment, attention to stakeholder perspectives requires consideration of how examinees’ understanding of the purpose of a test and their trust in the integrity of the testing process may facilitate or hinder test validity. It can also include considering how the way in which a client’s assessment report is written may affect family members or other third parties. In therapy, stakeholder sensitivity entails attending to clients’/patients’ responses to treatment and modifying approaches based on such feedback rather than simply categorizing failure to respond as a form of resistance or other weakness on the part of the client/patient. Sensitivity also requires understanding that family caretakers of children or mentally impaired adults and other professionals providing services in schools, organizations, or integrated health care systems can be affected by or have an effect on treatment outcomes.

By taking steps to understand the concerns, values, and perceptions of clients/patients, research participants, family members, organizational clients, students, IRBs or corporate compliance officers, and others with whom they work, psychologists can avoid making decisions that would be ineffective or harmful (Fisher, 1999, 2000).

Steps in Ethical Decision Making

A number of psychologists have proposed excellent ethical decision-making models to guide the responsible conduct of psychological science and practice (e.g., Barnett, Zimmerman, & Walfish, 2014; Canter et al., 1994; Handelsman et al., 2005; Kitchener & Anderson, 2011; Koocher & Keith-Spiegel, 2008; Newman, Gray, & Fuqua, 1996; Rest, 1983; Staal & King, 2000). A six-step model is proposed that draws on these models and the importance of ethical commitment, awareness, and competence:

· Step 1: Through a sustained professional commitment to doing what is right, develop the skills to identify when a situation raises ethical issues. This commitment includes (a) continuous reflection on the personal versus professional values and potential conflicts of interest influencing reactions to ethical dilemmas and (b) ongoing implementation of appropriate self-care strategies to guard against the influence of occupational stress.

· Step 2: Consider the relevant APA Ethics Code General Principles and Ethical Standards and scientific and professional guidelines as well as organizational policies.

· Step 3: Determine whether there are local, state, and federal laws specific to the ethical situation. Identify also the procedures required to be in compliance with these laws and the consequences of legal action for the welfare of individuals with whom the psychologist works and relevant third parties.

· Step 4: Make efforts to understand the perspective of different stakeholders who will be affected by and who will affect the outcome of the decision. These efforts should help illuminate aspects of the dilemma that are related to power, privilege, and sociopolitical oppression.

· Step 5: Apply Steps 1 to 4 to generate ethical alternatives. Assess the competencies required to implement each alternative and consult with colleagues if necessary. Consider how different ethical theories might prioritize each alternative. Select the alternative that best fulfills one’s obligations under the Ethics Code and has the greatest likelihood of protecting the rights and welfare of those who will be affected.

· Step 6: Monitor and evaluate the effectiveness of the course of action. Modify and continue to evaluate the ethical plan if feasible and necessary.

The cases at the end of each chapter and the 10 case studies in  Appendix A  provide readers with the opportunity to creatively apply the ethical decision-making model described above and the knowledge they gain in reading chapters throughout this book to ethical challenges across a broad range of psychological work. The  next section  provides an example of how the six ethical decision-making steps can be applied to an ethical dilemma.

Step 1: Ethical Commitment.

Dr. Ames is committed to doing the right thing. She thinks of herself as honest, judicious, respectful, and compassionate. She struggles with her desire to maintain James’ confidentiality about his HIV status and her concern about the health risks to Angela and her pregnancy. She recognizes that as a new mother herself, she places a high value on the importance of parental responsibility for an infant’s health and welfare, and her new parental status is influencing her reaction to Angela’s disclosure. Since her return from a maternity leave, she has been diligent in instituting self-care strategies to address the dual stressors of work and new parenthood.

Case Example

An Example of Ethical Decision Making

Dr. Ames conducts individual and group therapy for young adults with dual diagnosis (substance dependence and anxiety disorders) whom she sees in her private practice. Although Dr. Ames was careful not to enter into the group those of her patients who were friends, partners, or relatives, she has recently learned that two group members (James and Angela) have started to date one another. In her next individual therapy session, Angela excitedly tells Dr. Ames that she is pregnant and is planning to move in with James, the father of her baby. When asked if she has seen a doctor, Angela replies that she does not have health insurance and has nothing to worry about since neither she nor James has any diseases. Dr. Ames knows from previous individual sessions with James that he is HIV positive. She asks Angela’s permission to speak with James about their new situation, and Angela agrees. During his next session, James tells Dr. Ames that he does not plan to tell Angela that he is HIV positive because she would leave him. He also angrily reminds Dr. Ames that she is “sworn to secrecy” because she promised that everything he told her, except child abuse or hurting someone, would be confidential.

Step 2: Relevant ethical principles, standards, guidelines, and organizational policies.

Dr. Ames reviews the Ethics Code standards. She realizes that because two of her group therapy patients have unexpectedly entered into a romantic relationship discussed only in their individual sessions that she is confronting an unforeseen potentially harmful multiple relationship (Standard 3.05b, Multiple Relationships). She realizes that her concerns regarding the health risks to Angela and her baby and her conflict over maintaining James’ confidentiality can potentially compromise her objectivity and effectiveness in performing her job. According to Standard 3.05b, she must take reasonable steps to resolve the problem with due regard for the best interests of all the affected persons.

Dr. Ames also recognizes that while it is important to protect James’ confidentiality (Standard 4.01, Maintaining Confidentiality), the Ethics Code permits her to disclose confidential information to protect others from harm (Standard 4.05, Disclosures). She had thought that her informed consent procedure was consistent with ethical standards, since she did inform James and all her individual and group clients/patients of her legal obligation to report child abuse and the possibility that disclosure could also occur to protect others from harm (Standard 4.02, Discussing the Limits of Confidentiality). However, although she was prepared to address issues of group members fraternizing outside of group, she did not anticipate that this type of situation would arise, and she is unsure about the answers to the following questions. Should James’ decision to intentionally keep his HIV status secret and to continue to have unprotected sex with Angela be considered “harm” to another person? Did the consent language adequately inform Dr. Ames’ clients/patients that the risk of transmitting HIV would meet the criteria for disclosure (Standards 10.01, Informed Consent to Therapy; 10.03, Group Therapy)?

Dr. Ames also reviews the Ethics Code’s aspirational principles. She recognizes that she has a fiduciary responsibility to both James and Angela that rests on establishing relationships of trust (Principle B: Fidelity and Responsibility) and worries that the therapeutic alliance with James may be jeopardized if she discloses his HIV status to Angela and that her therapeutic alliance with Angela may be compromised if she is perceived to be colluding with James in a secret that could be harmful to the health of Angela and her baby (Principle A: Beneficence and Nonmaleficence, Principle C: Integrity, and Principle E: Respect for People’s Rights and Dignity).

Step 3: Federal, state, and civil law.

Dr. Ames consults with legal counsel at her state psychological association and discovers that her state does not have a “duty to protect” law requiring clinicians to take steps to protect identified others from harm (see  Chapter 7 ), nor does it impose criminal penalties on people living with HIV who know their HIV status and potentially expose others to HIV. In addition, her state’s mandatory child abuse–reporting laws do not extend to pregnancy. Her state does not have a prohibition against a mental health professional revealing a client’s HIV status to a third party if there is a high risk of transmission to this third party. HIPAA also permits disclosure of information to protect against serious harm to others. However, the attorney also informs her that if she disclosed such information, she might incur legal liability under a variety of civil laws.

Step 4: Stakeholders.

Dr. Ames consults with medical colleagues regarding the probability that James will transmit the virus to Angela and the risks to the fetus and learns that infectivity rates are highly variable, ranging from 1 per 1,000 to 1 per 3 contacts, that mother to child transmission is 15% to 30% and occurs mostly in the last trimester, and that diagnosis and treatment during pregnancy can reduce perinatal transmission (Centers for Disease Control and Prevention, 2015). She also speaks to the prenatal department of the community clinic and finds out that health care providers there routinely provide pregnant women with information regarding HIV risk protection and available HIV testing. To ensure that she is sensitive to the cultural context from which James’ and Angela’s reactions to her decision may be embedded, she also consults with staff in the community outreach department. Some staff express the belief that the risk of HIV is well-known in the community and that Angela is responsible for protecting herself. Others believe that James is violating community standards and that he has therefore given away his right to confidentiality (see Fisher et al., 2009). Still others point out that Dr. Ames may lose the trust of the rest of her group therapy members if she violates James’ confidentiality (Standard 10.03, Group Therapy). Through all of these discussions, Dr. Ames is careful not to reveal the identities of James and Angela (Standard 4.06, Consultations).

Step 5: Generating alternatives and selecting a course of action.

Dr. Ames begins to contemplate alternative actions. From a Kantian/deontic perspective, by not disclosing the HIV risk information to Angela, she would fulfill her confidentiality commitment to James, on which his autonomous consent to participate was based. At the same time, Kant’s idea of humanity as an end in itself might support taking steps to protect Angela and her fetus from harm. From a utilitarian perspective, the importance of protecting Angela and her fetus from a potentially life-threatening health risk must be weighed against the unknown probability of HIV infection to Angela and her fetus as well as Angela’s reaction to the disclosure. Dr. Ames also considers what type of decision would preserve the trust she has developed with her other group therapy clients/patients. The advisory board consultation suggested that there was not a broadly shared common moral perspective that would suggest a specific communitarian or multicultural approach to the problem. From a relational ethics perspective, failing to disclose the information to Angela might perpetuate the powerlessness and victimization of women. At the same time, disclosure might undermine Angela’s autonomy if in fact she is aware of HIV risk factors in general and knows or suspects James’ HIV positive status.

Dr. Ames decides that she will not at this point disclose James’ HIV status to Angela. She concludes that her promise of confidentiality to James is explicitly related to his agreement to participate in treatment, while her sense of obligation to protect Angela from James’ behavior is not related to Angela’s agreement to participate in individual therapy. The feedback Dr. Ames received from community outreach staff suggests that Angela is most likely aware of the general risks of HIV transmission among drug users, and some of Angela’s comments in Dr. Ames’ notes from previous sessions reinforce this inference. In addition, Dr. Ames’ visit to the clinic indicated that there are community health services that routinely advise pregnant women about these risks and provide HIV testing. Dr. Ames decides that at her next individual session with Angela, and during subsequent sessions, she will encourage her to visit the free prenatal clinic for HIV testing, as well as discuss sexual health, related prenatal risks, and the value of prenatal care. She will also tell James of her decision not to disclose his HIV status to Angela at this time, continue to encourage him to do so, and provide him with written information regarding prenatal HIV risk and safer sexual practices.

Step 6: Monitoring.

Dr. Ames will monitor and evaluate the effectiveness of her course of action. During sessions, she will keep apprised of whether Angela visits the prenatal clinic, including whether Angela is tested for HIV. She will also monitor whether James gains the confidence to reveal his HIV status to Angela, especially as Angela enters her third trimester. If Angela remains unaware of her risk, Dr. Ames will ask the couple to come in for a joint session and prepare James in advance for how the information will be shared. In addition, Dr. Ames will continue to evaluate whether the unexpected multiple relationship with James and Angela compromises her ability to maintain objectivity in her individual and group sessions with them and seek consultation if necessary. Dr. Ames also reflects on the adequacy of the criteria she has been using to determine the composition of therapy groups and begins to develop (a) more detailed screening procedures for her individual clients that can identify individuals who may be more prone to romantic or other types of involvement with group members and (b) a plan for referring such clients to another group therapist when appropriate.

Doing Good Well

Ethical decision making in psychology requires flexibility and sensitivity to the context, role responsibilities, and stakeholder expectations unique to each work endeavor. At their best, ethical choices reflect the reciprocal interplay between psychological activities and interpretation of ethical standards in which each is continuously informed and transformed by the other. The specific manner in which the APA Ethics Code General Principles and Ethical Standards are applied should reflect a “goodness of fit” between ethical alternatives and the psychologist’s professional role, work setting, and stakeholder needs (Fisher, 2002b, 2003c; Fisher & Goodman, 2009; Fisher & Ragsdale, 2006; Masty & Fisher, 2008). Envisioning the responsible conduct of psychology as a process that draws on psychologists’ human responsiveness to those with whom they work and their awareness of their own boundaries, competencies, and obligations will sustain a profession that is both effective and ethical.

Ethics requires self-reflection and the courage to analyze and challenge one’s values and actions. Ethical practice is ensured only to the extent that there is a personal commitment accompanied by ethical awareness and active engagement in the ongoing construction, evaluation, and modification of ethical actions. In their commitment to the ongoing identification of key ethical crossroads and the construction of contextually sensitive ethical courses of action, psychologists reflect the highest ideals of the profession and merit the trust of those with whom they work.

Hot Topic

The Ethical Component of Self-Care

The professional practice of psychology can be rewarding as well as stressful. Psychological treatment often involves working with clients/patients who express acute or chronic suicidality, engage in self-harm, are victims of abuse or assault, or are coping with the death of loved ones or with their own chronic or fatal disease. Clinicians treating veterans or others with posttraumatic stress disorder (PTSD) are regularly assessing and treating patients struggling with repetitive aggressive or homicidal episodes that may place the client/patient, their family, and the treating psychologist in physical danger (Voss Horrell, Holohan, Didion, & Vance, 2011). Those treating survivors of sexual abuse by family members or strangers may find their clients’ experiences have a personal impact on their own worldview and life meaning (Courtois, 2015).

The Emotional Toll of Professional Practice

The emotional toll and precarious nature of this work makes psychologists vulnerable to occupational stress, including emotional exhaustion, depersonalization, and a feeling of lack of personal accomplishment. These outcomes can in turn lead to burnout, overcompensating efforts to “save” clients/patients or participants, boundary violations, and other behaviors that impair job performance (APA Committee on Colleague Assistance, 2006; Lee, Lim, Yang, & Lee, 2011; Webb, 2011). For example, military psychologists with extended deployments to war zones who practice in life-threatening contexts risk direct trauma-related distress and vicarious distress working with traumatized military personnel (W. B. Johnson et al., 2011; Johnson, Bertschinger, Snell, & Wilson, 2014). Psychologists working with patients or research participants who graphically describe child or partner abuse, homelessness and hunger, drug abuse and violence, or death and dying may also experience vicarious or secondary trauma, guilt, or a sense of powerlessness for which there is little institutional support (Fisher, True, Alexander, & Fried, 2013; Mailloux, 2014; McGourty, Farrants, Pratt, & Cankovic, 2010; Simmons & Koester, 2003). Psychologists who have a client/patient die from suicide, accident, or fatal disease may not recognize or receive social support for their own grief reactions (Doka, 2008).

Psychologists conducting clinical research requiring strict adherence to manualized treatment protocols and those working in schools, military hospitals, or correctional facilities may experience the painful feelings and psychological disequilibrium that characterizes moral distress—lack of professional control to do what they believe is right (Corely, 2002; Fried & Fisher, in press) in response to institutional constraints on caseload, resources, use of evidence-based practices (EBPs), up-to-date assessment instruments, or trained personnel (Maltzman, 2011; O’Brien, 2011; Voss Horrell et al., 2011). School psychologists working in underpopulated rural settings may experience stressors associated with isolation when they feel detached from both the surrounding community and their professional community (Edwards & Sullivan, 2014). Or in response to work-related stressors, psychologists may develop compassion fatigue or begin to process client/patient experiences on a purely cognitive level, a syndrome W. B. Johnson et al. (2011) described as “empathy failure.”

“Wounded Healer”

Competent treatment of fatally ill, violent, or suicidal clients/patients may require extensive patient contact, behavioral monitoring, interactions with family members, and significant flexibility in identifying appropriate treatment strategies. Not surprisingly, many ethical dilemmas for psychologists working with these patients revolve around decisions regarding maintaining an appropriate balance between personal and professional boundaries (e.g., Standards 3.04, Avoiding Harm; 3.05, Multiple Relationships; 7.07, Sexual Relationships with Students and Supervisees; and 10.05, Sexual Intimacies with Current Therapy Clients/Patients).

Working in emotionally charged therapeutic contexts can lead to work-related exhaustion, a sense of urgency, and worries that may compromise competent therapeutic decisions (Standard 2.06, Personal Problems and Conflicts). Practitioners who have little or no preparation for treating posttraumatic phenomena may overrespond by engaging in rescue behaviors that blur appropriate professional boundaries or underrespond by distancing, blaming, or responding aggressively to the client, thereby causing additional interpersonal damage (Courtois, 2015). On the other hand, such experiences can lead to unique professional growth. Jackson (2001) introduced the term wounded healer to describe how the emotional experience of working with such clients/patients can serve to eventually enhance psychologists’ therapeutic endeavors. Voss Horrell et al. (2011) have described similar positive developments in compassion satisfaction and posttraumatic growth in response to the challenges of treating veterans with PTSD.

Mindfulness-Based Stress Reduction

Research and clinical scholarship on the potential for and diminished work competence associated with burnout, social isolation, compassion fatigue, depression, and vicarious traumatization among psychologists working with high-risk populations have led to a widening endorsement of self-care practices as an essential ethical tool in ensuring competence in psychological work (APA, 2012f). Discerning when stress becomes impairment is difficult in the present moment (Barnett, 2008) and thus requires a proactive approach to self-care that mitigates the effect of stressors on professional competence (Tamura, 2012).

One such approach is mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1993) as adapted for the practice of psychology. MBSR is rapidly becoming a popular approach for maintaining appropriate competencies under stressful work conditions. MBSR is a technique for enhancing emotional competence through attention to present-moment inner experience without judgment. It is seen as an effective means of reducing emotional reactions toward and identification with clients’/patients’ problems that can lead to therapeutic deficits (Christopher & Maris, 2010; Davis & Hayes, 2011; Shapiro, Brown, & Biegel, 2007). Several recent studies have demonstrated positive effects of MBSR training on counseling skills and therapeutic relationships, including distribution of self-care educational materials in graduate courses and modeling and mentoring self-care habits in supervisory relationships (Christopher, Christopher, Dunnagan, & Schure, 2006; McCollum & Gehart, 2010).

Practical Guidelines for Self-Care

While there are empirical studies on effective approaches such as MBSR for maintaining and developing the competencies required, several psychologists have generously shared their own experiences and hard-earned professional insights on personal and professional approaches to such challenging cases (Barnett, Cornish, Goodyear, & Lichtenberg, 2007; Bearse, McMinn, Seegobin, & Free, 2013; O’Brien, 2011; Tamura, 2012; Webb, 2011).

Specific self-care strategies for competent practice include the following:

· Minimize risks posed by the social isolation of working in individualized therapeutic settings through formal (peer consultation or supervision) and informal (professional conferences, lunch with peers) activities.

· Schedule activities that are not work related and develop daily strategies for transitioning from work life to home life.

· Develop healthy habits of eating, sleeping, and exercise.

· Set appropriate boundaries for work-related activities such as beginning and ending sessions on time and limiting work-related phone calls or emails to specific times of the day or early evening.

· Diversify work activities and/or caseload.

· Utilize personal psychotherapy as a means of addressing psychological distress and enhancing professional competence through increased self-awareness, self-monitoring, and emotional competence.

Preparing Psychology Trainees for Work-Related Risks and Self-Care

Self-care strategies should be included in graduate education and training and encouraged as lifelong learning techniques (Bamonti et al., 2014; Barnett & Cooper, 2009). Trainees and young professionals may be particularly susceptible to stressors associated with clinical work, especially when programs have not provided training in self-awareness and self-regulation techniques to balance self and other interests and because they lack experience in maintaining emotional competence (Andersson, King, & Lalande, 2010; Shapiro et al., 2007; Tamura, 2012). W. B. Johnson et al. (2011) proposed that psychologists acknowledge the ethical obligation to routinely assess their colleagues’ performance. This is especially important in graduate and internship programs in which students may rely on peer and faculty reactions as measures of their own competence. Programs should thus strive to create a culture of community competence that encourages trainees to recognize themselves as vulnerable to work-related stress and reduced competence, to recognize personal and professional dysfunction, and to develop professional self-care habits that support emotional and professional competence. Developing such a culture will require a shift from the current reactive self-care training climate to a proactive and preventive professional one with a focus on wellness and responsibility to self and others (Bamonti et al., 2014).

Chapter Cases and Ethics Discussion Questions

A primary care medical center (PCMC) hires an organizational psychologist to help reduce patient complaints about conflicting diagnoses and treatment recommendations from different members of the interdisciplinary team. Discuss the types of professional virtues or moral dispositions that would be most important to nurture in a program designed to improve the performance of treatment staff.

A psychologist is treating a client with explosive anger disorder who has been in several fights with gang members in his neighborhood. The client has expressed a desire to purchase a firearm as protection against the gang. The state has just enacted a law requiring mental health professionals to file a report with a firearm background check database if the client threatens harm to themselves or others. Discuss how different ethical theories might lead to different decisions about whether reporting the client is ethically justified. (Readers may wish to refer to Kangas and Calvert, 2014.)

A graduate teaching assistant (GTA) has repeatedly cancelled the undergraduate experimental psychology lab section she is teaching and was late grading students’ final papers. The professor responsible for the class was aware the GTA was having trouble keeping up with her graduate coursework and, as a result, had taken on some of the GTA’s responsibilities during the semester. The professor is required to complete an end-of-semester GTA evaluation. A poor evaluation can contribute to the GTA losing her assistantship. Discuss how the perspectives and interests of different stakeholders should be considered as the professor decides what to include on the evaluation form.