assignment

A Positive and Proactive Approach to the Ethics of the First Interview

Sharon K. Anderson • Mitchell M. Handelsman

Published online: 7 September 2012

� Springer Science+Business Media, LLC 2012

Abstract Some may view the initial interview as a mech-

anistic procedure complete with a list of tasks to accomplish.

The primary purpose of this article is to deconstruct this

perspective and encourage psychotherapists to explore the

initial interview through an ethical acculturation lens. Using

a case scenario, we demonstrate the need for purposeful

reflection to better understand important judgments and

choices psychotherapists make while conducting initial

interviews. Employing a proactive approach to ethics using a

‘‘wide-angle’’ lens, we organize the discussion around per-

sonal, professional, and global themes. We offer practical

tips to facilitate ethical excellence as psychotherapists

engage in their first client contacts.

Keywords Psychotherapy � Initial session � Ethics

Consider the following case:

Francis sat in her new upholstered chair, listening to

her new client. Francis felt herself lean forward,

clasped her hands, and gave Samantha her undivided

attention. Although this had become a usual scene for

her since finishing graduate school a couple of months

ago, the initial interview continued to be a captivating

experience for Francis, engendering a range of feel-

ings. On one hand, each client was unique and Francis

relished the opportunity to know somebody so deeply

and to have an impact on another life. On the other,

there was much to accomplish and a high level of

routine. As the conversation ensued, Francis worked

through the ‘‘roadmaps’’ she had learned in her

training—all the different questions and areas to

explore during an initial interview. It seemed that with

each graduate course—on domestic abuse, substance

issues, couples communication—she was told, ‘‘You

need to assess for this issue early in treatment—

preferably during the first session!’’ And, of course,

there was the matter of filling out all the forms that the

agency, insurance company, and others required.

During this initial session, Francis is involved in the

sometimes dizzying array of tasks including identifying

and clarifying Samantha’s concerns, collaboratively setting

goals, gathering historical information for context, evalu-

ating present functioning, providing information about

therapeutic process and prospects, and establishing rapport

(Jones 2010). Some of Francis’s first-session scripts have

explicit ethical or legal components, such as signing con-

sent forms and conveying information about confidential-

ity. However, at different times with different clients she

may not see more subtle ethical dimensions embedded in

many of her other tasks—nor, indeed, in preparation for the

session itself.

At first glance, many psychotherapists may perceive the

initial interview as a mechanistic procedure with a definite

script including specific questions to ask, information to

gather, and forms to review. In reality, the initial interview

is anything but mechanistic; psychotherapists make many

The contributions of Sharon K. Anderson and Mitchell M.

Handelsman to this article were equal.

S. K. Anderson (&) School of Education, College of Applied Human Sciences,

Colorado State University, Room 210, Fort Collins, CO 80523-

1588, USA

e-mail: [email protected]

M. M. Handelsman

Department of Psychology, University of Colorado Denver,

Denver, CO 80045, USA

123

J Contemp Psychother (2013) 43:3–11

DOI 10.1007/s10879-012-9219-3

important judgments and choices, often without thinking

about them. We contend that proactive reflection about

these judgments and choices is not only a good idea but

also promotes ethical excellence. Employing a proactive

approach with ethics is a useful and important filter or lens

with which therapists can better understand and conduct

the first interview. Our primary purpose in this article is to

explore the advantages of viewing the initial clinical

interview through a positive, proactive ethics lens.

We recommend that psychotherapists approach the ini-

tial clinical interview with a positive, proactive ethical lens

that might best be described as ‘‘wide-angle.’’ By this we

mean two things. First, many current notions of ethical

decision making (Cottone 2012) are very cognitive and

treat personal emotions and motivations as contaminants in

the process of making good judgments (e.g., Ford 2006). In

contrast, we see these emotional and personal components

as essential parts of a broader ethical choice making pro-

cess (Anderson et al. 2006) that may lead to more sound

decisions and ones with which therapists can see as fitting

with their professional ethical identity (Anderson and

Handelsman 2010; Handelsman et al. 2005).

Second, our wide-angle ethical lens is a positive—not to

say rose-colored—one. Our argument for a positive

approach stems from the idea that ‘‘current notions of

professional ethics focus too heavily on avoiding or pun-

ishing misconduct rather than promoting the highest ethical

conduct’’ (Handelsman et al. 2002, p. 732). A similar

approach exists in business; for example, Campbell (2006)

wrote about compliance education in terms that reflect a

positive approach: ‘‘When we focus on compliance alone,

we are setting the bar too low … something more holistic is increasingly required’’ (para 5). Campbell saw a need for

business ethics to become ‘‘embedded in every action we

take and … no longer an inelegant appendage’’ (para 8). Our wide-angle, positive ethical lens is consistent with

the argument that self-reflection is an important part of

competence (Fouad et al. 2009). A positive approach to

ethics and choice making—not just paying attention to

obeying the rules—may have several benefits for thera-

pists, including (a) better practice, (b) improved risk

management, (c) prevention of later ethical problems, and

even (d) more professional fulfillment.

Although many authors have written about positive

approaches to ethics, Handelsman et al. (2009) organized

their discussion into three major levels, each with several

subthemes. The first level is personal awareness, including

understanding one’s own values and motives, developing

ethical sensitivity, self-care, and enhancing virtues. The

second level is professional awareness, which includes

ethical acculturation, ethical reasoning, the moral traditions

of psychotherapy, and issues of prevention. The third level

is global awareness, including multicultural awareness and

political sensitivity. Because of space limitations we are

prohibited from addressing all of subthemes; however, our

organization for this article will follow the three major

levels. The subthemes within the themes are not necessarily

sequential, but readers can use tips in each section as an

outline of purposeful exploration of who they are as per-

sons coming into a profession (Anderson 2009) and a

choice-making procedure that they can adapt depending on

the agency, background, orientation, and other factors.

Each of these levels expands the angle of the ethical lens.

The themes of positive ethics as outlined by Handelsman

et al. (2009) are shown in Fig. 1.

Personal Awareness

Many students—and seasoned professionals—may be sur-

prised when consideration of ethics starts someplace other

than presenting and explicating ethical rules. However, in

day-to-day practice, ethics codes, rules, policies, and laws

may make more sense to psychotherapists in the context of

their own personal moral and ethical backgrounds. A posi-

tive approach supports the assumption that ethical rules can

help psychotherapists actualize their own values and morals,

rather than being perceived as a constraint on their behavior.

Values and Motives

Let’s return to our case scenario.

Samantha’s first concerns were ones that Francis had

heard before. Samantha was frustrated with how rela-

tionships had gone from good to bad and wanted to

understand her part in the dismal failure of her most

recent relationship. As Francis listened she realized

that Samantha had not given this former partner a name

and seemed to take great pains to avoid giving too

THEMES of POSITIVE ETHICS

I. A. Values and Motives – noble and personal THEME ONE: Personal Awareness

B. Ethical Sensitivity C. Self-Care D. Virtues – Who should I be?

II. A. Ethical Acculturation THEME TWO: Professional Awareness

B. Ethical reasoning and choice making C. Moral traditions D. Prevention – consultation, continuing education, ethics rounds

III. A. Multicultural sensitivity THEME THREE – Political (Global) awareness

B. Political Sensitivity C. Political Action

Adapted from Handelsman, Knapp, & Gottlieb, 2009

Fig. 1 Themes of positive ethics

4 J Contemp Psychother (2013) 43:3–11

123

much information about the person. Francis wondered

why. Should she ask for any information about the

partner like name, how they met, or gender? Although

Francis didn’t want to make assumptions, she also

didn’t want to come across as either interrogative or

uninterested. She decided early on not to ask these

questions and just listen. She felt that being respectful

of Samantha’s presentation style was more important

at this point than gathering complete information.

Had Francis seen the first session simplistically or

mechanistically, she might have simply asked for the

information that would make her initial report or treatment

plan look more thorough. However, she realizes that the

interview provides an opportunity to demonstrate many

facets of the therapy process and therapeutic relationship.

Questions of how and when to demonstrate various thera-

peutic components during the initial interview is partly a

function of therapeutic knowledge and skill. At the same

time, these choice points are heavily influenced by the

interviewer’s experiences, motivations, and values.

Francis’s primary motivation may be to help clients, but

she may also be motivated by such things as curiosity (both

professional and personal), the need to be perceived as

helpful, money, and the wish to live up to the high expecta-

tions of parents, mentors, and herself. Thus far, she seems to

be aware of at least some of these motivations in her choice

making. She also made a conscious decision to value

Samantha’s need not to disclose higher than the need to gather

information (at least in the early stages of the interview).

In regard to personal values and motives, therapists may

want to ask two deceptively simple questions as they pre-

pare for first interviews: ‘‘What am I doing here?’’ and,

‘‘What needs am I fulfilling?’’ The answers to these

questions may bear directly on both process and outcome.

For example, if Francis’s motivation is to be perceived as

therapeutic, she may miss seeing the possibility that

Samantha may be better served by another therapist, or

may not need therapy at all. The answers may also help

identify sources of bias, including feelings of attraction,

disgust, and other difficult reactions during the interview

(Pope et al. 2006).

Ethical Sensitivity

Readers may be thinking at this point: ‘‘The questions

about what am I doing here and what are my needs are

interesting, but what do they have to do with ethics?’’ This

question leads directly into the next component of positive

ethics: ethical sensitivity.

Rest (1984) defined ethical sensitivity as assessing or

interpreting a situation as having an ethical component and

recognizing that one’s decisions or behavior will influence

the ‘‘interests, welfare, or expectation of other people’’

(p. 21). We start from the assumption that ethical judg-

ments are not limited to dilemmatic situations (Rogerson

et al. 2010). We suggest that all decisions have ethical

dimensions and have the potential to contribute to future

ethical dilemmas. For example, issues of values and

motivations form the basis for considerations of conflicts of

interest and competence. In our scenario, at some point

Francis may ask herself, ‘‘Whose needs are being met?’’ An

explicit recognition of her own needs may help her determine

whether her needs are overshadowing those of Samantha

(Corey et al. 2007). To the extent that psychotherapists

explore their motives, values, and needs and incorporate

them into their choice making—about issues with explicit

ethical considerations (e.g., securing informed consent) and

implicit considerations (e.g., goal setting), they may avoid

pitfalls of not seeing ethical issues and/or of seeing ethics as

an external set of constraints. By exploring these more per-

sonal parts of the self, therapists may go beyond simply

following rules to ‘‘develop a comprehensive and coherent

ethical identity’’ (Anderson and Handelsman 2010, p. 18).

Virtues

Along with seeing the ethical dimensions in the situation,

therapists can look at their own personal and professional

qualities or traits that guide their choices. We consider

these characteristics, called ethical virtues (Jordan and

Meara 1990; Meara et al. 1996; Peterson and Seligman

2004), to be aspects of professional identity. As Meara

et al. (1996) suggested, virtue ethics help clarify those

internal aspects (e.g., motivations, ideals, core character,

and emotions) that drive therapists’ everyday professional

decisions and present ‘‘a more complete account of the

moral life than actions based on rules or principles’’ (p. 24).

Fowers (2005) took virtue ethics to a more defined level:

‘‘Virtue ethics has a clear focus on the pursuit of goodness,

the character strengths that make pursuit possible, and the

practical wisdom that guides ones seeking what is good’’

(p. xi). Some of the major virtues identified in the literature

are humility, prudence, respectfulness, compassion,

empathy and integrity (Beauchamp and Childress 2004;

Fowers 2005; Meara et al. 1996).

In our case example so far, Francis may exhibit

respectfulness by not assuming that Samantha will be just

like other clients with similar presentations. Rather, she

will appreciate Samantha as having unique characteristics

and unique concerns. When Francis finds those character-

istics and concerns and reflects them back with compassion

and accurate empathy, Samantha will likely feel respected

and understood. Humility and prudence come into play as

Francis does her best to withhold negative judgment about

the client’s worldview and/or issues.

J Contemp Psychother (2013) 43:3–11 5

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Virtue ethics may give therapists a more personal and

therefore effective foundation from which to make choices.

In addition, virtue ethics or moral character, as some sug-

gests, ‘‘is more important than conformity to rules because

a virtuous person is more likely to understand the princi-

ples and rules on which he or she acts’’ (Kitchener and

Anderson 2011, p. 58). For example, saying that therapists

should not practice beyond their limits of competence

because it is forbidden by the APA Code (and grounds for

malpractice action) may be less compelling than judging

that such actions do not actualize cherished virtues of

integrity, prudence, and kindness. In some cases, virtues

may help therapists make good decisions when there are no

explicit guidelines. For example, in some agencies the

person conducting the initial interview may be strictly an

evaluator who gathers information from the client and

passes it on to the therapist. In this situation, professionals

acting on virtues such as respectfulness will (a) tell clients

quickly that they will have to share their stories again with

their therapist, (b) remind clients of this several times

throughout the interview, and (c) exercise discretion in

asking questions that would be interesting but not neces-

sary for the assessment.

For most virtues, too little or too much can be a prob-

lem. As Bhuyan (2007) stated, ‘‘A virtuous habit of action

is always an intermediate state between the opposed vices

of excess and deficiency’’ (p. 47). For example, as Francis

decides how much to push Samantha to provide informa-

tion, she may be attempting to actualize her virtue of

humility. Too little humility may lead to arrogance and

assumptions that she knows best which client information

is most important and that she would be the best therapist.

On the other hand, too much humility can lead to Francis to

acting too timidly, not asking necessary questions, and

performing an inadequate assessment.

Some authors consider integrity to be an overarching

virtue consisting of the ability to consciously balance the

other virtues and to act consistently over time and in the

face of pressures to act otherwise. Some also consider

practical wisdom, the ability to deliberate and choose

courses of action, to be a ‘‘master virtue’’ (Schwartz and

Sharpe 2006, p. 377).

Professional Awareness

With a firm grounding in personal awareness we can

broaden our lens and consider how our motivations, values,

and virtues are applied in the professional context. Once

again we look in on our case:

As Samantha became a bit more comfortable in the

interview Francis began to feel slightly confused and

uncomfortable. First, Samantha made a passing ref-

erence to the ‘‘abusive relationships’’ she has expe-

rienced since she was a kid. Then, toward the end of

the interview, Samantha mentioned the decision she

really came to talk about: whether to start identifying

as a male because that is how she really felt inside.

Francis was not prepared for this last piece of infor-

mation. This was definitely new for her. She had not

worked with a client who presented with such gender

identity issues.

Ethical Acculturation

Part of the discomfort Francis is feeling may be because she

has reached the limits of her ordinary moral sense—her

intuitive, non-reflective judgments (Kitchener and Anderson

2011). The therapeutic situation demands technical skills

and ethical judgments that are unique and sometimes

implicit. For example, Francis might be trying to assess and

deal with the possibility of needing to break confidentiality

with this disclosure of ‘‘abuse.’’ Does she need to breach

confidentiality about the ‘‘times of abuse’’? Is she competent

to provide therapy to Samantha based on Samantha’s desire

to explore her gender identity? At the same time, she doesn’t

want to turn Samantha away for fear of appearing biased or

discriminatory. Or is the discomfort, on some level, a con-

flict of personal ethics and values of origin? Does Francis

feel offended by Samantha’s desire to be ‘‘Sam’’ rather than

Samantha? Do her personal values, motivations and

worldview interfere with her ability to offer respectful and

nonjudgmental therapy? Francis cannot afford to ignore the

discomfort or affective response she feels. She needs to take

a few moments for ‘‘purposeful reflection and exploration’’

of what’s going on inside (Anderson 2009). By doing this

reflection and exploration, she can determine the need to

adapt her pre-existing values, motivations, and virtues to the

professional situation or culture. Handelsman et al. (2005)

termed this adaptation process ethical acculturation.

Handelsman et al. (2005) speculated that adapting to the

culture of psychotherapy might involve processes similar to

the acculturation process of immigrants, refugees, and

others as they adapt to a new culture. They adapted the

acculturation model of Berry, a cross-cultural psychologist,

and his colleagues (Berry 1980, 2003; Berry and Kim 1988;

Berry and Sam 1997). Berry and Sam (1997) defined

acculturation as ‘‘a set of internal psychological outcomes

including a clear sense of personal and cultural identity,

good mental health, and the achievement of personal sat-

isfaction in the new cultural context’’ (p. 299). Handelsman

et al. (2005) adapted this definition to the idea of ‘‘ethical

acculturation’’ by substituting the word ‘‘ethical’’ for the

word ‘‘cultural’’ in the definition.

6 J Contemp Psychother (2013) 43:3–11

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As Francis enters the new culture of psychology and psy-

chotherapy she is consciously and unconsciously addressing

two ethical acculturation tasks: (a) maintenance and (b) con-

tact and participation. The task of maintenance prompts the

therapist to explore the question: ‘‘What of my personal

background (my virtues, ethics, morals, and values) will I

keep in this new culture?’’ This question is essential for

Francis to reflect upon. As we and others have stated, the

person part of the psychologist—their personal ethics, values,

and motivations—needs to be explored in light of entering a

new professional culture (Anderson and Handelsman 2010;

Handelsman et al. 2005; Kitchener and Anderson 2011).

Francis also faces a second task, the task of contact and

participation—she must work through how much she

chooses to identify with and adopt the traditions, values,

and behaviors of the professional culture. ‘‘What of this

professional culture do I see as having value and want to

adopt as my own?’’ Thus far in Francis’s training and

professional practice, she has found the values and ethics of

the profession ones she wholeheartedly adopts.

Berry and Sam (1997) conceived of these two tasks—

(a) maintenance and (b) contact and participation—as

continua along which the therapist’s response to the tasks

can be high or low. They discussed the resulting attitudes

and behaviors in terms of four strategies of acculturation:

integration, assimilation, separation, and marginalization.

Integration

If Francis chooses to maintain her personal values and moral

sense as well as adopt the professional culture’s values and

ethics, her acculturation strategy is integration. She can

demonstrate this strategy in several ways. First, she could act

in accordance with her personal value of respect, which

overlaps to a great extent with professional values and

principles. To show respect and her desire to understand,

Francis might ask for more information about the concerns

Samantha has related to gender identity, while also gently

inquiring about her abuse history. Second, Francis might

modify the expression of a personal value—for example, by

showing compassion and asking for more details rather than

utilizing her previous methods of respectful silence and an

occasional empathic remark. Third, she could create and

internalize a new value—for example, she might adopt a

new professional value of confidentiality, which is different

from her old personal values of privacy and loyalty. Finally,

she can reorganize or reprioritize her values. For example,

her previous top priority of respecting privacy might move

lower in her professional hierarchy and the values of con-

scientiousness and diligence would move up.

In regard to psychological acculturation, Berry and his

colleagues concluded, ‘‘Evidence strongly supports a posi-

tive correlation between the use of this strategy and good

psychological adaptation during acculturation’’ (Berry and

Sam 1997, p. 298). It may be that therapists who can inte-

grate their personal and professional ethics will experience

the best ethical adaptation (Anderson and Handelsman

2010). Striving to implement integration strategies can bring

to light disparities and tensions between the existence and

expressions of personal and professional values; through

purposeful reflection and exploration therapists can work to

find ways to honorably reduce the tension between the two.

Assimilation

Sometimes when entering a new professional culture people can

believe that their new professional roles are so different from

who they are that they put aside their own moral sense and

wholeheartedly adopt the profession’s ethical values and tra-

ditions. This is an assimilation strategy. For example, Francis

might assess the abuse issues with Samantha only to see if

reporting is necessary, and do this without tempering her

approach with the respect and compassion she would show to a

friend. On the face of it, this assimilation strategy appears to be

good because Francis is doing the right thing. Those observing

Francis may assume she is engaged in or using an integration

strategy. A potential danger in the assimilation approach,

however, is that Francis may feel less personally connected with

the profession and regret losing her sense of self to the profes-

sion. The result may be feelings of alienation and burnout.

Separation

Separation strategies involve high maintenance of the per-

sonal moral self but low contact with professional culture and

values. If Francis felt little real connection with the ethical

culture of psychotherapy, she may see reporting require-

ments as an unwarranted intrusion of government into the

special relationship she has with clients in general, and with

Samantha in particular. Also, she might fail to conduct an

adequate assessment of her competence to assist Samantha

with her gender identity concerns by perhaps saying to her-

self, ‘‘I can help anybody because I’m a good listener. I don’t

need an ethics code to tell me to be careful. I’m a nice person

and a good therapist.’’ She might also attempt, as she

sometimes does with friends, to persuade Samantha that her

concerns are baseless and that she’s just fine the way she is.

Separation strategies might be facilitated by such factors as

ignorance of the professional culture, an unrealistic assess-

ment of abilities (Dunning et al. 2004), or an unwillingness or

inability to appreciate different values and worldviews.

Marginalization

‘‘Those exhibiting marginalization will obey ethical stan-

dards out of personal convenience rather than a sense of

J Contemp Psychother (2013) 43:3–11 7

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moral commitment’’ (Handelsman et al. 2005, p. 61).

Sometimes burnout or psychological distress or dysfunc-

tion can result in therapists being disconnected from both

their moral core and that of the profession. Clearly, this is

the worst of the acculturation strategies and has been

described as being somewhat like a ship with no rudder or

anchor aimlessly drifting about on the sea (Gilley et al.

2008). Fortunately, Francis appears to have too much

emotional stability, self-awareness, and knowledge to

adopt marginalization strategies.

Ethical Reasoning and Decision (or Choice) Making

Many authors have promoted ethical reasoning procedures

that typically include the steps of gathering information,

generating alternative courses of action, looking at policies,

codes, and laws for guidance, making a decision, and

evaluating the decision (Cottone 2012; Knapp and

VandeCreek 2006). Many psychotherapists may think of

using these reasoning processes only when ethical trouble

is looming. Some authors regard these procedures as pri-

marily or purely cognitive in nature. However, a positive

approach, including ethical sensitivity, suggests that better

decisions, behaviors, and clinical outcomes may ensue

when (a) ethical justifications are explicitly explored for all

professional choices, (b) ethical thinking takes into account

emotions and other non-rational factors (Rogerson et al.

2010), (c) the choice making process is affected by and

encompasses multiple conscious and unconscious factors

(Anderson et al. 2006), and (d) deliberations are framed in

terms of acculturation tasks (Anderson and Handelsman

2010). Our discussion in this section will revolve around

two issues that always involve many complex choices:

informed consent and competence.

Informed Consent

Most therapists do not bring a well-defined concept of

informed consent with them into the profession. They are

not used to asking friends, for example, for consent to go

have a pizza, after having informed them of the risks and

benefits involved. Thus, informed consent and the foun-

dational issues that surround it are major aspects of the

therapeutic culture that need to be integrated into their

ethical framework and incorporated into the initial session.

The American Psychological Association (2010) Ethics

Code provides guidance about informed consent to psy-

chotherapy. Standard 3.10 (informed consent) states in part:

‘‘When psychologists … provide … therapy … they obtain the informed consent of the individual … using language that is reasonably understandable to that person….’’ The Standard goes on to state that psychotherapists inform

‘‘persons who are legally incapable of giving consent’’ and

clients mandated to attend therapy, even though those

individuals cannot consent. Standard 10.01 states in part:

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 confiden-

tiality and provide sufficient opportunity for the cli-

ent/patient to ask questions and receive answers.

Other relevant APA Standards include 3.07 (third-party

requests for services), 4.03 (recording), and 6.02 (mainte-

nance, dissemination, and disposal of confidential records

of professional and scientific work).

Although values and traditions regarding informed

consent are new to most therapists, the doctrine fits well

with existing ethical values and virtues in such areas as

respect, conscientiousness, and helping. This is especially

true if therapists approach informed consent as a collabo-

rative process that continues throughout therapy, rather

than a one-time event that happens only at therapy’s

threshold (Pomerantz 2012). Those whose therapeutic

values include empirical support for their activities will be

happy to know that research has shown that the presence of

a consent process and documents leads to better impres-

sions of therapists by potential clients, including increased

ratings of therapist trustworthiness, expertness, and liking

(for reviews see Handelsman 2001; Pomerantz 2012). In

our case study, Francis can integrate the ethical require-

ments of informed consent, whatever legal requirements

for disclosure of information her state may have, and her

desire to be helpful and respectful, by providing Samantha

with written information that is composed in personal and

simple language (e.g., ‘‘I will keep what you say private’’

rather than, ‘‘Pursuant to state statute, the therapist-client

relationship is governed by confidentiality’’). In addition,

Francis can talk with Samantha about important aspects of

treatment, including limits of confidentiality, the effort

involved in the process, and other topics that Samantha

asks about or Francis feels might be important to review.

Francis can make this conversation part of the therapy

rather than an unrelated bit of paperwork.

Competence

Another element in the choice-making process critical to

the initial session is the determination of therapist compe-

tence, which is a complex issue involving skills, knowledge,

and diligence (Kitchener and Anderson 2011; Welfel 2010).

Indeed, competence has been referred to as the very cor-

nerstone of ethics (Fisher 2009; Kaslow et al. 2007) and the

American Psychological Association (2002) Code gives

considerable attention to the necessity for psychologists to

practice within their scope of expertise.

8 J Contemp Psychother (2013) 43:3–11

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In our case example, Francis has many questions to

consider at this point, including: Am I competent to work

with this client at this time? What are my personal values

as they relate to Samantha’s concerns and presenting

issues? How do my personal values interact with my pro-

fessional values of respect, conscientiousness, etc.? Do my

personal values negatively impact my ability to serve the

client? What ethical acculturation strategy do I see myself

leaning toward thus far in my time with this client?

Moral Traditions

Integration strategies can be difficult if psychologists don’t

appreciate the rationales (aka: moral traditions) behind

codes, rules, laws, and policies. Thus, when Francis is try-

ing to understand why she may have to violate confidenti-

ality to report abuse that may have occurred many years

ago, it may be useful for her to apply ethical theory.

One group of ethical theories revolves around basic or

foundational principles, including autonomy, beneficence,

nonmaleficence, justice (Beauchamp and Childress 2008)

and fidelity (Kitchener and Anderson 2011). As an example,

child abuse reporting may be seen as the intrusion of gov-

ernment into the most intense aspects of professional rela-

tionships. On the other hand, it also can be seen as the clash

of at least two principles—beneficence and autonomy.

These ethical principles provide a useful foundation for

the first session. An initial interview has two general pur-

poses: to provide information and to obtain information. As

clients receive information they can begin to make

informed decisions about entering or not entering therapy

with the therapist—their autonomy is respected. On the

other side of the coin, therapists gather important infor-

mation about the client to determine if they are competent

to provide benefits for the client (beneficence) and not

harm them (nonmaleficence).

Prevention

Although it may appear rather late to bring up the concept

of prevention, virtually all of the previously mentioned

issues—ethical choice making, informed consent, rules,

standards, and guidelines—exist to prevent harm and other

ethical violations. For example, informed consent is clearly

designed to prevent harm to clients and promote good

decision making. In this section we highlight two addi-

tional issues: boundaries and conflicts of interest.

Boundaries

Therapists can tune into their professional roles and

boundaries during the first session: They are assessors,

therapists, educators, and consultants. They may also play

the role of independent broker or advocate—trying to

secure optimal services, which may ultimately be provided

by another therapist. These roles shift as therapy pro-

gresses. After the initial interview the therapy or thera-

peutic role may come to the forefront and other roles

recede. For the therapist in our case study, Francis needs to

clarify upfront for Samantha (and herself) what her role or

roles will be during the initial interview as well as her role

in the following sessions (Pope and Keith-Spiegel 2008).

It can be argued that the various roles are not separate,

but simply dimensions of the therapist role—all of which

are within the boundaries of the therapeutic relationship.

When boundaries are crossed however, suboptimal or

dangerous multiple relationships can occur (Greenberg and

Shuman 1997; Kitchener 1988). For example, role shifts

from individual therapist to child custody evaluator are

very problematic and inadvisable.

Conflict of Interest

Conflict of interest is another issue that should be assessed

during an initial interview. The question is not whether

conflicts of interest exist, but to what extent. Any therapist

who receives money to provide therapy has some degree of

conflict. Once again, being aware of such conflicts and

engaging in thoughtful, explicit choice making can prevent

harm.

Another way to incorporate prevention into the first

session of therapy is to anticipate the last session. As Pope

and Vasquez (2007) wrote: ‘‘Therapists have a fundamental

responsibility to clarify the boundaries of the relationship

with their clients. Two of the most important boundaries

are the beginning and ending of therapy’’ (p. 117). Rice and

Follette (2003) recommended discussing termination issues

as part of the initial informed consent conversations.

Global Awareness: Multicultural Sensitivity

The widest setting on our ethical lens is a global one, which

includes political sensitivity, political action, and multi-

cultural sensitivity (Handelsman et al. 2009). The first two

issues are beyond the scope of this article; we focus here on

multicultural sensitivity.

The cultural and ethnic backgrounds of Francis and

Samantha have not been identified; readers may have

formed their own pictures of the characteristics. What if

they were of different nationalities, races, sexual orienta-

tions, disability status, etc.? The meanings of information

about therapy and the therapeutic process, boundary issues,

and confidentiality might be understood differently by

members of different groups (Pedersen et al. 2008). Such

differences in meanings and interpretation may create

J Contemp Psychother (2013) 43:3–11 9

123

barriers to effective counseling and challenges to ethical

choice making. For example, it may be harder to take the

client’s perspective to decide what to include in an

informed consent process (Wise 2007), especially if the

first languages of therapist and client are different (Barnett

2007).

Beyond Ethical Acculturation: The Client’s

Acculturation Process

If readers are persuaded that it is useful to think of thera-

pists engaging in an ethical acculturation process whereby

they integrate their previous moral notions into a new

professional culture, perhaps they will permit one more

extension of the model: Clients need to adapt to the culture

of psychotherapy. Part of therapists’ tasks, then, becomes

not only understanding clients as people but orienting them

to the culture of therapy. Some clients have no experience

in therapy, but even clients who have been in therapy

before may need more information, because therapies and

therapists vary. Therapists’ assessments can include cli-

ents’ assumptions about therapy (O’Neill 1998).

Younggren and Davis (in press) argued that ‘‘clients

have a duty to the treatment relationship and it is at the

outset of the treatment relationship that expectations begin

to emerge.’’ They believe that clients need information

about their responsibilities in the treatment, and that dis-

cussing client responsibilities might have practical benefits

(Jobes and Schneidman 2006).

It could be that clients experience parallel acculturation

strategies. For example, in our case study Samantha might

choose a separation strategy and treat the therapy as a

friendship hoping that Francis will be a ‘‘friend.’’ Or

Samantha could choose the assimilation strategy believing

that she needs to be the ‘‘perfect client’’ by having all the

appropriate insights, although never actually changing her

behaviors. Our hope would be that she adopts an integra-

tion strategy. Here she would use the strengths she has to

fully utilize the insights and skills received in therapy.

Overall, if Francis adopts a positive, integrative approach

to ethics, we believe she will be more effective in helping

Samantha navigate a successful therapeutic acculturation

and be more successful in reaching her therapeutic goals.

Conclusion

The primary purpose in this article was to explore the initial

interview through a positive, proactive approach to ethics.

The initial interview is a time when psychotherapists make

many important choices and judgments about clients, client

issues, and treatment planning. Without purposeful self-

reflection on multiple levels, psychotherapists might mis-

understand clients, client issues, and their own cognitive

and affective responses along the way. We believe self-

reflection can be enhanced with our ‘‘wide-angle’’

approach. The result may be that therapists not only provide

better service by staying out of trouble and avoiding mis-

understandings and ethical pitfalls, but they also broaden

their understanding of clients in a global context. The cli-

ents we serve and the profession we work in is situated in a

multicultural context. An awareness of biases, such as

unintentional racism, sexism, or ageism, is of absolute

necessity (Ridley 2005). We believe this approach we’ve

described affords therapists the opportunity to experience

more professional fulfillment by providing a framework

they can use to think about actualizing their highest moral

and professional ideals even during initial interviews. As we

conclude our discussion, we encourage therapists to

remember some of our preliminary comments. The initial

interview can be more than a routine process. As a psy-

chotherapist, many of our judgments and choices during the

initial interview have ethical elements. We believe this

proactive reflection about choices made during the initial

interview will promote ethical excellence.

References

American Psychological Association. (2002). Ethical principles of

psychologists and code of conduct. American Psychologist, 57, 1060–1073.

American Psychological Association. (2010). Ethical principles of psychologists and code of conduct (2010 amendments). Wash- ington DC: Author.

Anderson, S. K. (2009). A proactive approach to teaching ethics: from

the inside-out. Career Planning and Adult Development Journal, 25, 134–146.

Anderson, S. K., & Handelsman, M. M. (2010). Ethics for psycho- therapists and counselors: a proactive approach. Malden: Wiley.

Anderson, S. K., Wagoner, H., & Moore, G. K. (2006). Ethical

choice: an outline of being, blending, and doing. In P. Williams

& S. K. Anderson (Eds.), Law and ethics in coaching: how to solve and avoid difficult problems in your practice (pp. 39–61). Hoboken: Wiley.

Barnett, J. E. (2007). Seeking an understanding of informed consent.

Professional Psychology: Research and Practice, 38, 179–182. Beauchamp, T. L., & Childress, J. F. (2004). Principles of biomedical

ethics (5th ed.). Oxford: Oxford University Press. Beauchamp, T. L., & Childress, J. F. (2008). Principles of biomedical

ethics (6th ed.). New York: Oxford University Press. Berry, J. W. (1980). Acculturation as varieties of adaptation. In

A. M. Padilla (Ed.), Acculturation: theory, models, and some new findings (pp. 9–25). Boulder: Westview.

Berry, J. W. (2003). Conceptual approaches to acculturation. In

K. M. Chun, P. B. Organista, & G. Marin (Eds.), Acculturation: advances in theory, measurement, and applied research (pp. 17–37). Washington DC: American Psychological Association.

Berry, J. W., & Kim, U. (1988). Acculturation and mental health. In

P. R. Dasen, J. W. Berry, & N. Sartorius (Eds.), Health and cross-cultural psychology (pp. 207–236). Newbury Park: Sage.

10 J Contemp Psychother (2013) 43:3–11

123

Berry, J. W., & Sam, D. L. (1997). Acculturation and adaptation. In

J. W. Berry, M. H. Segall, & C. Kagitçibasi (Eds.), Handbook of cross-cultural psychology (pp. 291–326). Needham Heights: Allyn & Bacon.

Bhuyan, N. (2007). The role of character in ethical decision-making.

The Journal of Value Inquiry, 41, 45–57. Campbell, C. (2006, June 15). Online education and services: A new

education. Legalweek.com. Retrieved July 5, 2006, from http:// callcenterinfo.tmcnet.com/news/2006/06/14/1683423.htm

Corey, G., Corey, M. S., & Callanan, P. (2007). Issues and ethics in the helping professions (7th ed.). Pacific Grove: Brooks/Cole.

Cottone, R. R. (2012). Ethical decision making in mental health

contexts: representative models and an organizational frame-

work. In S. Knapp, M. Gottlieb, M. M. Handelsman, & L.

VandeCreek (Eds.), APA handbooks in psychology: APA hand- book of ethics in psychology (Vol. 1, pp. 99–121). Washington DC: American Psychological Association.

Dunning, D., Heath, C., & Suls, J. M. (2004). Flawed self-assessment:

implications for health, education, and the workplace. Psycho- logical Science in the Public Interest, 5, 70–106.

Fisher, C. B. (2009). Decoding the ethics code: a practical guide for psychologists (2nd ed.). Thousand Oaks: Sage.

Ford, G. G. (2006). Ethical reasoning for mental health professionals. Thousand Oaks: Sage.

Fouad, N. A., Grus, C. L., Hatcher, R. L., Kaslow, N. J., Hutchings,

P. S., Madson, M. B., et al. (2009). Competency benchmarks: a

model for understanding and measuring competence in profes-

sional psychology across training levels. Training and Education in Professional Psychology, 3, S5–S26.

Fowers, B. J. (2005). Virtue and psychology: pursuing excellence in ordinary practices. Washington DC: American Psychological Association.

Gilley, J. W., Anderson, S. K., & Gilley, A. (2008). Ethics in human

resources. In S. Quatro (Ed.), Executive ethics: ethical dilemmas and challenges for the C-suite (pp. 191–212). Charlotte: Information Age.

Greenberg, S. A., & Shuman, D. W. (1997). Irreconcilable conflict

between therapeutic and forensic roles. Professional Psychol- ogy: Research and Practice, 28, 50–57.

Handelsman, M. M. (2001). Accurate and effective informed consent.

In E. R. Welfel & R. E. Ingersoll (Eds.), The mental health desk reference (pp. 453–458). New York: Wiley.

Handelsman, M. M., Gottlieb, M. C., & Knapp, S. (2005). Training

ethical psychologists: an acculturation model. Professional Psychology: Research and Practice, 36, 59–65.

Handelsman, M. M., Knapp, S., & Gottlieb, M. C. (2002). Positive

ethics. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of positive psychology (pp. 731–744). New York: Oxford Univer- sity Press.

Handelsman, M. M., Knapp, S., & Gottlieb, M. C. (2009). Positive

ethics: themes and variations. In C. R. Snyder & S. J. Lopez

(Eds.), Oxford handbook of positive psychology (2nd ed., pp. 105–113). New York: Oxford University Press.

Jobes, D., & Schneidman, E. S. (2006). Managing suicidal risk: a collaborative approach. New York: The Guilford Press.

Jordan, A., & Meara, N. (1990). Ethics and the professional practice

of psychologists: the role of virtues and principles. Professional Psychology: Theory and Practice, 21, 106–114.

Jones, K. D. (2010). The unstructured clinical interview. Journal of Counseling & Development, 88(2), 220–226.

Kaslow, N. J., Rubin, N. J., Bebeau, M. J., Leigh, I. W., Lichtenberg,

J. W., Nelson, P. D., et al. (2007). Guiding principles and

recommendations for the assessment of competence. Profes- sional Psychology: Research and Practice, 38(5), 441–451.

Kitchener, K. S. (1988). Dual role relationships: what makes them so

problematic? Journal of Counseling and Development, 67, 217–221.

Kitchener, K. S., & Anderson, S. K. (2011). Foundations of ethical practice, research, and teaching in psychology and counseling (2nd ed.). New York: Routledge/Taylor & Francis Group.

Knapp, S. J., & VandeCreek, L. D. (2006). Practical ethics for psychologists: a positive approach. Washington DC: American Psychological Association.

Meara, N., Schmidt, L., & Day, J. (1996). Principles and virtues: a

foundation for ethical decisions, policies, and character. The Counseling Psychologist, 24, 4–77.

O’Neill, P. (1998). Negotiating consent in psychotherapy. New York: New York University Press.

Pedersen, P. B., Draguns, J. G., Lonner, W. J., & Trimble, J. E. (Eds.).

(2008). Counseling across cultures (6th ed.). Thousand Oaks: Sage.

Peterson, C., & Seligman, M. E. P. (2004). Character strengths and virtues: a handbook and classification. New York: Oxford University Press.

Pomerantz, A. M. (2012). Informed consent to psychotherapy

(empowered collaboration). In S. Knapp (Ed.-in-Chief), M.

Gottlieb, M. M. Handelsman, & L. VandeCreek (Assoc. Eds.).

APA handbooks in psychology: APA handbook of ethics in psychology (Vol. 1, pp. 311–332). Washington DC: American Psychological Association.

Pope, K. S., & Keith-Spiegel, P. (2008). A practical approach to

boundaries in psychotherapy: making decisions, bypassing

blunders, and mending fences. Journal of Clinical Psychology, 64, 638–652.

Pope, K. S., Sonne, J. L., & Greene, B. (2006). What therapists don’t talk about and why. Washington DC: American Psychological Association.

Pope, K. S., & Vasquez, M. J. T. (2007). Ethics in psychotherapy and counseling: a practical guide (3rd ed.). San Francisco: Jossey- Bass.

Rest, J. R. (1984). Research on moral development: implications for

training counseling psychologists. The Counseling Psychologist, 12(3), 19–29.

Rice, N. M., & Follette, V. M. (2003). The termination and referral of

clients. In W. O’Donohue & K. Ferguson (Eds.), Handbook of professional ethics for psychologists: issues, questions, and controversies (pp. 147–166). Thousand Oaks: Sage.

Ridley, C. R. (2005). Overcoming unintentional racism in counseling and therapy: a practitioner’s guide to intentional intervention. Thousand Oaks: Sage.

Rogerson, M. D., Gottlieb, M. C., Handelsman, M. M., Knapp, S., &

Younggren, J. (2010). Non-rational processes in ethical decision making. Unpublished manuscript. Baltimore: The Johns Hopkins University School of Medicine.

Schwartz, B., & Sharpe, K. E. (2006). Practical wisdom: aristotle

meets positive psychology. Journal of Happiness Studies, 7, 377–395.

Welfel, E. R. (2010). Ethics in counseling and psychotherapy: standards, research and emerging issues (4th ed.). Pacific Grove: Brooks/Cole.

Wise, E. H. (2007). Informed consent: complexities and meanings.

Professional Psychology: Research and Practice, 38, 182–183. Younggren, J. N., & Davis, D. D. (in press). Ethical issues in the

beginning and end of therapy. In S. Knapp (Ed.-in-Chief),

M. Gottlieb, M. M. Handelsman, & L. VandeCreek (Assoc.

Eds.), APA handbooks in psychology: APA handbook of ethics in psychology (Vol. 1, pp. 417–431). Washington DC: American Psychological Association.

J Contemp Psychother (2013) 43:3–11 11

123