Wearing Multiple Hats

Ethical Clinical Practice and Sport Psychology: When Two Worlds Collide

Jeffrey L. Brown Department of Psychiatry

McLean Hospital and Harvard Medical School

Karen D. Cogan Center for Sport Psychology

University of North Texas

From their own practices, the authors offer insight into potential ethical dilemmas that may frequently develop in an applied psychology setting in which sport psychol- ogy is also being practiced. Specific ethical situations offered for the reader’s con- sideration include confidentiality with coaches, administration, parents, and athlete–clients; accountability in ethical billing practices and accurate diagnosing; identification of ethical boundaries in nontraditional practice settings (locker room, field, rink, etc.); and establishment of professional competence as it relates to profes- sional practice and marketing.

Keywords: confidentiality, ethics, sport psychology

The study of human behavior and the activity of sport each have rich histories dating back more than a century (Gould & Weinberg, 1995; Wertheimer, 2000). As the paths of these two disciplines have gradually merged, a unique specialty of applied sport psychology has developed. Today, sport psychology is a young yet broad field of study. Researchers have examined countless aspects of how sport and the human mind are interrelated. For example, research has brought some understanding to sport-related topics ranging from social factors and multicultural differences (Balague, 2003) to parenting influences (Hellstedt, 1995) and coaching styles (Hollembeck & Amorose, 2005). In addition to these topics that fall under the rubric of sport psychology, it is not surprising that professional ethics should also play a sig-

ETHICS & BEHAVIOR, 16(1), 15–23 Copyright © 2006, Lawrence Erlbaum Associates, Inc.

Correspondence should be addressed to Jeffrey L. Brown, 691 Massachusetts Ave., Suite 3, Arlington, MA 02476. E-mail: [email protected]

nificant role in all domains of the field. Because of the novelty of this field of study, the ethical issues faced by sport psychology practitioners often differ to some degree from those who practice a more traditional form of psychology.

Ethical practice is emphasized more today than ever before for the licensed psy- chologist practicing in an applied setting. Far from the carpet-covered sofa of Freud, the contemporary sport psychologist may be found in a university counsel- ing center, private practice, locker room, playing field, or sport competition venue. Although a wide range of professionals practice in the area of sport psychology (e.g., coaches, academicians, nutrition counselors, etc.), not all of them hold to the same code of ethics. Those practicing as psychologists in an applied clinical set- ting should be particularly alert to ethical situations unique to the sport culture to avoid committing ethical violations when the two worlds of applied clinical prac- tice and sport psychology come together.

In the provision of direct service delivery, ethics may have nuances for any ap- plied psychologist that could be difficult to negotiate if not readily recognized. This is especially true when one considers that it is essential for practitioners to be able to identify ethically unstable situations and identify the nuances of these situa- tions if they are to behave in an ethical manner. These nuances should be particu- larly important to the licensed health care clinician providing sport psychology services. The previous brief, rather simplistic description of the union and evolu- tion of human behavior and sport does not comprehensively describe the range of potential ethical dilemmas that can be found in sport psychology today. Routinely, professional contacts with athletes and coaches may occur outside of a traditional clinical setting. Therefore, applied sport psychology consultants must be aware of ethical issues from a perspective quite different from that of traditional psycho- therapy. Certainly, ancient Greek athletes were not concerned about third-party payments. Nor were the early philosophical thinkers likely purchasing malpractice insurance or establishing professional competence through continuing education courses. Times have changed, and it is requisite of the psychologist practicing with athletes or teams to be in a “defensive stance,” ready to identify and resolve as ef- fectively as possible those ethical situations arising in an applied setting.

The authors have highlighted four areas from clinical practice for the reader’s consideration. These areas of discussion include (a) confidentiality, (b) diagnosis and third-party billing, (c) maintenance of ethical boundaries when working in nontraditional clinical settings, and (d) establishing and maintaining competence and marketing.

CONFIDENTIALITY WITH ATHLETES

It is common for a referral to be made to a sport psychologist by a source other than the athlete with whom the psychologist will eventually work. For example, a coach, parent, sports medicine professional, or administrator may call on a psy-

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chologist to provide services to an athlete. With the referral being made, the refer- ral source may assume access to information regarding treatment or that other sensitive information will be automatically shared by the psychologist. This assumption can be particularly common when parents are very involved with their child’s sport training, when an exceptional athlete has hit a slump, or when an ath- lete’s deteriorating performance is beginning to affect a team’s success. Athletic administration, coaching staff, and occasionally media, may assume they too should have access to privileged information when they do not.

Confidentiality may be one of the most important factors that characterizes and fosters a trusting therapeutic relationship (Zaro, Barach, Nedelman, & Dreiblatt, 1993, pp. 13–14). Inasmuch, the licensed psychologist who specializes in the area of sport is bound by both the professional standards of psychologists and legisla- tive requirements to make decisions about when to maintain confidentiality. The psychologist should be keenly aware of confidentiality requirements specific to the state or province in which he or she practices. With this awareness, the psycholo- gist can accurately inform the athlete–client as well as the referral source of the limits to this confidentiality (Koocher, Norcross, & Hill, 2005).

The psychologist must clearly establish the boundaries of confidentiality with consideration for the athlete–client, the psychologist, and any referral source who may be a coach, parent, teammate, team physician, or athletic administrator. A common complicating factor here is that some referral sources may be financially supporting an athlete’s treatment. When this happens, referral sources may find it objectionable to be denied access to clinical information and ultimately find them- selves being left out of the loop. The psychologist who is initially contacted by a referral source on behalf of an athlete will find it useful to review confidentiality and its ethical limitations with the source at the time the referral is made. Then, if appropriate, the psychologist could ask the referral source to request that the ath- lete contact the consultant directly. Encouraging a referral source to support an ath- lete’s treatment by honoring confidentiality can be an essential step in building an alliance with the referral source and the athlete, while at the same time protecting information the athlete may share in treatment over time.

Unless otherwise described by legislative or professional ethics, the athlete (or his or her guardian in the case of a minor client) will ultimately hold the privilege of confidentiality. Certainly, the athlete may choose to provide written permission to allow all or any specific portion of information to be shared by the psychologist with a referral source or other party. Again, the psychologist holds the responsibil- ity of knowing state or provincial requirements for confidentiality and explaining those guidelines to the athlete as early in treatment as possible.

In a university setting such as a counseling center, sport psychology consultants may have established relationships with coaches, athletic trainers, or other sport personnel who consistently refer athletes to them for treatment. If the consultant is also a psychologist, he or she may also get referrals for athletes whose needs go be- yond regular performance enhancement to also address clinical issues such as eat-

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ing disorders, substance abuse, anxiety, or depression. In such cases, it is not un- common for the referral source to want confirmation that the athlete is attending counseling and to understand how the athletic department personnel may be of as- sistance to the athlete. Sometimes an athlete’s competitive or training status is de- pendent on receiving treatment (e.g., an anorexic athlete needs to attain a mini- mum weight to train or compete), and the athletic trainer may have an active role in the treatment process and in ascertaining that treatment is indeed taking place. In such cases, athletes are typically required to sign a release of information docu- ment to allow communication between athletic department personnel and the con- sultant. When this happens, it is very important to discuss the release of informa- tion with the athlete and be clear with them about the parameters and limits of disclosure. For instance, it may be determined that athletic personnel will be given information about whether the athlete attends counseling only, rather than specific content or involvement in counseling sessions.

It is also common for coaches, even though they may have been informed of confidentiality boundaries, to ask how an athlete is doing or if an athlete has come for counseling. On occasion, when an athlete does well, the coach may want to know what the consultant told the athlete. Coaches are more likely to ask a consul- tant these types of questions if they know the consultant well or if the consultant is traveling with a team and the coach has ongoing access to the consultant. Most coaches usually mean well and are truly concerned for the athlete’s well-being. At times, it may be tempting for the consultant to hide behind the ethical standards and cite the confidentiality clause, but this response can be construed negatively by the coach. It is probably more conducive to the coach–consultant relationship to acknowledge the coach’s concern for the athlete and then refer the coach to the ath- lete. For instance, a coach may say, “Wow, Sandy did really well in that last compe- tition, and I know she talked to you beforehand. What did you say to her?” One re- sponse is to say, “Yes, she did an outstanding job. Why don’t you ask her what she took away from that conversation?” In this case, the coach is probably most inter- ested in how he can assist Sandy in the future when there is no sport psychology consultant present. It would seem useful for psychologists to ask their clients up front, what, if anything, they would want communicated to their coach in these fre- quently encountered, ethically challenging situations. Then discussions between the coach and consultant can reflect the planned way of handling this situation, putting both individuals at ease.

ETHICAL DIAGNOSING AND THIRD-PARTY BILLING

A consideration early in the therapeutic relationship may be whether a clinical di- agnosis exists. If it does, licensed practitioners or counselors need to consider how that diagnosis will be shared with a third-party payer, if at all. Those practitioners

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who suspect a clinical diagnosis may exist with an athlete and who are not also li- censed mental health practitioners will need to consider making a referral to a li- censed clinician who can assist in diagnostic clarification and provide competent treatment.

First, an athlete must undoubtedly meet diagnostic criteria to receive a legiti- mate diagnosis. After a thorough initial interview, it is commonplace for a psychol- ogist to determine an accurate and appropriate diagnosis (Kamm, 2000). With an athlete referral, differentiating a clinical syndrome from simply lacking talent or skill can be tricky. Given this, it may be helpful to conceptualize the athlete’s sport as “work” when formulating an accurate diagnosis. The following clinical exam- ple may help clarify the challenge of a clear diagnosis. If an accountant presented for treatment complaining of increased errors in calculation, reduced work produc- tivity, and a failing relationship, many psychologists would likely continue to query with clinical antennae raised for anxiety, depression, or some other adjust- ment reaction. Furthering this example, a basketball player who reports poor con- centration, dissatisfaction with the game, and relationship problems should, too, be further evaluated for a psychological disorder such as anxiety or depression, and not just be assumed to have performance enhancement issues. Comparing an ath- lete’s performance in an athletic arena to an employee’s performance in a business arena may be one helpful way of accurately diagnosing an athlete who may need more than training in performance enhancement skills.

When filing for insurance reimbursement, a patient must have met specific di- agnostic criteria for payment to be made (Harris & Bennett, 2005). Further, an insurance company may no longer pay for sessions if clinical symptoms have subsided. Clinicians who are licensed by the state in which they practice are of- ten eligible to receive third-party reimbursement and may receive various types of referrals ranging from performance anxiety to eating disorders or from a sim- ple adjustment disorder to a more significant bipolar disorder. Athletes who present with a clinical syndrome should almost certainly be eligible for insur- ance benefits. However, clarification of benefits from insurance companies may be best sought prior to treatment to avoid any financial surprises for the patient or clinician.

In some instances, athletes are referred only for performance enhancement is- sues. Such a referral may or may not reach a diagnostic level. For example, a sec- ond baseman who wants only to improve concentration while waiting for the pitcher to put the ball in play, complaining his mind drifts and he thinks about fans in the stadium, may simply need to work on concentration skills related to perfor- mance. He has not likely met criteria for an attention deficit disorder that would be typically covered by an insurance plan. The psychologist must strive for accurate diagnosing and not be persuaded by a client or referral source to make a fraudulent diagnosis based on third-party payer funding. Such misrepresentation of a clinical diagnosis can be considered insurance fraud and is simply unethical and illegal.

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Second, does the diagnosis have to be shared with a third-party payer? In almost all cases in which insurance is involved, sharing the diagnosis for reimbursement purposes is a requirement. Although some insurance companies may want more information about the patient’s progress and symptom profile, others may not. De- termining the requirements of insurance companies and the information they ex- pect should be clearly understood and articulated early in the treatment process. It is appropriate to have clients contact an insurance company on behalf of them- selves to discuss payment procedures with regard to confidentiality and reimburse- ment. Other third-party payers such as athletic departments, athletic associations, or parents, for example, may pay out-of-pocket. Paying out-of-pocket simply means that insurance companies may not be involved with reimbursement at all; therefore confidentiality may be maintained more tightly. Some athletes may pre- fer to pay out-of-pocket so that a diagnosis does not go on any confidential record other than the one kept by the psychologist. Regardless of any payment arrange- ment in which fees are not paid directly by an athlete, the psychologist should take measures to clarify the role and accuracy of a diagnosis, other confidential infor- mation, and payment procedures.

COMPETENCE AND MARKETING IN APPLIED SPORT PSYCHOLOGY

Although it may seem commonsensical to suggest a clinician’s competence be a good fit for a referral, a clinician may be tempted to accept a referral to build a practice rather than closely evaluate his or her ability to treat the client and the pre- senting concern. Further, holding oneself out to the public as having a specific area of expertise in sport psychology when in actuality one does not possess such skills is also an ethical violation (American Psychological Association, 2005). For ex- ample, a former college soccer player who has earned an undergraduate degree in psychology, has read several books on coaching soccer, and has coached a junior team to a championship level is insufficiently trained as a sport psychology consul- tant by industry standards. In contrast, a sport psychology consultant who has es- tablished competence and who has received adequate training to provide sport psy- chology services will likely have completed a graduate degree in a behavioral or physical education program, completed graduate coursework specifically in sport psychology, and been supervised by a sport psychology professional competent to provide supervision.

Some individuals, licensed or not, seem to believe competence in sport psychol- ogy can be established by having been a successful athlete, possessing strong inter- est in a particular sport, being well read on a particular sport topic, or joining pro- fessional organizations or so-called vanity boards. These beliefs and practices do

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not establish competence. The issue of competence to practice in the area of sport psychology should be an immediate and ongoing consideration for a clinician. There are several issues to be balanced here. On the one hand, psychologists are of- ten asked to take on new and challenging issues, and consequently may find they need to seek consultation to provide effective treatment. For instance, athletic de- partments may seek treatment for their athletes from the university counseling cen- ter even if no one there is specifically trained in sport psychology. Counseling cen- ter psychologists are often in the position of being asked to provide treatment to many individuals because outreach to a variety of campus groups and populations is part of their job description. Because of such circumstances, both authors have received e-mails from counseling center psychologists asking for input on cases specific to athlete needs or requesting workshops or other types of educational in- terventions. Counseling center psychologists need to determine whether they can ethically intervene with the consultation or if a referral is necessary.

To help identify competency issues, the Association for the Advancement of Applied Sport Psychology (2005) puts forth standards for Certified Consultants. However, the burden of proof of competence rests with the clinician and may have implications that reach much further than certification. It is prudent to document any training or supervision through transcripts or other avenues of formal docu- mentation. Such documentation provides the clinician with evidence that specific, formal training has occurred under the supervision of an individual who possesses competence to teach as well as expertise in the subject or skill being taught. Docu- mentation could include official university transcripts reflecting appropriate grad- uate coursework, course syllabi that describe a specific academic course success- fully completed as a student, or supervision contracts in which both supervisor and supervisee have identified specific learning objectives or technical skills and eval- uated them throughout the training experience. In short, even licensed mental health practitioners should not assume that by virtue of their advanced training in psychology they are qualified to provide sport psychology services to athletes. This is a specialized domain and requires specialized training to become a compe- tent practitioner.

BOUNDARIES IN NONTRADITIONAL SPORT SETTINGS

Boundary issues in sport psychology are much more difficult to maintain and often much less rigid than they are in traditional psychology or counseling. Sport psy- chology professionals often find themselves practicing in a nontraditional setting such as a gymnasium, locker room, or practice field. In fact, some sport psychol- ogy consultants may eat with a team while traveling or have housing accommoda- tions in the same hotel or training dormitory. Certainly a team’s budget can force a

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situation in which a professional must stay on constant ethical guard (e.g., interna- tional travel where the consultant is sharing a small living space in a hotel room or condo with team staff members). In these instances, it is not so much a matter of avoiding these potentially compromising positions but knowing how to handle them if and when they arise.

Traveling and essentially living with a team presents opportunities as well as potential dilemmas. The opportunities involve getting to really know the athletes and coaches and thus having a better sense of how to intervene when there is a cri- sis. Both athletes and coaches are more likely to feel increased comfort with the consultant as they get to know each other and will seek well timed consultation “moments” because the consultant is right there.

Potential dilemmas involve what to do when the consultant is invited to after- practice events such as a postcompetition dinner and party or debriefing with coaches over a drink in a bar. It is not always necessary to turn down these well in- tentioned invitations, but the consultant must be cognizant of the social setting and make good professional and personal decisions. For example, one of the authors often becomes the designated driver for events in which alcohol is available. This allows the consultant to be included in the event but to also have a specific role in assisting the team.

CONCLUSION

In summary, it is clear that the professional psychologist practicing in an applied sport psychology setting faces an assortment of potentially atypical ethical dilem- mas. Among these are how, if at all, to share confidential information in a competi- tion venue or when to respond to a coach or parent inquiry about an athlete’s indi- vidual work. The authors believe that ethical dilemmas such as those presented should be considered in light of current standards of professional practice to pro- mote the specialty of sport psychology while continuing to provide equitable men- tal health services to athletes. Therefore, although practitioners in this specialty need to be just as aware and sensible about maintaining ethical behavior as tradi- tional psychologists, it is important to realize that nontraditional situations are likely to arise that call for nontraditional means of remaining ethical. In short, when concerned about the ethicality of a specific practice, be aware of the differ- ences between sport psychology and traditional psychology and always be willing to consult with a fellow practitioner.

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Association for the Advancement of Applied Sport Psychology. (2005). What is a certified consultant? Retrieved April 15, 2005, from http://www.aaasponline.org

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Kamm, R. L. (2000). The sport psychiatry examination. In D. Begel & R. W. Burton (Eds.), Sport psy- chiatry (pp. 159–190). New York: Norton.

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