The Ethics of Leadership in Psychology

Stephen A. Ragusea, Psy D, ABPP

Guest Blog

It is often said that psychologists have the most complex and demanding set of ethics of all the professions.  Whether or not that is so, we are clearly obligated to behave ethically in our professional lives, and certainly providing leadership is part of that professional existence.

The essence of leadership may be examined in a variety of ways (Thompson 2008) and the ethics of leadership in the field of psychology may similarly be perceived from different perspectives.  Think about the problems caused by ethical mistakes made by leaders that are now significant parts of our collective history. For example, the words Nixon, Enron, and Madoff bring forth a flood of memories about ethical breaches of leadership that clearly impacted the recent past.  Within psychology, the name Abu Ghraib now has special meaning and the debate within psychology about our leadership role there is ongoing.  Of course, these are extreme examples provided to emphasize the importance of ethical leadership.

As psychologists, our Ethical Standards provide us with much general guidance.  We are advised by our Ethical Principles that in all our work as psychologists we should act with “Beneficence… Fidelity and Responsibility… Integrity… Justice… and…Respect for People’s Rights and Dignity….” That’s a significant list of demands. We’re just human beings, after all.  But, we psychologists tend to demand a lot from ourselves. 

It is noteworthy and perhaps surprising that nothing in the Ethical Principles of Psychologists and Code of Conduct (2002) specifically addresses our leadership roles. Yet, psychologists function in leadership positions wherever they work and that includes their efforts within psychological organizations.  So, we must look to other sources for guidance on leadership ethics.

A literature review quickly reveals that little psychological research has been done on ethics in leadership, despite its importance in our world. In fact, it seems that the subject of ethical leadership is more likely to be considered by business scholars than psychologists.  However, there has been some research and scholarly writing done by psychologists, which we can peruse.

On a fundamental level, we psychologists seem to agree that leadership may be described as a “basic tension between altruism and egoism.  That is, some leaders balance the development of themselves and their subordinates, raising the aspirations of both the leaders and the led in the process…. Other leaders wield power to satisfy their own needs and have little regard for either helping the development of their subordinates or behaving in socially constructive ways.” (Turner 2002). 

When considering ethical matters, both psychologists and business professionals tend to embrace models of leadership such as Transformational Leadership. Within that model, leaders provide a vision for change and then endeavor to inspire the other members of the group to pursue that transforming vision.  This model is seen as morally superior and stands in contrast to other models of leadership that involve the direct control of others through coercive transactions.   Such transactional models are tempting for a variety of reasons.  For example they have the advantage of being, at least temporarily, expedient.

Indeed, transactional leadership has been utilized in organizations and nations throughout history and is very often effective for a limited time.  Such was the case with Attila, who served as King of the Huns from 433-453 (Wess 1989).   However, as Gandhi pointed out, “all through history…there have been tyrants…and for a time they seem invincible but in the end, they always fall.  Think of it, always.” Therefore, from both ethical and effectiveness perspectives, it appears that more altruistic leadership based on inspiration is usually superior to self-centered intimidation in most realms.

For that reason alone, it is would be wise for all of us involved in leadership roles to remember that we are primarily there to serve our profession and our patients, not ourselves.  And, research suggests that we lead best by sharing a vision that inspires others to action.  In so doing, we embrace our core ethical principles of “Beneficence… Fidelity and Responsibility… Integrity… Justice… and…Respect for People’s Rights and Dignity….” And, that is our ethical obligation.

References

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist,Vol. 57, 1060-1073.

 

Roberts, Wess (1989). Leadership Secrets of Attila the Hun, New York, Warner Books.

Thompson, A.D., Grahek, M., and Ryan, E.P. (2008).  The Search for Worthy Leadership.  Consulting Psychology Journal: Practice and Research. Vol. 60, 4, 366-382.

Turner, N., Barling, J., Epitropaki, O., Butcher, V. and Milner, C. (2002). Transformational Leadership and Moral Reasoning.  Journal of Applied Psychology.  Vol. 87, 2, 304-311.

Social Connection and Suicide

 John D. Gavazzi, PsyD, ABPP

Chair of the Ethics Committee

In Thomas Joiner's book, Myths About Suicide, he notes that suicide risk is related, in part, to a person's sense of connection with other individuals.  This factor is not the only or main factor in determining risk for suicide, but an important clinical variable in the assessment process.  When an individual reports stronger interpersonal connections with others or a greater the sense of belonging to a group, there is a lower likelihood of an individual committing suicide.  He gives numerous examples in his book (as well as other pertinent risk factors when assessing suicide).

The reason to post about social connectedness and suicide relates to a study to be presented to the American Psychiatric Association on military unit cohesion and suicidal ideation.  Here is a summary of the research:

Unit cohesion appears to be an important factor in determining whether soldiers think about suicide during a period after combat exposure, according to a study presented at the American Psychiatric Association Annual Meeting.

U.S. Army researchers surveyed more than 1,600 soldiers from two combat brigades who had been deployed once. The survey was designed to measure of combat exposure, unit cohesion and self-reported thoughts of suicide. Soldiers who reported higher combat exposure and lower unit cohesion had the greatest odds for reporting suicidal thoughts during the previous four weeks. In addition, soldiers with similar combat exposure were more likely to have suicidal thoughts if they reported less unit cohesion.

This brief description highlights how perceived social connection via group cohesion can the reduce the risk of suicidal ideation.  This study supports the research and writing of Dr. Joiner.

As an aside, I strongly recommend the book to every psychologist and psychologist-in-training due to his research and insights on suicidal ideation and behavior.

We're Blogging for Mental Health



"Informed journalists can have a significant impact on public understanding of mental health issues as they shape debate and trends with the words and pictures they convey. They influence their peers and stimulate discussion among the general public, and an informed public can reduce stigma and discrimination."

- Rosalynn Carter

We are participating in the American Psychological Association's program Blogging for Mental Health.  The overarching goal of this program is to help people recognize the importance of good mental health, overcome stigma, and seek out professional mental health services when needed. 

We decided to highlight an advocate of mental health issues and treatment services, who also has made significant efforts to decrease the stigma surrounding mental health.



Former First Lady
Rosalynn Carter


Rosalynn Carter has been a major advocate for mental health awareness and mental health services.  She supported mental health parity and collaborated with many others to help push this legislative initiative for years.  The Mental Health Parity law was enacted in October 2008.

"Blogging for Mental Health" seems to be a natural extension of Mrs. Carter's project to help raise awareness about mental health through journalism.  While blogging is not officially journalism, the blogosphere is a new medium in which to advocate, educate, heighten awareness, and reduce stigma about mental health issues and mental health treatment.  As psychologists, public education is an aspirational ethic.  Aspirational ethics exemplify the highest standards and best practices of our profession (and not a minimum requirement).

Rosalynn Carter Fellowships for Mental Health Journalism provide money for journalists to promote mental health awareness.  The quote listed above summarizes her position on this program.  More specifically, the goals of Mrs. Carter's project include:

•  Increase accurate reporting on mental health issues and decrease incorrect, stereotypical information
• Help journalists produce high-quality work that reflects an understanding of mental health issues through exposure to well-established resources in the field
• Develop a cadre of better-informed print and electronic journalists who will more accurately report information through newspapers, magazines, radio, television, film, and the Internet and influence their peers to do the same.

We thank and salute Mrs. Carter for her program, her advocacy, and her tireless efforts on behalf of those who suffer with mental health issues.  She demonstrates our aspirational ethic of educating the public on psychological issues and treatment.

Switzerland: Assisted Suicide Remains Legal

Story from the BBC



The Suicide
Madalina Iordache-Levay



Voters in Zurich, Switzerland, have rejected proposed bans on assisted suicide and "suicide tourism".

Some 85% of the 278,000 votes cast opposed the ban on assisted suicide and 78% opposed outlawing it for foreigners, Zurich authorities said.

About 200 people commit assisted suicide each year in Zurich, including many foreign visitors.

It has been legal in Switzerland since 1941 if performed by a non-physician with no vested interest in the death.

Assistance can be provided only in a passive way, such as by providing drugs. Active assistance - helping a person to take or administer a product - is prohibited.

'Last resort'

While opinion polls indicated that most Swiss were in favour of assisted suicide, they had also suggested that many were against what has become known as suicide tourism.

Many citizens from Germany, France and other nations come to die in Switzerland because the practice remains illegal abroad.

One local organisation, Dignitas, says it has helped more than 1,000 foreigners to take their own lives.
Another group, Exit, will only help those who are permanently resident in the country - saying the process takes time, and much counselling for both patients and relatives.
 
Its vice-president, Bernhard Sutter, said the result showed Swiss voters believed in "self-determination at the end of life".

The referendum had offered a proposal to limit suicide tourism, by imposing a residency requirement of at least one year in the Zurich area in order to qualify for the service.

It was backed by two conservative political parties, the Evangelical People's Party and the Federal Democratic Union.

But the major parties of the left and right, including the Swiss People's Party and the Social Democratic Party, had called on their supporters to vote against both motions.

The BBC's Imogen Foulkes, in Geneva, says the size of the vote against a ban on assisted suicide reflects the widely held belief among the Swiss that is their individual right to decide when and how to die.
Their rejection of the proposal to limit assisted suicide to those living in Zurich shows that concerns about suicide tourism carry less weight with voters than their conviction that the right to die is universal, our correspondent says.

But the debate in Switzerland will continue, she adds. Polls show voters do want clearer national legislation setting out conditions under which assisted suicide is permitted.

The Swiss government is planning to revise the country's federal laws on assisted suicide.

It has said it is looking to make sure it was used only as a last resort by the terminally ill, and to limit suicide tourism.

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Blogger Note: Many ethical issues are found in this story.

To Friend or Not to Friend: That is the Question

Anthony S. Ragusea, Psy.D.

Florida Psychological Association

Guest Blog 


Recently on the Florida Psychological Association (FPA) listserv there was a spirited debate about whether or not it is professionally appropriate to accept a “Friend” request on Facebook by a client.  The fact that the debate was happening at all speaks to the enormous change that the Internet and a private social media company, Facebook, is having on the practice of psychology.  For the uninitiated, Facebook provides a space, much like any personal web page, where one can post pictures, text, links to other sites, and share all that personal information with a select group of “Friends.” Friends are other users of Facebook who are invited by you to see everything you’ve posted on your page, engage in conversations with you, and otherwise interact with you.  One can also create professional pages, but most users prefer personal profiles.

Facebook has over 500 million users worldwide, so the chances are good that some of your clients have Facebook pages.  In fact, as the debate on the FPA listserv suggests, many psychologists who use Facebook have encountered situations where clients have asked to become Friends of their psychologist.  Whether or not to accept such a request is a complicated decision, depending on one’s level of comfort with dual relationships, whether the dual relationship is unethical, the theoretical orientation of the psychologist, the risk management practices of the psychologist, the unique circumstances of the request, and perhaps other factors as well. 

In other words, there are legal, ethical, professional, and personal factors to consider.  Each of these general factors is separate from the others.  For example, a psychologist may be personally comfortable with having a client as a Friend, but from a psychoanalytic orientation may have concerns about what that relationship may have on the development of transference in therapy.  Or, a humanistic psychologist may feel that to draw a relationship boundary with a client over Facebook would be a sign of disrespect, a way of creating a hierarchical relationship with the client that suggests “you must be self-disclosing with me, but I will not disclose myself with you,” yet may still choose not to accept a client as a Friend because of concerns that the relationship may increase the chances of the client filing a complaint against the psychologist or terminating therapy.  Several articles have been written recently about managing such concerns on Facebook, Google, and the Internet in general.  A very good one about Facebook was written by psychologist Ofer Zur (2011), and the full text is available on his website.  I will briefly address the ethical dilemma with current clients here. 

As always, when deciding whether a professional behavior is ethical or not, we look first to the APA’s Ethical Principles of Psychologists and Code of Conduct.  The most relevant standard relates to Multiple Relationships (3.05).  This standard reads in part:

“A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.

 Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.

(b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code.”

This standard informs us that to “friend” a client is not inherently unethical, because a Facebook relationship is not intrinsically harmful and may not impair the psychologist’s effectiveness in the professional relationship.  It is up to the psychologist to predict whether harm may come to the client or to the professional relationship.  Some conceivable harms could include: the client learns personal information about the psychologist which causes the client to dislike the psychologist; the client develops an unhealthy fantasy about the psychologist as a result of this window into the psychologist’s life; the psychologist comes to view the relationship as more casual than professional, resulting in impaired objectivity or failure to maintain professional standards of behavior; or, finally, the online relationship results in an accidental breach of confidentiality that offends or harms the client in some way. 

The risk of harm by “friending” must also be weighed against the harm, albeit unlikely, that could come to the client by not accepting the request.  For example, the client may be inappropriately offended by the refusal, resulting in damage to the professional relationship.  This harm could likely be avoided through a frank discussion with the client about why the client wants to be Friends, and why the psychologist does or does not wish to accept.  If the psychologist does accept the request, there is still an obligation to be vigilant so that if harm occurs it can be minimized as quickly as possible.
 

If the FPA listserv may be considered a crude survey of the prevailing attitudes of psychologists, most maintain a policy to not accept Friend requests, and maintain strict controls over privacy on Facebook to prevent possible clients from viewing their personal profiles.  To “friend” a client is not automatically unethical, but clearly there are many risks with few apparent benefits, so the answer to the question posed in the title according to emerging consensus appears to be, “Not.”

Reference

Zur, O. & Zur, A. (2011). The Facebook Dilemma: To Accept or Not to Accept? Responding to Clients' "Friend Requests" on Psychotherapists' Social Networking Sites. Independent Practitioner, 31(1), pp. 12-17.

What should I call myself?

Samuel Knapp, EdD, ABPP

Director of Professional Affairs

The names and titles that psychologists use, the clothes that they wear, and the decor in their offices are part of the “public self-disclosure” of the psychologist. That is, psychologists convey something about themselves and their relationships with their patients by the names and titles they use, the way they dress, and the way their offices are decorated.

How should psychologists refer to themselves in professional settings? Should psychologists who have doctorates always refer to themselves as “doctor;” should they refer to themselves by their first name; or should they use some other mode of address? Do psychologists who fail to insist on using the title “doctor” diminish the profession or fail to recognize the substantial academic and personal accomplishment involved in becoming a psychologist? After all, physicians refer to themselves as “doctor.” Or, does insisting on the title “doctor” reflect elitism, classism, or an assertion of power or privilege over another person?

Dr. Richard Small usually introduces himself as Dr. Small. When asked what he prefers to be called, he responds “either Rick or Dr. Small.” When she meets with adults for the first time, another psychologist introduces herself with her full name, but does not use her title (which is on her business card and on her office door). She asks patients what they would like to be called and follows a pattern of mutuality in titles. She says “If you would prefer to be called by your first name, you may call me by mine. If you would prefer that I use a courtesy title to address you, you may use mine.” Both of these approaches allow adult patients to use (and to be called by) whichever name or title appears comfortable for them, and recognizes that individuals vary in their comfort with titles, which often differ according to age, social background, or perceptions of courtesy. Sometimes when given an option, patients will adopt a middle ground and refer to the psychologist as “Dr. Sam,” “Dr. K.,” or some other polite variation. Giving adult patients options of what name to use also avoids the appearance of trying to establish a hierarchy of power or distance between individuals. The assumption is that the effectiveness of therapy will occur because of the quality of the relationship and the effectiveness of the therapeutic intervention.     

The use of titles and names depends a lot on context, and it is impossible to establish one rule for all situations. Although insisting that patients use the title “doctor,” in and of itself, is unlikely to cure many patients, at times it may be clinically indicated to do so. One attractive woman psychologist initially refers to herself as “doctor” when working with men to ensure that they do not misconstrue the use of her first name as an invitation to enter into inappropriate boundary crossings. However, she allows women or men she knows well who do not appear to have boundary issues to call her by her first name. Also, it is generally considered bad manners for children to refer to adults by their first name (other than relatives, such as “Aunt Sally,” or “Uncle John”), although this standard has become weakened in recent years. Some psychologists will allow children to call them “Dr. First Name,” which balances familiarity with respect for the adult.

Of course, patients who usurp the right to use first names may be showing clinical features of relevance. For example, a psychologist who conducts child custody evaluations notes that some fathers will use his first name at their first meeting or even the first phone call, which he interprets as an effort to create a male-to-male bond or alliance in the relationship. Rebellious adolescents may also use first names as a way to assert power or defiance of authority. The appropriate response may vary according to the situation and patient dynamics, but the overriding goal should be to respond in a manner consistent with overarching ethical values that promote professional goals in the context of a supportive but structured relationship.

Vignette 2: A Suffering Caregiver

A colleague of yours, Dr. Solomon, contacts you for advice regarding a new client she has just seen. The client, Mr. Don Tellanyone, is a 47-year-old man who is seeking services for depression. During the initial phone contact, he asked repeatedly about privacy and wanted assurances that information discussed in session was confidential. The patient repeated this line of questioning during the first face-to-face session.

As the session progressed, he revealed that the source of his depression was the death of his mother one year ago. His mother had suffered from a combination of severe respiratory problems and Alzheimer’s. Mr. Tellanyone had been caring for her and his father in his home for 6 years prior to her death.  During the last two years, she required total care. He revealed that she had been suffering greatly and, out of compassion for her, he gave her an excess dose of her sleeping and pain pills. Medical personnel never questioned the death as the woman had been quite sick and “It was only a matter of time.”

Mr. Tellanyone goes on to explain that he is now caring for his father in similar circumstances, although there is no dementia. His father has declined rapidly since the death of his wife and now requires total care. Mr. Tellanyone reveals that recently he had a conversation with his father in which the father commented how peaceful his wife’s death was and how he hoped for a similar passing.

Mr. Tellanyone is feeling quite guilty about his mother.  Simultaneously, he strongly believes he made the right decision. He would like help to work through the issues. He is also very concerned about confidentiality and wants assurances from Dr. Solomon.

Dr. Solomon, feeling uncomfortable with the situation, contacts you for a consultation about the potential ethical issues for this case.

What are the potential ethical issues in this case?

What would you advise?

Amending the Ethics Code

APA’s Council of Representatives voted to amend the association’s Code of Ethics to make clear that its standards can never be interpreted to justify or defend violating human rights.

The action, which came during the winter meeting of APA’s governing Council of Representatives, amended the code’s Introduction and Applicability section, as well as Ethical Standards 1.02 and 1.03, to resolve any potential ambiguity in the original language. These changes become effective June 1, 2010.

“APA’s longstanding policy is that psychologists may never violate human rights,” said APA President Carol D. Goodheart, EdD, announcing the changes. “These standards now unquestionably conform to that policy.”

The standards, from APA’s “Ethical Principles of Psychologists and Code of Conduct” (2002), address situations where psychologists’ ethical responsibilities conflict with law, regulations, other governing legal authority or organizational demands. Previously, it appeared that if psychologists could not resolve such conflicts, they could adhere to the law or demands of an organization without further consideration. That language has been deleted and this new sentence added: “Under no circumstances may this standard be used to justify or defend violating human rights.”

These amendments to the Ethics Code provide clear guidance to psychologists regarding their ethical obligations when conflicts arise between psychology ethics and the law or ethics and organizational demands.

An APA Ethics Committee task force last revised Ethical Standard 1.02 on conflicts between ethics and law in September 2001. The standard, which had been previously revised in 1992, had been criticized by psychology practitioners, particularly those in the forensics community. The 1992 standard said that when ethics and law conflict, psychologists should “make known their commitment to the Ethics Code and take steps to resolve the conflict in responsible manner.” Practitioners were concerned because at times judges, who were unfamiliar with psychology ethics, would order that clients’ raw test data and psychotherapy notes be submitted into legal proceedings. Judges had also made custody, visitation or supervision recommendations without first seeking appropriate evaluations. Psychologists said they were being placed in a conflict between ethics and law.

The task force had responded to such concerns by revising Standard 1.02’s language to say that if a conflict arises between ethics and law, psychologists should make known their commitment to the Ethics Code and seek to resolve the conflict. If that process was not successful, a psychologist had the option of following the “law, regulations or other governing legal authority.”

The language created a process for resolving a conflict between ethics and law but did not require a psychologist to violate a court order and thus risk being jailed or fined. The psychologist could, however, engage in civil disobedience, if he or she chose. The ethics task force approved the revision with minor edits and APA’s Council of Representatives adopted it in 2002.

That solution was called into question after Sept. 11, 2001, when the Bush administration used abusive interrogation techniques that it defended under the law. The question arose as to what a psychologist’s ethical obligations would be if they were ordered to engage in torture or cruel, inhuman or degrading treatment or punishment and whether Ethical Standard 1.02 could be used as a defense.

The full story can be read here.

Book Review: The Singularity is Near

by John Gavazzi, PsyD, ABPP

Disclaimer: The Singularity is Near by Ray Kurzweil is dense with facts, ideas, and future projections. However, space limitations of this blog post prevent me from a much more detailed review.

If you are interested in the interface of technology and human existence, then this book is a meaningful read. While the text is dated (published in 2004), I never imagined that this book would try to deal with consciousness and “self” within the context of non-biological intelligence.

Consciousness is the most complex outcome of evolution, so far. However, The Singularity focuses on possible paths in which the human brain will be enhanced through nanotechnology and other engineering developments. Kurzweil also makes the claim that non-biological entities will achieve consciousness, most likely near 2045!!

Sound farfetched? Too Star Trek for you?

Kurzweil covers a wide range of topics including brain science, technological advances, nanotechnology, reverse engineering the brain, the importance of chaos theory and algorithms, and some advances in medical research. The brain science portions of the book explore the human brain from intracellular processes of the neurons, to neurotransmitters and synapses, to localized brain functioning, to overall brain functioning, to mind as an emergent function of a chaotic, complex system.

Kurzweil’s engineering perspective and sharp insights are effective throughout the text. While Kurzweil writes in a friendly, easy manner, make sure that you have a working knowledge of complexity theory (chaos theory), quantum physics, and biological conceptualizations (DNA, RNA, epigenetics) to appreciate fully the depth and breadth of his points.

There are some minor weaknesses. First, Kurzweil gives short shrift to the general idea of consciousness. Because consciousness is not well defined or well measured, the author does not spend much time on consciousness. However, he addresses that non-biological entities will achieve consciousness, but, other than passing the Turing test, he does not elaborate in a meaningful way. Furthermore, consciousness is tied up with sensation, perception, acculturation, expectations, etc. that are not addressed within the context of non-biological enhancements.

Second, the concept of “self” is sketchy at best for Kurzweil. He does not connect how a "centered self" applies to non-biological intelligence or enhanced intelligence. Kurzweil seems to argue for a de-centered “self” or a distributed model of consciousness. While I agree with this premise (that many portions of consciousness are distributed), Kurweil only implies this possibility, without spelling out all of the ramifications of a de-centered self.

Overall, the book is a fascinating foray into the melding of human intelligence and non-biological enhancements to human existence. The book raises the issue of what makes us human, and, how far can we create hybrid life forms that are still considered human?  So, the ethical issue stems from the degree to which human beings are willing to use cognitive and physiological enhancements and still consider us to be human.  Medical devices have already been implanted into the human body to repair damaged or unhealthy organs (implantable cardioverter-defibrillator).  The future challenge is: how far will individuals go with cognitive, emotional and physiological enhancements and society still considers that hybrid entity to be “human”? 

  

Kurzweil makes some interesting projections as to how possible inventions will change the human race in 20, 30, or 40 years.  This brief video highlights some of the main points in this book.

If you choose to read this book, hopefully you will enjoy it as much as I have.  The Transcendent Man is a related movie that I have yet to see.