Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy

Friday, May 27, 2011

The Internet's Ethical Challenges

A common theme on this blog is the nexus of psychology and ethics on the internet.  The capacity to communicate, interact and build relationships at a distance is becoming increasingly easy and affordable.  From a number of discussions with college students, some individuals actually prefer texting and skyping to outdated emailing and talking on the phone.

Psychologists will continue to venture into telepsychology and building relationships over the internet.  As clinical practice continues to move into this brave new world, psychologists need to consider the ethical implications of new technologies with their work as well as their personal lives.

Sara Martin from the APA's Monitor wrote a story entitled The Internet's Ethical Challenges.  A portion of the article is listed below.  The information just begins to scratch the surface of ethical issues related to a psychologist's presence on the internet.


Should you Google your clients?

Should you ‘friend’ a student on Facebook?

APA’s Ethics Director Stephen Behnke answers those questions and more.

No form of client communication is 100 percent guaranteed to be private. Conversations can be overheard, e-mails can be sent to the wrong recipients and phone conversation can be listened to by others.

But in today’s age of e-mail, Facebook, Twitter and other social media, psychologists have to be more aware than ever of the ethical pitfalls they can fall into by using these types of communication.

“It’s easy not to be fully mindful about the possibility of disclosure with these communications because we use these technologies so often in our social lives,” says Stephen Behnke, PhD, JD, director of APA’s Ethics Office. “It’s something that we haven’t gotten into the habit of thinking about.”

Stephen Benhke

The Monitor sat down with Behnke to discuss the ethical aspects of the Internet for psychology practitioners and how to think about them.

Does the APA Ethics Code guide practitioners on social media?

Yes. The current Ethics Code was drafted between 1997 and 2002. While it doesn’t use the terms “social media,” “Google” or “Facebook,” the code is very clear that it applies to all psychologists’ professional activities and to electronic communication, which of course social media is.

As we look at the Ethics Code, the sections that are particularly relevant to social media are on privacy and confidentiality, multiple relationships and the section on therapy. The Ethics Code does not prohibit all social relationships, but it does call on psychologists to ask, “How does this particular relationship fit with the treatment relationship?”

Is the APA Ethics Office seeing any particular problems in the use of social media?

Everyone is communicating with these new technologies, but our ethical obligation is to be thoughtful about how the Ethics Code applies to these communications and how the laws and regulations apply.

For example, if you are communicating with your client via e-mail or text messaging, those communications might be considered part of your client’s record. Also, you want to consider who else might have access to the communication, something the client him- or herself may not be fully mindful of. When you communicate with clients, the communication may be kept on a server so anyone with access to that server may have access to your communications. Confidentiality should be front and center in your thinking.

Also, consider the form of communication you are using, given the kind of treatment you are providing. For example, there are two very different scenarios from a clinical perspective: In one scenario, you’ve been working with a client face-to-face and you know the client’s clinical issues. Then the client goes away on vacation and you have one or two phone sessions, or a session or two on Skype. A very different scenario is that the psychologist treats a client online, a client he or she has never met or seen. In this case, the psychologist has to be very mindful of the kind of treatment he or she can provide. What sorts of issues are appropriate to treat in that manner? How do the relevant jurisdiction’s laws and regulations apply to the work you are doing?

That’s an example of how the technology is out in front of us. We have this wonderful new technology that allows us to offer services to folks who may never have had access to a psychologist. At the same time, the ethical, legal and regulatory infrastructure to support the technology is not yet in place. A good deal of thought and care must go into how we use the technology, given how it may affect our clients and what it means for our professional lives.

APA needs to be involved in developing that ethical, legal and regulatory infrastructure and needs to be front and center on this.

What do you want members to know about using Facebook?

People are generally aware that what they put on their Facebook pages may be publicly accessible. Even with privacy settings, there are ways that people can get access to your information.

My recommendation is to educate yourself about privacy settings and how you can make your page as private as you want it to be. Also, educate yourself about how the technology works and be mindful of the information you make available about yourself. Historically, psychology has talked a lot about the clinical implications of self-disclosure, but this is several orders of magnitude greater, because now anyone sitting in their home or library with access to a terminal can find out an enormous amount of information about you.

Facebook is a wonderful way to social network, to be part of a community. And of course psychologists are going to use this, as is every segment of the population. But psychologists have special ethical issues they need to think through to determine how this technology is going to affect their work.

Thursday, May 26, 2011

Cultivating a Role in Parenting Coordination

There is an excellent introductory article for psychologists who are considering expanding their practice as a parenting coordinator.

APA’s Good Practice interviewed Helen T. Brantley, PhD, about  the new guidelines for the Practice of Parenting Coordination.  This hyperlink will take the reader directly to the .pdf file from APA.

Here are the first three paragraphs of the article.

The process of parenting coordination is designed to help parents or guardians involved in high conflict custody disputes implement and comply with parenting plans, make timely decisions consistent with children’s developmental and psychological needs, and reduce the amount of damaging conflict between caretaking adults to which children are exposed. 

The American Psychological Association (APA) Practice Directorate has been involved for the past several years with developing parenting coordination as an emerging practice area for psychologists. The association appointed a task force in 2008 to draft parenting coordination guidelines. APA’s Council of Representatives approved the proposed guidelines as policy in February 2011.

Good Practice interviewed Helen T. Brantley, PhD, chair of the guidelines development task force, about the content and uses of the guidelines and how psychologists can prepare themselves to practice as parenting coordinators.
In order to access the article, the reader needs to be an APA member.  This magazine is another benefit of membership from our national organization.

These guidelines will help psychologists understand the role of the psychologist-as-parent-coordinator, minimum requirements of this specialized role, and ethical issues related to becoming a Parent Coordinator.

Wednesday, May 25, 2011

The Ethics Committee: Part 1

This post is the first of several that will describe what we do as part of the Ethics Committee.  In the distant past, one role of the committee was to adjudicate ethics complaints lodged against PPA members.  We no longer conduct ethics investigations.  The Pennsylvania Psychological Association refers individuals with ethics complaints to the State Board of Psychology and/or the American Psychological Association.

As a committee, there are plenty of other goals and activities related to ethics and ethics education.  The Pennsylvania Psychological Association provides our mission via the bylaws.  Part of our mission is:
The committee shall provide information to the membership and to the public about the formal ethical principles and the evolving standards of practice of psychologists. Such information shall be distributed regularly and proactively as well as in response to inquiries.
PPA, through its Ethics and other committees, works to help members understand and fulfill their ethical mandates.

Continuing Education

  • PPA’s Continuing Education Committee sponsors workshops and home study ethics CE courses. Also, Ethics Committee members and PPA staff sometimes present ethics CE programs for agencies or local psychological associations in the state. Using mostly articles published in the Pennsylvania Psychologist, PPA offers a certificate of completion to psychologists who complete a sequence of home study ethics courses.
  • Members of PPA’s Colleague Assistance Committee often present at CE programs to promote self-care and provide referrals for psychologists in distress.
  • Members of PPA’s Child Custody Committee often present at CE programs to promote high ethical standards in psychologists who provide services to divorcing families. In addition to having its own e-group, where committee members can consult with each other on issues related to custody, its members have participated in several interdisciplinary conferences with attorneys, judges, psychiatrists, and other professionals involved in child custody determinations.


  • Members of the Ethics Committee regularly write or solicit articles for PPA’s publication, the Pennsylvania Psychologist.  Many of these are then placed in the “Members Only” section of the PPA Web site and have been combined into home studies or online CE courses. Members of other committees, such as the Colleague Assistance, Forensic and Criminal Justice, or Child Custody Committees, may also write articles on ethics related to their specific concerns.
  • PPA publishes Pennsylvania Law, Ethics, and Psychology (Knapp, VandeCreek, Tepper, & Baturin, 2010) which reviews the laws and ethics codes relevant to Pennsylvania psychologists. It is now in its fifth edition and is often used in ethics courses in psychology doctoral programs.

We also view this blog as an extension of our goal to educate the public and our members about ethics and ethical principles.

More to follow.

Monday, May 23, 2011

Distance Therapy Comes of Age: Article Review

John D. Gavazzi, PsyD ABPP
Ethics Chair

A friend recommended that I read Distance Therapy Comes of Age by Robert Epstein in the magazine Scientific American Mind.  While the title seemed appealing, the article treats telehealth and e-therapy quite superficially.  There is little in the way of empirical support for conclusions made in the article.

The article indicates that there is an "avalanche of evidence" supporting the efficacy of e-therapy.  I reviewed one of the sources for this article, "Current Directions in Videoconferencing Tele-Mental Health Research" by Richardson and others.  Here is one important quote from the article that undermines the overall conclusion of the article:

"Compared to symptom reduction and cost effectiveness, satisfaction is a simple variable to measure, and it is perceived to be a necessary first step for the development of good therapist-client relationships (Rees & Haythornthwaite, 2004). However a common weakness of tele-mental health research, particularly in small studies and novel demonstrations, has been to overemphasize patient satisfaction as being the same as clinical effectiveness. Furthermore, the majority of studies examining satisfaction with tele-mental health have typically used study-specific measures of this outcome, and the psychometric properties of these instruments are largely unknown. Finally, we do not know whether patient satisfaction with tele-mental health would remain as high in the presence of alternative mental health services, or if ratings of high satisfaction are a by-product of simply being pleased to receive any service at all."
Additionally, one of the "Fast Facts" in the article states "brief therapeutic communiques using mobile phones can help combat eating disorder, alcohol abuse, cigarette smoking and anxiety, among other problems."  The author cites research from Kristin Heron and Joshua Smyth to support the point; however, there is no reference given as to who published this research or where to find it.

There were some positive components to the article.  The first is a quote from Gerry Koocher, which states "the important thing is that you're practicing competently, no matter how you are delivering the therapy."  Koocher also made the important points that e-therapy may not be appropriate for everyone as well as the potential for fraud exists.

Psychologists need more definitive information and guidelines about telepsychology and e-therapy to practice at the highest level.

Fortunately, there is positive movement for psychologists interested in telehealth, e-therapy, and telepsychology.  The Committee for the Advancement of Psychology recently announced the formation of a new Task Force on Telepsychology.

We are pleased to announce the members of the newly formed Task Force on Telepsychology.  The Task Force members represent the American Psychological Association (APA), the Association of State and Provincial Psychology Boards (ASPPB), and the American Psychological Association Insurance Trust (APAIT).  The purpose of the Task Force will be to develop telepsychology guidelines that will provide direction to psychologists as they navigate the numerous ethical, regulatory, legal and practice issues that arise in their use of technology in the delivery of psychological services.  We want to acknowledge and thank these new members for their leadership and commitment to participate in this multi-organizational Task Force.
Psychologists will need to rely on credible sources of information before embarking in e-therapy and telepsychology.  Some interesting issues include informed consent, practicing across state lines, and the overall efficacy of telepsychology. 

This blog will update our readers on recent research about the effectiveness of telepsychology as well as any outcomes from the Task Force on Telepsychology.  Psychologists need to be informed on the ethical, legal, and competent practice of telepsychology.

Saturday, May 21, 2011

The Ethics of Leadership in Psychology

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.


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.

Thursday, May 19, 2011

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.

Wednesday, May 18, 2011

We're Blogging for Mental Health

Mental Health Blog Party Badge
"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.

Monday, May 16, 2011

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.


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

Saturday, May 14, 2011

To Friend or Not to Friend: That is the Question

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.”


Tuesday, May 10, 2011

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.

Thursday, May 5, 2011

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?

Monday, May 2, 2011

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.

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