Janet R Matthews. 21st Century Psychology: A Reference Handbook. Editor: Stephen F Davis & William Buskist. Volume 2. Thousand Oaks, CA: Sage Publications, 2008.
Psychologists who practice psychotherapy regularly face a variety of issues that have no clearcut answers. The Ethical Standards and Code of Conduct published by the American Psychological Association (APA; see www.apa.org/ethics) provides them with guidance in handling these issues (APA, 2002; see also Chapter 12, Ethics of Psychological Research). It is often simply called the ethics code by psychologists. The document is divided into two parts: general principles and ethical standards. The general principles are considered aspirational in nature; they guide psychologists in making ethical decisions rather than mandating specific behavior. The standards are something that you are expected to do; they are enforceable rules of conduct for psychologists. The applications section of this chapter describes Section 10, standards of psychotherapy. Later in the chapter I will talk about guidelines, which are different from standards. Guidelines are not considered mandatory but rather provide information psychologists use to provide the best level of care possible. Guidelines are similar to the general principles but provide considerably more information.
The ethics code does not provide answers to the issues psychologists face but rather helps the psychologist make the best judgment possible in each specific situation. Psychologists also seek consultation from their colleagues when they face ethical dilemmas. When seeking collegial consultation, psychologists must maintain confidentiality by using only broad details of the situation and limited identifying personal information about the patient when they ask the opinion of colleagues who may have had a similar experience in their work. Psychology is not the only profession that practices psychotherapy and has an ethics code but because this book is about psychology, I have limited my comments to that profession. Readers who are interested in the ethics codes of other mental-health professions may use Codes of Ethics for the Helping Professions (2003) as a starting point for their investigation. Because of the geographic proximity of Canada to the United States, some readers may wish to look at the Canadian Psychological Association’s ethics code as well (www.cpa.ca/ethics2000.html). Due to space limitations, the focus of this chapter is the United States, with occasional references to Canada. This does not mean, however, that the practice of psychotherapy is not regulated by specific ethical codes in other countries.
When practicing psychotherapy, the most important code of ethics is the one included in the licensure requirements of the psychologist’s state. Violation of this code can lead to loss of the psychologist’s license. If that psychologist is a member of APA, the psychologist’s state licensing board will also report its disciplinary actions to APA. The APA Ethics Committee will review the case and make a recommendation to the APA Board of Directors about whether that person should be allowed to remain a member of APA. That is not to say that the psychologist can therefore ignore the APA ethics code. As a member of APA, each psychologist agrees to abide by that code as well, and violation of the APA code can also lead to a complaint being filed with the APA Ethics Committee and the process described above, even if the behavior does not violate state law. If a psychologist is expelled from APA membership for an ethics violation, that information is sent to all other members of APA with a notation of the parts of the ethics code that the psychologist failed to obey.
The Association of State and Provincial Psychology Boards (ASPPB) is an organization of all the psychology licensing boards in the United States, Canada, and U.S. territories. This organization also has a suggested ethics code. The ASPPB code is a model that may be used by its member jurisdictions but is not a membership requirement. Some state psychological associations have an ethics committee that may also investigate violations of ethical practice. If a psychologist is found to have behaved unethically, the state association may expel that person from membership and report the details to APA. Some psychologists are also members of specialty organizations related to their theoretical orientation or area of practice. Some of these organizations have developed ethics codes as well. For example, a practicing psychologist who specializes in marriage and family therapy might be a member of the American Association for Marriage and Family Therapy (AAMFT). AAMFT has both an ethics code and an ethics committee to enforce that code. Thus, this psychologist needs to abide by the APA ethics code, the code of his or her state license, and the code of the AAMFT. Like the state psychological associations and APA, however, AAMFT may expel a member for an ethical violation but they do not have the power to take away that psychologist’s license to practice. Only the state licensing board has that authority. In summary, the psychologist who is practicing psychotherapy may need to be aware of the requirements of several different codes of ethics. When there is a conflict among these codes, the psychologist attempts to solve that conflict but ultimately follows the dictates of the state licensing law.
Why do psychologists need a set of ethical principles and an ethics code? Several assumptions are relevant to answering this question. First, there is an assumption in psychotherapy that there is an imbalance in power between the psychologist and the client or patient. Some psychologists call the recipients of their services clients whereas others use the term patients. I will use client for the remainder of this chapter. People seeking psychotherapy assume that their psychologist has special expertise they themselves do not have. This differential knowledge level can lead to feelings of inferiority on the part of the client. Second, people who seek psychotherapy tend to feel more vulnerable than the average person and therefore have the potential to become victims more easily than they might under ordinary circumstances. “Our ethics acknowledge the great responsibilities inherent in the promise and process of our profession. They reflect the fact that if we do not fulfill these responsibilities with the greatest of care, people may be hurt” (Pope & Vasquez, 1998, p. 1). Thus, an overall reason for psychologists to have ethical principles is to protect the public.
Like other professions with ethics codes (e.g., medicine, law), psychologists tend to believe that they are the ones who are best qualified to monitor ethical behavior among members of their profession. As times change and the scope of practice of psychology grows, new issues arise. The ethics code is revised on a regular basis to address these new issues. In order to get maximum input from the profession and consider many possible changes that may be advisable, the process of revision takes several years. For example, the current ethics code does not specifically address some potential issues resulting from modern technology. The section of the ethics code dealing with privacy and confidentiality notes that psychologists who deliver their services electronically need to make sure their clients understand the limitations of privacy and confidentiality. The section on psychotherapy, however, does not specifically address ethical issues in teletherapy, which is one name for psychotherapy provided via the Internet. Virtual reality therapy, currently being evaluated with some specialized groups, may increase in the future. If these changes do occur, the next revision of the ethics code may include a section on technology in psychotherapy.
One aspect of the ethical practice of psychotherapy is to have an understanding of the unique characteristics of the client. Although psychologists do not consider the client’s sex a unique characteristic, the rise of feminism led to the development of feminist therapy. Feminist therapy provides concepts that other specialty groups also consider. For example, feminist therapy led practitioners to consider whether this specific form of psychotherapy needed its own code of ethics (Lerman & Porter, 1990). The reasoning about this need as well as the process of ethics code development illustrates the process of work with emerging groups.
As the profession of psychology has paid greater attention to issues of diversity, APA adopted practice guidelines as association policy. A practice guideline is a document providing information about the education and training a practitioner needs to be able to work with specific groups. These documents also provide information on the current state of the research literature on this topic. Reading practice guidelines helps psychotherapists learn what background is considered necessary for competent work with diverse client populations. Among the current practice guidelines approved by APA are those describing multicultural competence, geropsychology competence, and working with gay, lesbian, and bisexual individuals. Copies of these practice guidelines can be found on the APA Web site (www.apa.org).
Part of being an ethical psychologist is being competent to do what you are doing. At first, this concept may seem rather simple. However, on reflection, competence may be difficult to define. Koocher and Keith-Spiegel (1998) suggest that “intellectual competence may also refer to a clinician’s general ability to assess, conceptualize, and plan appropriate treatment for a particular client or problem” (p. 54). Within the APA Ethical Standards, competence is the topic of Standard 2 (APA, 2002). This standard includes the points that ethical practice requires psychologists to know the boundaries of their competence and practice within those boundaries. Although there is no specific definition of competence provided in the standard, it does mention that competence is not derived from a single source. Competence comes from a combination of educational and professional experiences. The competence standard also notes that ethical practice requires the psychologist to maintain competence. This requirement implies that competence is not static. In order to practice ethically, psychologists must engage in ongoing activities that maintain the ability to do their work.
Although ethical standards are an important part of psychotherapy, it is also imperative to realize that a psychologist does not leave his or her humanity at the door of the therapy session. Ethical practice of psychology involves being aware of how that humanity influences the psychotherapeutic process (Pope, Sonne, & Greene, 2006). If psychologists do not acknowledge the fact that they will make mistakes in their work, will sometimes get sick, or will just not know what to do with a particular client, they are likely to become distressed and therefore less competent therapists. This approach to psychotherapy is another example of the evolving nature of our professional ethics. Many years ago, the training of psychologists included the concept that good psychotherapists learn to leave their views and problems “outside the door” of the therapy office. Today, the training of psychotherapists includes the concept that they should be aware of how their personal issues may impact therapy. If they believe their own personal issues may be impacting their work, ethical psychotherapists may seek their own therapy and still remain active practitioners.
How do psychologists learn about the ethics of psychotherapy? Psychology students learn about ethics through a combination of didactics and supervision. Undergraduate psychology students often read about practice ethics in their abnormal psychology or research methods/experimental psychology class. If they take a field placement course where they spend time in a clinical setting, they will need to abide by the APA ethics code as students of psychology. Typical graduate programs in applied psychology specialties offer a formal course in ethics or practice issues. In this course, students may read a number of the resources listed at the end of this chapter as well as participate in class discussions of the ethical issues described in these books. They learn the distinctions between ethical and legal issues as well as how these distinctions may become blurred in actual clinical situations. It is important in these courses for students to learn not only the things they need to avoid but also to learn what are considered the best practices. Without a knowledge of best practices, beginning psychotherapists are likely to be less comfortable with their independent role. Professional psychologists continue their ethics education through reading and attending professional workshops. Some of these professional workshops provide information and education about the overlap of ethics and legal issues specific to the state in which the psychologist practices. The state psychological association or other local groups who are aware of the nuances of that individual jurisdiction’s system often sponsor these specialized programs.
Ethics education includes not only the difference between right and wrong but also what is currently considered the best option among many in various situations. This approach to ethics education, sometimes called an acculturation model (Handelsman, Gottlieb, & Knapp, 2005), emphasizes the development of a sense of ethical identity and learning how that differs from one’s personal identity. There is a transition as the student moves from a personal sense of ethics to a professional one. Ethics educators suggest that this approach to ethics training encourages students to ask questions rather than fear they just don’t understand some rule. This model also helps the trainee to appreciate the fact that ethics education is a long-term developmental process rather than the subject of one course for which they desire a high grade. The focus tends to be on working through a decision-making process rather than searching for a correct answer. Ethics courses that are taught from an acculturation perspective often include assignments designed to have students reflect on how they developed their present concepts of what it means to be an ethical professional. Ethics autobiographies and ethics genograms may be used as part of this process. An ethics autobiography focuses on the individual student, whereas the ethics genogram encourages students to consider the moral values of significant others in their lives (e.g., family members, mentors). This approach makes continuing education about ethics a natural progression rather than a potential mandate for license renewal.
Ethics self-awareness related to psychotherapy includes an understanding of your attitudes and beliefs, your overall knowledge of the discipline, and your level of skill. With the ever-increasing diversity of our population, it is imperative for psychotherapists to understand their level of cultural self-awareness. Although that concept may seem logical, the actual process of assessing one’s cultural self-awareness may be a bit more complicated. It is important to understand both the client’s worldviews and your own biases that may influence your perception of those worldviews. Roysircar (2004) developed a cultural self-awareness assessment curriculum with measurable goals and objectives that students can use to evaluate their progress. The three major goals in her model are for trainees to become aware of personal values and biases, to expand their awareness of worldviews that are different from their own, and to manage interpersonal relationships with people from different cultural backgrounds. Students who wish to learn more about the objectives used to reach these goals are referred to her article.
When psychologists approach ethics from this perspective, it may be easier for them to also understand the role of Principle A in the 2002 APA ethics code—beneficence and nonmaleficence. According to this principle, part of the work of the psychotherapist is to benefit the client as well as to do no harm to the client. For the psychologist to be able to develop a solid understanding of what would be a positive life for a specific client at this time in the client’s life, understanding that client’s worldview is a necessity.
In this section, I consider some common ethical issues that are encountered in practice. As noted, APA’s Standard 10 is devoted to therapy. We will examine each of the subsections here. Although confidentiality is not one of the subareas of Standard 10, it will also be covered because of its relation to therapy and studies of ethical issues.
In order to evaluate the outcome of ethics education as well as to consider possible changes that are needed in future revisions of the ethics code, psychologists must gather data on both ethical dilemmas and transgressions. One way to study ethical dilemmas of psychologists is to look at the violations reported by state licensing boards as well as to consider data from surveys of practicing psychologists. Surveys of psychologists’ concerns about ethical dilemmas they face often report issues related to confidentiality and dual relationships as most common. Standard 4.01 addresses maintaining confidentiality, and Standard 4.02 covers the need to discuss the limits of confidentiality. Standard 3.05 addresses multiple relationships whereas several standards under Standard 10 (therapy) address issues of sexual intimacy with current or former clients or therapy with former sexual partners. When you look at the data on ethics complaints, confidentiality is mentioned most often as an issue when individuals are surveyed regarding dilemmas they face in practice.
Early work on ethical dilemmas centered on licensed psychologists. More recently studies about the ethical problems of psychology graduate students have been conducted. One study asked training directors of APA-accredited doctoral programs in clinical and counseling psychology about the ethical problems they had found among their trainees. The most frequently reported category was confidentiality (Fly, van Bark, Weinman, Kitchener, & Lang, 1997). For example, a student discussed a client while in a social setting and did not sufficiently disguise that client so that identification was impossible. Another student who had taken home a client report dropped it on the ground, and it was returned to the facility by someone who had found it on the street. These samples illustrate how easily ethical problems can occur.
As with professionals, the second most frequently cited category involved relationship issues. One student therapist offered the option of having the client visit the student’s residence if the client felt depressed. Another student therapist, after doing an intake but not being assigned as therapist for that client, called the client and indicated personal availability for a social relationship. Because over half of these transgressions occurred after the students had completed their required course in ethics, some psychologists suggest that the profession needs to look more closely at how ethics courses are taught. As noted in the previous section of this chapter, a broader perspective on ethics is one suggestion for beginning to address this problem.
An area of the ethics code that initially appears quite simple but upon examination is quite complex is informed consent as this topic relates to psychotherapy. Informed consent, in its broad context, is addressed in Standard 3.10. Most psychology students first read this standard as it applies to research participants (see Chapter 12). In the context of psychotherapy, psychologists are expected to provide sufficient information for the patient to be able to make an informed decision about whether to enter into this therapeutic relationship. Even in cases where the client may be legally incapable of giving informed consent, psychologists attempt to explain the process in a way that the client can agree. Minors and severely developmentally delayed adults are two client examples that fall in this category. Of course, in these cases the guardian must also give consent. How does the psychologist determine that the client has actually understood what is implied by signing the informed consent to treatment paper? Traditionally, understanding the implications of treatment is equated to a client signature. From another perspective, some psychologists suggest that the psychologist is obligated to ask questions designed to assess that level of understanding. Because of the importance of assuring client understanding of this agreement, sample informed consent forms are now available from various professional sources (e.g., the APA Insurance Trust at www.apait.org). Regardless of the educational level of the client, most professionals agree that the reading level of these forms should be somewhere between the fifth grade and eighth grade. When a psychological practice typically sees only highly educated clients, a higher reading level can be used. Although earlier generations of psychotherapists might have been comfortable having a client sign a consent form given to them by a receptionist, 21st-century psychologists are more likely to discuss the meaning of the form with the client prior to requesting a signature.
Standard 10.01a builds on this foundation and is specifically related to informed consent for psychotherapy. It is in this standard that the timing of this discussion becomes somewhat unclear. Under this standard, psychologists should “inform clients/patients as early as feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers” (APA, 2002, p. 1072). Perhaps because of their background in obtaining informed consent for research by using a form that is signed, psychologists can easily miss the implication that informed consent for psychotherapy may be different. That phrase “as early as feasible” suggests that it may be ethical to wait until a later session or even to parcel out the concepts covered under informed consent across multiple sessions. Standard 10.01b adds the concept that if the psychologist is using an intervention that does not yet have established procedures, the psychologist should also explain the developing nature of the intervention as well as possible alternative treatments. Standard 10.01c addresses the procedures the therapist who is still in training needs to use. In this case, the consent form includes the trainee status as well as the name of the supervisor.
To clarify some of the questions about timing of informed consent, Pomerantz (2005) surveyed Missouri licensed psychologists about informed consent. One topic on this survey was the earliest point in psychotherapy to present various aspects of the process to the client. He used Standard 10.01 to generate 21 different pieces of information the psychologist may include in the informed consent discussion. Most respondents felt 12 of the 21 topics were appropriate for the first session. These topics included such basic information as confidentiality and its limits, how long an individual session would last, the payment policies of the office, and information about the supervisory status of the psychologist. Most of the items these psychologists wanted to delay for later sessions related to the actual substance of the therapy and included such topics as how often therapy would occur, the specific therapeutic approach the psychologist planned to use, whether there were alternative treatment approaches that the psychologist could use, and specific activities that might occur. The respondents suggested that most of these topics should not be covered until at least the end of the second session and might require longer depending on the individual client. The greatest suggested delay involved the actual projected duration of psychotherapy. The respondents suggested that this topic should not be covered until at least the end of the third session. Psychologists need this amount of time to more accurately assess the needs of the client. Thus, these psychologists tended to support the model that informed consent for psychotherapy is a process rather than a single event. Based on these data, the informed consent document may need to provide an overview of topics but not discuss all of them in that first session. In this way, the client becomes aware of the process nature of informed consent. The psychologist discusses informed consent in the context of the early sessions and obtains signatures on multiple occasions. The psychologist explains that knowing the client more completely is a prerequisite for some of these topics.
Standard 10.02 deals with therapy involving couples or families. In this case, the psychologist is seeing people who have a prior relationship with each other. A major ethical concern in this case is the role the psychologist has with each individual within the unit. In some cases the psychologist may be seeing not only the unit but also members of that unit individually. It is important to clarify in advance what types of information will remain between that individual and the psychologist and what information the psychologist may share in joint sessions. If there is a change in the relationship of these people during the course of their therapy, the psychologist must determine whether or not it is appropriate to continue seeing each of these individuals for therapy or if someone needs to be transferred to another psychologist. For example, consider the psychologist who is doing family therapy and during the process of this therapy, the couple decide to divorce. As with many families, there are custody issues. The psychologist may be called as a witness by one member of the couple, whereas the other member does not want the psychologist to testify. This psychologist should have clarified at the beginning of therapy the potential use of information from the sessions in any future legal proceedings. When a divorce action starts, the psychologist may also consider the used in the need to terminate therapy with one of the members of this couple.
Group therapy is similar to family therapy except that the participants usually do not have a prior relationship. Standard 10.03 covers some of the major ethical issues involved in group therapy. As part of preparing clients for group therapy, the psychologist needs to clarify the individual expectations for this type of therapy. Although the psychologist is ethically and legally bound by rules of confidentiality, those rules do not apply to the individual members of the therapy group. The psychologist asks these clients to keep the information confidential but they do not have the legal protections afforded to the psychologist if they are called to testify in legal proceedings, nor do they have the personal obligation to remain silent in other settings. Thus trust becomes a major issue for discussion in this form of therapy.
During a client’s initial appointment with a psychologist, it is important for the psychologist to determine whether that client is currently receiving mental health services from another provider. Standard 10.04 covers ethical issues related to this situation. Some clients will make appointments with more than one provider in order to try to determine which one they prefer. Others will become angry with their current provider and thus schedule an appointment with another provider and not even inform their initial provider about it. Standard 10.04 raises several issues related to this topic. At the core is the question about what is best for the client. The psychologist needs to discuss these treatment issues openly with the client so there is no confusion about the psychologist’s role. Depending on the type of other mental health services the client is currently receiving, the psychologist may need to obtain a release from the client to talk to the other provider so that this clarification can be extended to that person as well. The psychologist should be sensitive about cases that might be construed as “stealing” a client from another provider. On the other hand, the client has the right to choose a therapist and cannot be forced to continue with a therapist with whom he or she is no longer comfortable. The key point is to be open about the change.
The topic of sexual intimacy in relation to psychotherapy has been popular in film, books, and the public media. It is not surprising that the ethical standards related to psychotherapy address this subject. There are four different standards that cover this broad topic. Standard 10.05 is a statement noting that psychologists do not have sexual intimacies with clients they are currently seeing for psychotherapy. Although this concept may seem quite logical, it is important to remember that psychologists are human. They cannot necessarily determine in advance how their emotions may develop toward a particular client. The ethical issue, however, is that the psychologist does not act on those emotions. If the psychologist cannot follow this prohibition, then he or she may need to transfer the client to another provider. This termination of therapy, however, does not permit the psychologist and former patient to now establish an intimate relationship. As always, the welfare of the client is the foremost concern.
A topic of considerable discussion during the current revision of the standards was whether a psychologist should ever be permitted to have sexual intimacies with a former client. Even if such a relationship should be allowed, how much time should pass prior to starting such a relationship? At core in this case is the concept of exploitation. Psychotherapy involves a unique emotional tie. Some psychologists argue that this tie is never completely severed and therefore these individuals will not be able to establish a healthy relationship. According to Standard 10.08, the psychologist and former client are prohibited from establishing this type of relationship for at least two years. This does not mean, however, that after two years there is no problem. It is incumbent upon the psychologist to be able to justify the fact that there is no exploitation based not only on the passage of time but also on such factors as the client’s current mental status and the nature of the therapy that occurred. Some psychologists argue, for example, that a client who received short-term behavior therapy for smoking cessation does not develop the same type of emotional tie to the psychotherapist as the client who has received long-term analytic therapy.
Because of the personal nature of psychotherapy, the sexual intimacy prohibition includes individuals who are important in the lives of their current clients. Standard 10.06 notes that this prohibition extends not only to relatives or guardians of the client but also to significant others of the client. In a world where people may have an ongoing relationship but not a legal one, it is important to make this point clear in the standards. Finally, psychologists do not accept as therapy clients people with whom they have previously had a sexual relationship. The standards do not include a time span for this prohibition. According to Standard 10.07, psychologists never see these individuals for psychotherapy.
The final two therapy standards address process issues. Psychotherapy therapy is usually viewed as an uninterrupted process. However, that is not always the case. With the advent of managed care, many people expect their health insurance to pay for psychotherapy. Most insurance policies specify the number of sessions allowed both during a 12-month period and for the life of the insured. Thus, if the client is not ready to terminate therapy when the insurance ends, there will need to be some change in the payment procedure. In some cases, the client will begin to pay the therapist, called self-pay. Other arrangements are used if the client cannot afford that provider’s rates. This change may involve a transition to a community-funded agency or some accommodation by the therapist in terms of the usual fee. In other situations, a client may have a job transition that requires moving to a different community and therefore will need to find a new therapist. Depending on the job and the timing of the move, this transition may occur over a period of time or move rather quickly. Finally, there may be situations when the psychologist cannot continue with therapy. For example, the psychologist may be ill and need recuperation time or the psychologist may die suddenly. According to Standard 10.09, psychologists make preparations in advance for the transition of their clients in any situation when they need a change. Of utmost importance is the welfare of the client. Thus, the psychologist may need to see the client for several sessions for little or no reimbursement while arranging for a new therapist when finances are the issue. Psychologists also make plans for who will provide transitional coverage of their clients in case of illness, injury, or death.
Even the ending of a therapeutic relationship is not an abrupt activity. In the majority of cases, therapists provide a transition period during which the client is able to discuss any issues about completing therapy. Standard 10.10 not only describes this transition process but also notes those cases when transition may not be possible. If a psychologist feels threatened by the client or someone from the client’s life, the psychologist may terminate the therapeutic relationship at that time. This is a situation where psychologists need to care for themselves. Psychologists should also be aware when they are no longer benefiting their clients, or even potentially harming them, and let the clients know that is the case. In those situations, the psychologist should also terminate therapy.
Therapists who work in institutional settings may need to be aware of additional rules. Institutions may promulgate their own rules that relate to the provision of psychological services. The APA ethical standards, however, provide a general background for understanding some of the issues faced by therapists.
Because the focus of this section of the chapter is on legal issues, it is important to consider the difference between ethical questions and legal issues. Many people confuse ethical and legal issues. Consider the terms confidentiality and privilege. The former term relates to ethics and the latter is a legal term. Both of these terms relate to the importance of psychotherapy patients’ being able to tell their therapists information with the understanding that their therapist will not disclose this information to others. A common assumption about psychotherapy is that patients will not truly disclose their issues if they feel the psychologist may be able to tell others about them. Privilege is a legal term referring to the fact that people have the right to control personal information provided to such professionals as psychologists, lawyers, and physicians. If the client is either a child or a person a court of law finds incompetent, privilege rests with the parent or legal guardian. Thus, confidentiality is something that relates to the psychologist’s behavior whereasprivilege rests with the patient. In most cases, those professionals who learn confidential information from clients must get permission from them before releasing such information to any outside source. However, this issue may become truly problematic if the psychologist receives a subpoena to testify in court in a case involving that patient. Initially, individual state courts established the right of licensed psychotherapists to refuse to testify in court about confidential information. This right was finally established on a national basis in 1996 in the U.S. Supreme Court decision in Jaffe v. Redmond. There are, however, exceptions to confidentiality and privilege that are established in state law.
There are specific situations, however, when psychologists must violate confidentiality. These situations include being a student therapist, when patients are dangerous either to a specific person or to themselves, and when state law specifies they must do so. One exception to maintaining confidentiality involves student therapists. When a psychologist in still in training, and thus under the supervision of a licensed psychologist, the supervisor must have access to all client records. The client needs to understand in advance that the psychotherapist is a trainee and thus will be discussing the case with a professional who is held to the standards of confidentiality.
Another case where psychologists may violate confidentiality is when they believe their patient is dangerous to a specific other person. A common term for this situation is the duty to protect or duty to warn. This concept first received broad attention in a 1976 California case, Tarasoff v. Regents of the University of California, when a patient being seen in outpatient psychotherapy at the University of California told his therapist he wanted to harm his former girlfriend. Although the therapist had campus police come for the young man, they let him go after talking to him. Several days later, this young man killed his former girlfriend. Her family sued both the university and the therapist. The California Supreme Court ruled confidentiality does not hold when there is public peril. Not all states have duty-to-protect statutes, and the specifics of these laws vary from one state to another. In most cases, the laws specify that confidentiality must be breached when there is a specific, named victim who is in imminent danger of death. The psychologist in these cases does not need to fear a civil suit by the patient. Thus, a decision the psychologist must make in these cases is whether there is an imminent danger of death to the named person. Some cases are rather obvious. For example, if a patient says that he plans to shoot his next-door neighbor because he always puts his trash can in your patient’s driveway, there is obvious imminent danger. On the other hand, the patient who is HIV+ and tells his psychologist that he plans to have unprotected sex with his live-in girlfriend and not tell her about his health status presents a more complicated situation. Although this behavior has the potential to lead to infection of the partner and subsequently to death, that death is not imminent.
Many states also have mandatory reporters of certain behaviors. Professionals who fall within this category must report certain types of behavior their clients confess to them without needing the patient’s permission to do so. The underlying assumption in these cases is that the victims are not likely to be able to report for themselves. Mandatory reporting in many states includes child or elder abuse or abuse of a mentally challenged person. These people are identified in the law because of the potential that they may not have the ability to protect themselves. Therefore, the law requires others to assume that responsibility. Likewise, psychologists are required to follow procedures for involuntary hospitalization of those clients psychologists believe are actively suicidal. Thus, they are breaching confidentiality by sharing information with admitting personnel at the hospital.
Prior to starting psychotherapy, psychologists inform potential clients about the limits of confidentiality; this is often done in writing and signed by both the psychologist and patient. Although some therapists may have concerns that telling clients about the exceptions to confidentiality before the establishment of rapport may lead to clients not returning or being overly careful about what they say, most 21st-century psychologists find that such full disclosure is necessary to meet modern standards of care. The client has the right, in most cases, to either accept or refuse the psychologist’s services based on this information.
One role of the state licensing board that oversees the practice of psychology is to monitor the ethical behavior of their licensees. The licensing laws of each state include rules of ethical behavior. Some states have incorporated the APA ethics code into their rules of practice, whereas others have developed their own ethics code for their licensees. A state licensing board mandate is to protect the public. Part of that protection means ensuring ethical behavior on the part of the psychologist. If a complaint about unethical behavior by a psychologist is made to a licensing board, that board will investigate the complaint. Although the investigation process varies from one state to another, the reason is to protect the public from unethical behavior. If the psychologist is found to have behaved unethically, the licensing board may do one of a number of things. If the psychologist has made what is viewed as a naïve or minor infraction, they may require some educational remediation but still allow the psychologist to see clients. This educational remediation may include readings, formal courses, and even supervision by another psychologist for a specified period of time. The purpose of this educational remediation is to help the psychologist understand the standard of care that is applicable in this case. If the licensing board views the ethical infraction as being more severe, they may require the psychologist to undergo personal psychotherapy or even take away that psychologist’s license to practice. When the licensing board mandates psychotherapy, the psychologist also waives privilege over psychotherapy records so that the therapist can report the psychologist’s sessions to the licensing board on a specified basis. In these severe cases, the licensing board also reports the psychologist’s name and the nature of the psychologist’s infraction to a national data bank. Thus, the psychologist cannot simply move to another state and apply for a new license without this information being available to the licensing board there.
In this chapter, I have provided a general introduction to ethical issues in psychotherapy conducted by psychologists in the United States. There are individual discussions of the specific parts of the APA Ethical Principles and Code of Conduct dealing with psychotherapy. Ethical and legal issues are distinguished from each other, and major precedent-setting legal cases were included. This chapter provides a starting point for further study of a very broad topic.