Ethical Issues in Clinical Psychology Research Paper

The focus of this research paper includes the sources of ethical principles and standards, the major ethical issues in clinical practice, and methods of regulation.

Ethics Codes and Regulations

The American Psychological Association’s (APA) ethics code has been the primary ethics document in psychology since the first APA ethics code, then called the Ethical Standards of Psychologists, was adopted (APA, 1953). The APA ethics code was commonly adopted as the disciplinary standards for states’ psychology licensure boards. However, this adoption has varied over the years. Some licensure laws write the content of a particular version of theAPAethics code into law, and others simply refer to the APA ethics code generally or to a particular version.When the content of a code has been written into law, changes may also be made so that individual standards may vary from the code used as the pattern. In addition, the same range of methods may be used in adopting disciplinary standards into licensure board regulations, rather than into the licensure law itself. Some states have adopted a model code of conduct recommended by the Association of State and Provincial Psychology Boards (ASPPB; 1991).

The American Psychological Association’s Ethics Code

Current Ethics Code and Revisions

APAadopted its first ethics code in 1951, and there have been several revisions since then. The version current as of this writing is the Ethical Principles of Psychologists and Code of Conduct (APA, 1992), and a revision of this code was nearing completion. A new code was projected for adoption in August 2002.

This makes writing about specific provisions in the ethics code difficult, but it also highlights a continuing problem for practicing psychologists. It is not enough for a psychologist to learn the version of the ethics code that was current when he or she was in training or sat for the licensure exam. As stated in the Preamble to the 1992 APA ethics code, “The development of a dynamic set of ethical standards for a psychologist’s work-related conduct requires a personal commitment to a lifelong effort” (p. 1599). The last two ethics codes, the versions adopted in 1981 and 1992, have been in effect for about 10 years each. The practicing psychologist must be prepared to learn each new code as it is implemented. Of course, when considering the real life changes that occur in licensure and other laws, court decisions, practice standards, new treatment methods, and other practice conditions, this requires an ongoing effort of continuing education. New ethics codes are simply one of the changes. Current information on the ethics code is available on the APA Web site at http://www.apa.org/ethics or through APA.

Aspirational and Enforceable

The first APA ethics code was distinctive in APA’s use of the critical incident method for its development. Although the form of the original code and the critical incident method were not continued, it was considered important to maintain some kind of tie to behavioral examples. The casebooks were the primary method for this, but this has proven increasingly difficult, as improved legal defensibility of the code for enforcement has made this a lower priority.

The 1992 Ethical Principles of Psychologists and Code of Conduct (APA, 1992), was the first APA code to differentiate explicitly between statements intended to be “aspirational” and those to be enforced. A casebook did not follow it, but an unofficial commentary was published by APA (Canter, Bennet, Jones, & Nagy, 1994).

Many psychologists argue for inclusion of more specific guidance in the ethics code. Others argue against including anything in an enforceable code that might add unreasonable or unnecessary standards.Areality is that the separation of aspirational from enforceable elements in the code does present some limits to the content of ethical standards. The ethics code cannot provide a full statement of how to behave ethically, and the “Ethical Standards” section in the 1992 ethics code is a statement of a minimum standard or code of conduct. Guidance for practice is more likely to be found in documents that focus on a limited content area and provide guidelines or principles that are not intended to be binding. APA has adopted the strategy of providing such information in guidelines such as the General Guidelines for Providers of Psychological Services (APA, 1987), the Standards for Educational and Psychological Testing (American Educational Research Association, APA, and National Council on Measurement in Education, 1999), and Publication Manual of the American Psychological Association–Fifth Edition (APA, 2001). Materials adopted by groups other than APA as a whole may also provide helpful information, including the APA Division 41 (Forensic Psychology)/American Psychology-Law Society’s Specialty Guidelines for Forensic Psychologists (Committee on Ethical Guidelines for Forensic Psychologists, 1991). In addition, groups may facilitate projects published as individuals that apply the ethics code to particular content areas, such as a book of cases related to industrial and organizational psychology (Lowman, 1998).

Revisions

Two changes to the APA ethics code in the 1980s and 1990s are of special importance to understanding the nature of the ethics code and its implied limitations. The first is related to the emergency revision of the code made by APA to produce the “Ethical Principles of Psychologists (Amended June 2, 1989)” (APA, 1990). The Bureau of Competition of the Federal Trade Commission (FTC) investigated APA regarding the code’s content related primarily to advertising and referral fees. The emergency revision was part of a negotiation to end the investigation (FTC, 1993). For example, the previous referral fee provision was being interpreted in such a way as to prohibit preferred provider organizations and the like.

Another change of special importance was the clearer conceptualization of aspirational as opposed to enforceable ethics provisions just discussed and first implemented in the 1992 APA ethics code (APA, 1992). Part of the legal impetus for this change was found in a court decision (White v. the North Carolina State Board, 1990) that found some provisions in the 1981 ethics code to be unconstitutionally vague in one state. Afundamental legal principle in enforcing ethics codes is that the rules must provide fair notice to the professional as to what behavior will lead to a sanction.

More complete descriptions of the history of the APA ethics code may be found in Canter et al. (1994) and Koocher and Keith-Spiegel (1998).

Content of the 1992 Ethics Code

The 1992 ethics code (APA, 1992) contains an introduction, the aspirational Preamble and General Principles, and the enforceable Ethical Standards. The introduction provides an overview and information regarding enforcement of the code andapplicationofthecodetootherprofessionalstandardsand to the law. It notes that the code may be adopted by licensure boardsandmayotherwisebeappliedtopsychologistswhoare not members of APA. The Preamble and General Principles sections state aspirational goals that apply broadly.

The Ethical Standards section provides enforceable rules. The standards are divided into seven sections. Three sections are intended to apply more generally to all psychologists: groups 1 (“General Standards”), 3 (“Advertising and Other Public Statements”), and 5 (“Confidentiality”). The other groups are “Evaluation, Assessment, or Intervention”; “Therapy”; “Teaching, Training Supervision, Research, and Publishing”; and “Forensic Activities.” Even though some sections may apply more consistently to some groups of psychologists than to others, it is important for all psychologists to consider the entire code when making ethical decisions. A psychologist in practice may rarely need to consider the section on research but must do so if doing research or engaging in other activities covered by that section. If the psychologist engages in research, it is not a defense to argue that the psychologist did not think he or she was engaging in research or did not know the relevant provisions of the ethics code.

The 1992 ethics code included a number of changes from previous codes. For the first time in an APA code, rules to be enforced were differentiated from aspirational statements, and the enforceable standards were more specific. Standards were also organized differently and limited as much as possible to single-behavior “unitary” concepts in individual standards. New provisions provided explicit guidance regarding sexual involvement with former clients (Standard 4.07) and with certain students (Standard 1.19), barter (Standard 1.18), informed consent to therapy (Standard 4.02), withholding records for nonpayment (Standard 5.11), and forensic services (Standards 7.01–7.06). There were also modified provisions regarding advertising (Standards 3.01–3.03) as well as referrals and fees (Standard 1.27), testimonials (Standard 3.05), and in-person solicitation (Standard 3.06). The advertising standards included provisions believed to be acceptable to the FTC as replacements for some standards rescinded in the 1989 revision.

Pending Revision

Most revisions have made only modest changes to content, and only the 1959 (APA, 1959) and 1992 revisions altered the format substantially. The pending revision, however, is the first since the major change in 1992, so it is more likely to involve changes in structure and content. Drafts of the pending revision suggest that there will be substantial changes to the General Principles and to the order and organization of the ethical standards. There are likely to be new standards and substantial changes to some ethical standards. However, many standards will remain unchanged or with modest changes. There is, of course, no way to predict the final decisions, which are made by the APA Council of Representatives.

Comment on revision drafts by practicing psychologists is very important and potentially influential on the groups drafting revision language. The pending revision is the first to post drafts on the APA Web site and to provide for making comments online. However, comments are most effective when the commenter understands points such as those just made about guidelines and enforceable standards. For example, some psychologists might suggest that the enforceable standards explicitly list all the elements required to be in psychological treatment records. While a benefit might be that the psychologist would know precisely the minimum required, it would also mean that any less in a record would subject the psychologist to a potential ethics violation. As noted, APA has taken the approach of providing such detail in guidelines, here in the form of theAPARecord Keeping Guidelines (APA, 1993).

Arguments that a particular provision is undesirable because it may result in psychologists’ being sued is not likely to persuade drafters because a purpose of the enforceable provisions in ethics codes is, in fact, to set standards. The important issue is to set the correct standards.

Other Codes and Standards

In addition to the APA ethics code, a variety of other ethics codes may be relevant to individual psychologists. For example, the Canadian Psychological Association (CPA, 2000) has adopted its own code. The CPAcode incorporates a decisionmaking process into the code itself and structures the code by relating each general principle to the more specific provisions. A psychologist who belongs to a variety of mental health professional organizations may be subject to multiple ethics codes.

As noted earlier, ASPPB adopted a model code of conduct in 1990. This was a recommendation to state boards, and it is effective only if adopted in a state. Some state licensure boards adopted this code. The scope of this code is different from APA’s because it substantially addresses only those areas needed in regulating licensed psychologists. Psychologists do not need to know this code independently; if it has been used in the psychologist’s state, the psychologist simply needs to know his or her own state’s laws and regulations.

Ethics codes do not provide all the information needed for psychologists to do good work. The 1992 APA ethics code says that psychologists should “consider other professional materials” (p. 1598) when the Code alone is not sufficient. As “most helpful in this regard” are the many “guidelines and standards that have been adopted or endorsed by professional psychological organizations” (p. 1598). A footnote lists guidelines, such as APA’s (1987) General Guidelines for Providers of Psychological Services. Guidelines are, of course, constantly being revised, adopted, and, occasionally, rescinded or otherwise determined to be out of date. The code clarifies that “such guidelines . . . , whether adopted by the American Psychological Association (APA) or its Divisions, are not enforceable as such by this Ethics Code, but are of educative value to psychologists, courts, and professional bodies” (p. 1598). Psychologists may be concerned that courts or others may use guidelines as if they were standards. This does in fact happen, as at least one state licensure board has used the APA’s (1994) Guidelines for Child Custody Evaluations in Divorce Proceedings in reviewing complaints about such practice. The point is not that this is either good or bad but that psychologists need to know what standards are being applied to them, to learn the standards, and to follow them.

In addition to ethics codes and practice guidelines and standards, there will be other standards that psychologists must know and follow. For example, psychologists need to know laws related to child abuse reporting and, if practicing in a particular hospital, professional staff regulations.

Licensure Board Regulations

As suggested earlier, the actual disciplinary standards written into psychology licensure laws and established by licensure boards through regulations vary from state to state and may or may not be based on a version of the APA ethics code. The actual contents of the major provisions, however, are very similar. For example, all such standards address a prohibition against sexual misconduct and improper multiple relationships, requirement to keep confidentiality, and so on. Such regulations also, however, address the mechanics of licensure, requiring such things as specific requirements for renewal of licensure, display of license, and payment of fees.

Major Ethical Practice Issues

Areview of the content of theAPAethics code makes it apparent that clinical practice is constantly involved with ethics. For example, Standard 2.02 in the 1992 ethics code, “Competence and Appropriate Use of Assessments and Interventions,” states in part (a) that “Psychologists who develop, administer, score, interpret, or use psychological assessment techniques, interviews, tests, or instruments do so in a manner and for purposes that are appropriate in light of the research on or evidence of the usefulness and proper application of the techniques” (p. 1603). Obviously, there is a great deal of information related to the research and evidence related to assessment. In providing information on these topics, authors are also providing information that is useful to interpreting the ethics code.

However, there are several major practice issues with special ethical relevance, and some key considerations are reviewed next.

Competence

Psychologists have an ethical responsibility to know their competencies and to practice only within those competencies. Professions are licensed based on a determination that the public lacks sufficient understanding to know who is qualified to provide the relevant professional services. But it is not possible for a licensure entity to determine the specific competencies possessed by each licensed professional. Accordingly, it is a primary requirement, ethically and in licensure laws and regulations, for each professional to practice within the limits of his or her competence.

Standards related to competence (e.g., 1992 ethics code Standard 1.04,“Boundaries of Competence”) may leave questions as to how one can establish competence in a specific, limited area. Competence in the major areas, however, is easy to consider. For example, a psychologist who had no academic coursework and no supervised experience in working with children has not established competence in working with children. A psychologist who had some coursework in developmental issues and completed some supervised experience in working with children might have his or her competence in working with children challenged but would have some basis for arguing that he or she was competent. It would be important for the psychologist to show evidence of training in the actual services that he or she was providing.

Using the Standard 1.04 as an example, competence can be established in a variety of ways. As Standard 1.04 states in part (a), “Psychologists provide services, teach, and conduct research only within the boundaries of their competence, based on their education, training, supervised experience, or appropriate professional experience” (p. 1600). This indicates that any of the four listed activities may be considered as a basis for competence. Continuing education is generally included in the methods by which a psychologist may develop competence.

The ethical principles of beneficence and nonmaleficence provide an important ethical basis for the emphasis on practicing within one’s competence. Maximizing benefit is achieved by ensuring that the psychologist knows what he or she is doing. Minimizing harm is achieved by not practicing in an area in which the psychologist is not trained.

In actual ethics cases, competence becomes an issue most frequently by an instance of practice that is clearly in error, not by a debate over precisely how many courses or supervised assessments are required for competence. In that context, demonstrating some basis for competence in training or other preparation might be a defense for not being competent by training. However, being unable to show clearly adequate preparation in the face of poor practice makes an easy case of unethical behavior. When a person is well trained and nonetheless makes an error in performance, this raises a question of malpractice more than one of ethics. Depending on the circumstances, of course, poor performance may also raise ethics concerns.

A credential such as a license may be required to practice legally but is not, in itself, required to practice ethically. (However, see the later discussion regarding public representations.) A credential that includes review of education and training and that assesses performance may itself establish that a psychologist is competent. Some credentials (e.g., vanity boards or most grandfathered credentials) do not establish competency, even if they otherwise give credibility to the psychologist’s services.

Graduate training in clinical psychology is the primary way to establish a credential in clinical psychology. But this relates more to the comments about a credential and not to competence, which relates more to actual practice activities such as techniques and populations. In other words, a psychologist may be competent as a clinical psychologist yet not be competent in working with children or doing a particular form of therapy.

The most common way in which a psychologist practices outside his or her competence is when beginning to work in a new area of practice. For example, this frequently happens when a psychologist without training in child custody evaluations accepts work in this area.

There are, of course, situations in which psychologists begin work in an area that is new to the field. Generally, this involves experimental work, whether those engaging in such work acknowledge this or not. The psychologist can still ensure that the work is grounded in methods for which he or she is competent and that all parties are informed of the nature of the work. (See the later discussion of informed consent.)

Confidentiality

Confidentiality is of special importance in clinical psychology because almost all clinical material carries with it the potential for harm if improperly revealed. Without confidence that their privacy will be respected, clients will be unable to provide information that is of critical importance to the success of interventions. Psychology has long recognized the importance of confidentiality and has always placed a high ethical value on maintaining confidentiality.

However, there are increasing compromises in this principle, and psychology’s ethics codes have recognized these limits. While psychologists have complained that such compromises are a problem, there appears to be little choice based on the types of situations that prompt compromises.

When a client is suicidal and unwilling to make an agreement to protect him- or herself, the psychologist may need to reveal confidential information (such as the client’s threat) in order to take appropriate protective action. Clinical psychology tends, of course, to focus on the welfare of the individual client, but society’s interests are served at times by compromise of the individual’s rights. Such analyses led to the Tarasoff ruling and are credited with stimulating a variety of laws and rulings that defined the circumstances in which psychologists have a duty to warn others about harm threatened by a client. Despite the extensive treatment of this topic in terms of the ethical issues, this is often a legal issue rather than a fundamentally ethical one. Where a duty to warn is required (e.g., in a jurisdiction in which case law applies or by state statute), the law, in essence, requires an action by the psychologist. No ethical rule or analysis is required to determine this. The psychologist’s most critical review is largely one of the clinical facts. Has this client threatened another person? Does the psychologist’s assessment of the client’s mental status meet a duty-to-warn test in the relevant jurisdiction? If the tests are met, the action is required. The primary ethical issue is whether confidential information may be provided, and the ethics code allows such reporting (e.g., in the 1992 APA ethics code, divulging confidential information without release in such a circumstance would be allowed because it is mandated by law).

There may be a variety of other situations in which providing confidential information is required, based on the welfare of someone other than the client, such as child abuse reporting when someone other than the child is the client. Some of the compromises in confidentiality, however, are the consequence of psychology’s success in offering useful information in situations such as malpractice litigation and family courts. The client may sign a release and in any event is told up front that the information that he or she will be providing is not going to remain confidential. The psychological relationship operates without the benefit of confidentiality from the other parties in the proceeding at least. If psychology insists on confidentiality, psychologists would simply not be used in such matters.

Autonomy and Informed Consent

Informed consent is based in part on a belief in individuals’ rights to autonomous choice and self-determination. Informed consent is addressed from the perspective of a person who has the capacity (legal and mental) to consent. In order for a person to give consent, it must be given without coercion and with sufficient information for the consent to be meaningful.

In the realities of modern practice, there are many situations in which treatment conditions are less than optimal. For example, the client’s ability to pay, whether due to personal financial limitations or the nature of the client’s insurance, may have an impact on the treatment itself or on adjunctive methods (e.g., in-patient treatment). One of the ways to address this is through informed consent. Even if conditions are not optimal, the client can participate in the decisions to maximize appropriate care.

Although informed consent is a primary issue in ethics, informed consent procedures and forms may also have clinical and risk management functions.

Multiple Relationships

The prohibition against certain dual or multiple relationships has been an important feature of ethics codes for psychologists. The problems for clients at issue include harm, exploitation, loss of the psychologist’s objectivity or other factors that would limit the psychologist’s effectiveness, and conflicts of interest for the psychologist. The multiple relationship prohibition is in addition to rules that prohibit actual exploitation of a client. Psychological treatment relationships involve a variety of emotional and cognitive reactions by both the client and the psychologist. Addition of roles other than the treatment relationship, such as friend or business associate, are likely to create problems. Accordingly, the multiple relationship rule prohibits addition of relationships that would be likely to create problems.

The rule, since the 1992 APA ethics code’s Standard 1.17, makes it clearer that such multiple relationships cannot always be avoided and provides more guidance for determining when to avoid becoming involved and also how to deal with relationships that result in problems despite the psychologist’s attempts to avoid them. The rule also makes it clearer that not all multiple relationships must be avoided, but only those that are likely to create problems. Some concern about the appearance of prohibiting all multiple relationships has been present among rural psychologists who may be involved with clients in a variety of situations that are unavoidable. This may also be true when dealing with small ethnic or other cultures within metropolitan areas.

It is important that those psychologists who have such concerns recognize that the real problem is not the ethics code, but the real dangers of multiple relationships. In most circumstances, it is prudent to use a more practical rule than the ethics code: When in doubt, avoid any multiple relationship that has any likelihood of creating even the most minor problem.

Sexual Misconduct

Some combined relationships have been considered to be so likely to be harmful that they are prohibited always; sexual relationships with clients are a primary example. Over several revisions, the APAethics codes made rules more explicit, so that in addition to prohibiting sexual involvement with current clients, explicit prohibitions were added regarding therapy with former sexual partners and sexual involvement with former clients.

The 1992 rule regarding sexual involvement with former clients is best understood as an “almost never” rule stated in two parts. It first provides that it is always wrong to become sexually involved with a former client “for at least two years after cessation or termination of professional services” (p. 1605). Second, it provides that “psychologists do not engage in sexual intimacies with former therapy . . . clients even after a two-year interval except in the most unusual circumstances” (p. 1605) and provides a list of variables that the psychologist would have to address in order to demonstrate that no harm to the former client occurred. Both the use of the phrase “most unusual circumstances” and the extensive list of factors to consider signal that it would be very rare to find a circumstance in which such involvement would be ethical.

Advertising and Public Statements

The ethical principle of integrity requires that public statements, such as advertising, be truthful and not misleading. Blatant violations of standards in this area are claiming a degree that the psychologist has not been awarded and claiming publications that were not published. Claims of particular results (e.g., “95% of our patients achieve treatment goals”) must be supported with reasonable data. Most of these standards related to accurate representations are in section 3 of the 1992 ethics code, “Advertising and Other Public Statements.” As stated in Standard 3.01, “Public statements include but are not limited to paid or unpaid advertising, brochures, printed matter, directory listings, personal resumes or curriculum vitae, interviews or comments for use in media, statements in legal proceedings, lectures and public oral presentations, and published materials” (p. 1604).

Psychologists should also make sure that others issuing statements on their behalf (e.g., a company hired to produce a brochure for the psychologist’s practice) are accurate, and the psychologist should review materials at various points. Although an error in the final version may not be preventable, the psychologist can prevent fraudulent or misleading statements that were present in earlier drafts. The psychologist can do so by providing good information in the beginning and reviewing later drafts and proofs. Such oversight may be less certain in large organizations such as hospitals and universities, but psychologists can still do much to keep such materials accurate.

In clinical practice one of the most contentious issues has been who has the right to claim the title “clinical psychologist.” Psychologists are typically licensed with a generic title (“licensed psychologist”), so this rarely resolves the issue. Although some psychologists would like to argue that only a graduate of an accredited clinical psychology program can claim the title, there are in fact a number of legitimate ways to argue that one is making an accurate statement in claiming the title “clinical psychologist.” The obvious, and not disputed, methods include receipt of a doctoral degree in clinical psychology from an APA-accredited institution, completion of a formal retraining program, receipt of an ABPP in clinical psychology, and receipt of licensure with a designation of “clinical psychologist.” Other methods that may be appropriate would take into account FTC guidelines for statements that are accurate and the APA’s (1987) General Guidelines for Providers of Psychological Services, which states in footnote 7 that “APA defines the term clinical psychologist in health service delivery legislation in a generic sense to include all qualified professional psychologists who provide relevant services” (p. 721). The fact that this statement occurs in an APA guideline does not mean that a particular psychologist’s use of the title is appropriate. An ultimate test is whether a particular title is “false or deceptive” in the context in which it is used and as defined in whatever ethics code or regulation is at issue. Some of these points were covered in a 1995 letter to the Division of Clinical Psychology expressing the position of the APA Ethics Committee.

One of the most serious problems involving misrepresentation is fraud in knowingly submitting false claims to payers, such as insurance companies. Psychologists may also be held accountable for the actions of office staff members who may file fraudulent claims in a manner that indicates that the psychologist did not exercise appropriate oversight. To avoid any argument that such claims were made privately and not in a public statement, the 1992 ethics code covers this in Standard 1.26, “Accuracy in Reports to Payors and Funding Sources.”

As noted earlier, an important change in APA’s ethics code in 1989 came about in part by an investigation by the FTC. This resulted in a consent order that restricted enforcement actions by APA but also explicitly allowed restrictions against almost all the types of advertising that APA would want to limit. Although the completion date of the cease and desist portion of the order is December 2002, the order uses concepts that are useful in understanding this area of ethics. These concepts are that psychologists should not use false or deceptive information in advertising, that individuals who are vulnerable should not be directly solicited for business or asked for testimonials, and that referral fees should be subject to disclosure.

Supervision

Both ethics codes and licensure regulations require that psychologists delegate to supervisees only clinical services for which the supervisees are competent and for which they will actually be supervised. In addition, psychologists must in fact provide as much supervision as is required by the services and level of preparation of the supervisee. Psychologists’services frequently deal with very sensitive aspects of clients’ lives and have the potential for serious harm. Accordingly, services provided by supervisees must be considered and overseen carefully.

This level of risk is one reason why psychologists found guilty of ethics violations for improper supervision may be severely sanctioned. For example, consider a psychologist who is supervising an unlicensed therapist who is accused of sexual misconduct with a client. The psychologist’s defense is that he did not engage in the misconduct and believed that the therapist knew the behavior was wrong and had not revealed signs of the misconduct in the office. But the psychologist was not conducting regular supervision meetings with the therapist and was not actually reviewing other indications of the handling of the case, such as the case record or the office staff’s reports about appointments and billing. If the therapist who engaged in the misconduct had, over several months, failed to follow office policies on reporting nonpayment to the office manager and had exceptions to office policy by scheduling appointments after regular hours when there were no other staff members present, the psychologist’s failure to supervise is likely to be seen as a substantial factor in the occurrence of the misconduct.

It should also be noted that requirements to keep records to ensure accountability suggest that records should be kept of supervision. (See, e.g., the 1992 ethics code’s Standard 1.23, “Documentation of Professional and Scientific Work.”)

Frequent Problems

Several subjects are among the more frequent areas of complaints or deserve special comment. These include sexual misconduct, forensic and child custody evaluations, managed care and insurance complaints, and raw data release.

Sexual Misconduct

Despite clear ethics prohibitions for many years and psychologists’ recognition that sexual involvement with current clients is harmful, such misconduct continues to be one of the most frequent major violations. A full consideration of this topic is beyond the scope of this research paper, and the reader is referred to other sources for more information. (See, e.g., Pope, 1994; Pope, Sonne, & Holroyd, 1993; Schoener, Milgrom, Gonsiorek, Luepker, & Conroe, 1990; as well as sections on sexual misconduct in ethics texts such as Koocher & KeithSpiegel, 1998.)

However, three elements to this situation will be discussed briefly. Sexual attraction to clients is relatively common, and psychologists generally handle such attraction in ways that are therapeutic or at least that avoid involvement or harm. However, therapeutic relationships can be intense, and psychologists who are in isolated practice situations may be more vulnerable to establishing an inappropriate relationship that can be the beginning of an even more dysfunctional relationship. Psychologists should stay involved with colleagues, especially if in a solo practice, and seek consultation about any cases that involve personal, emotional reactions.

An extension of such emotional reactions, which can occur at any time in a psychologist’s life, are the special vulnerabilities that occur when psychologists are experiencing problems. Such problems can include marital difficulties, depression, or the classic midlife crisis. Colleagues become especially important in attempting to intervene with a psychologist who has fallen in love with a client and who no longer cares about professional reputation or future. Earlier intervention is obviously easier, but it may still be difficult. The 1992 ethics code (Standard 1.13, “Personal Problems and Conflicts”) attempted to focus responsibility on dealing with problems such as depression at a point where a psychologist should know there is a problem but before the psychologist is actually impaired.

Many psychologists see clients who have been involved sexually with a prior therapist, and it is important to seek continuing education for addressing such issues if it was not covered in graduate training (see Pope, 1994).

Forensic and Child Custody Evaluations

Psychologists play increasingly important roles in a variety of court and legal activities. This is true for psychologists who have prepared for such roles, as well as for psychologists who are subpoenaed or otherwise asked to become involved in particular cases. In these activities psychologists have an important impact on the rights of individuals, families, and society. As such, practicing within the limits of the psychologist’s competence is very important, as is doing good and careful work.

There are more guidelines available now than in the past, but the guidelines are written in such a way that the psychologist still must exercise judgment in applying the guidelines to each case. Staying current on prevailing practices both locally and nationally is important. Any psychologist doing court work must be prepared to document the basis for his or her competence in terms of coursework, continuing education, and supervised experience. Also, doing any less than what would be considered excellent work risks criticism later. This is an area in which one should be very careful to avoid cutting corners, whether requested by the attorneys or the judge.

An example of what was once an evolving issue is the importance of including both parents in an assessment in issues in a child custody or visitation matter. Psychologists have been criticized when doing less, even when the fact that only one parent was involved in the assessment was understood and agreed to by all parties and the court. This is now treated as an established practice.

An example of a still evolving area is the importance of collateral information. Even though the psychologist has collected information from both parents and has assessed them and the children individually and jointly, the psychologist risks sanction if he or she has not obtained collateral support for important information that is in dispute. Also, expert forensic reviewers may expect to see reports that provide detailed information about the assessment. A reviewer may consider a report with less information to be inadequate, even if the psychologist provided detailed information later in the process, for example, in court testimony.

Since the mid-1980s, child custody–related complaints have been a significant proportion of the complaints filed with the APA Ethics Committee. In the article reporting on activity for 2000, 18 cases were opened that were not brought to the committee’s attention by other reviewing bodies (e.g., licensure boards). Of those 18, 5 were child custody matters.

The fact that there are a significant number of child custody complaints does not necessarily mean that there are more problems in this area than in other areas of practice. In part, the level of complaints is a measure of the contentiousness of the area. Once a child custody or visitation matter has gone to the level of court involvement, there is going to be a winner and loser. And the extreme emotions that result may be targeted at a psychologist who testified adversely.

Managed Care

If the ethics code discusses “managed care” explicitly, it will only be with a code subsequent to the 1992 APA ethics code. Even without explicit discussion, however, many sections of the ethics codes have direct applicability.

It should be noted that since managed care is not a single behavioral situation, no single ethical analysis will apply to it. In addition, theAPAethics code is applied to individual psychologists, and many of the basic concerns raised about managed care plans are not with regard to the behavior of the psychologist, but of the managed care review. Whether more explicit guidance regarding managed care is included in the ethics code, such provisions will be limited by the multifaceted nature of managed care and limitations to the length of the code.

Important elements in existing codes include provisions for informed consent, with an emphasis on describing relevant aspects of the nature of services and limits to confidentiality. Psychologists need to consider that clients may not understand provisions of their mental health coverage for a variety of reasons, including misrepresentation by managed care company, complicated materials, and failure of the client to read materials. Some managed-care review processes involve more extensive intrusion into records than do others, so there are limits to what the psychologist can anticipate.

Competence bears special importance to any managed care situations that involve direct or indirect pressure to provide services without referring. Psychologists must be very careful not to provide services (or to supervise services) for which they do not have competence. In addition, pressure to deliver high levels of services may interfere with quality of care. One of the most often raised problems is concern about professional reviewers disapproving continuing treatment based on contract limitations rather than treatment needs.

An ethical dilemma presented in some managed care cases occurs when the psychologist provider, who remains responsible for the actual treatment plan delivered, is unable to get approval for appropriate treatment. The provider may be charged with providing inadequate care if inappropriate treatment is provided. A legal case led to recommendations that providers always appeal denial of care when the psychologist believes that continued care was needed.

Several specific sections of the 1992 ethics code have direct relevance to managed care circumstances and dilemmas. Important provisions are any regarding contracts, for example, Standard 4.08, “Interruption of Services.” Part (a) includes the requirement that “Psychologists make reasonable efforts to plan for facilitating care in the event that psychological services are interrupted” (p. 1606) by several factors. Included in a nonexhaustive list are “the client’s . . . financial limitations” (p. 1606). Managed care plans often involve explicit limitations in the financing of individual clients’ care, which are known ahead of time. Accordingly, the psychologist is in a position to “make reasonable efforts” to plan for facilitating care in the event of interruption due to the limitations. The psychologist who makes no effort may be in violation of the code. Part (b) is an explicit requirement to take action at the point of entering into contractual relationships:

When entering into employment or contractual relationships, psychologists provide for orderly and appropriate resolution of responsibility for patient or client care in the event that the employment or contractual relationship ends, with paramount consideration given to the welfare of the patient or client. (p. 1606)

Note that the criterion to be used is “paramount consideration given to the welfare of the client.” This suggests that the psychologist must avoid a contract that does not allow consideration of client welfare in determining client treatment issues in the event that the contract ends.

Other important provisions relate to financial limitations. For example, requirements to discuss financing limitations are addressed by Standard 1.25. Part (e) of Standard 1.25, “Fees and Financial Arrangements,” is relevant when “limitations to services can be anticipated because of limitations in financing” (p. 1602). It requires that under those circumstances, the limitations must be discussed with the client as early as is feasible. Of particular concern here are managed care provisions that seek to prevent the psychologist from having such discussions.

Another provision deals with conflicts between provisions of the ethics code and organizational rules or agreements. Standard 8.03 is titled “Conflicts Between Ethics and Organizational Demands” and states that

If the demands of an organization with which psychologists are affiliated conflict with this Ethics Code, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and to the extent feasible, seek to resolve the conflict in a way that permits the fullest adherence to the Ethics Code. (p. 1611)

Unethical behavior is doing nothing when faced with such a conflict.

Psychologists who work as reviewers for managed care companies and who are APA members are subject to the ethics code, but only in their discretionary actions as individuals. To the extent that they are implementing provisions in a plan, their accountability to an otherwise unethical provision may be limited.

Raw Data Release

One of the most frequent ethics questions regards requests for raw data or other testing records to be released to attorneys, courts, and others. Concerns relate both to test security and to harm that may result to clients if test data are misinterpreted. While confidentiality is an obvious issue, it can be addressed by a client release. Ethics codes have discouraged release if it would constitute misuse of the tests by releasing raw materials especially to those who are not qualified to interpret the data. The dilemma for psychologists is that there has been relatively little guidance as to how far a psychologist must go before releasing data in response to a legal demand and as to who is qualified to receive test data. This provision was receiving substantial attention in the pending revision.

Because the most substantial question is the legal strategies available for responding to requests, the best guidance available has been a document by the APA Committee on Legal Issues (COLI) titled “Strategies for Private Practitioners Coping With Subpoenas or Compelled Testimony for Client Records or Test Data” (APA COLI, 1996). In addition, the APA Committee on Psychological Tests and Assessment (CPTA) issued a “Statement on the Disclosure of Test Data” in 1996 (APACPTA, 1996). This article includes a discussion of what constitutes raw data as opposed to other information such as normalized scores.

The language in Standard 2.02b from the 1992 ethics code regarding release to clients was confusing to some psychologists, who wondered if it meant that clients had a special right to receive test data even if they were not qualified to use them. An alternative interpretation was that in some states clients have a right to review their files, and “as appropriate” in the phrase “to patients or clients as appropriate” (p. 1603) refers to such a situation. Generally, clients should be provided information so that it is clearly understood, and release of raw data from records is not likely to be understood without other explanation.

Ethical Decision-Making Models

Asingle ethics code rule or legal statute rarely provides a full answer to a real-life situation. Psychologists regularly encounter situations that require a consideration of the proper ethical decision, and a number of decision-making models are available. (See, e.g., Canter et al., 1994; Haas & Malouf, 1989; Kitchener, 1984; Koocher & Keith-Spiegel, 1998.)

Most models include identifying the ethical aspects of the problem, identifying relevant ethical and other standards, determining relevant facts and collecting additional information as needed, identifying options and selecting an action plan, taking the action, and evaluating the results. Models also emphasize consultation with experts. It is generally recommended that psychologists document the process used, factors considered, action taken, and outcome observed.

Canter et al. (1994) emphasized actions taken prior to a point in time when an actual dilemma is encountered. This includes knowing the ethics code and applicable laws and legal and institutional regulations, taking continuing education workshops in ethics, and learning a formal method for analyzing ethical dilemmas. Obviously, having good ethics education during graduate training is critical. Identifying ethical challenges before they become problems is a key goal. The emphasis on preparation is especially important because many ethical problems require immediate action and a formal system for considering ethical options is not practical.

A simple method is helpful for situations in which action must occur quickly. For example, a psychologist may ask, “Is my action ethical, practical, and reasonable?” or “Am I acting in a responsible and accountable manner?” A method by Callahan, cited by Haas and Malouf (1989), is for the psychologist to imagine him- or herself in a “clean, well-lit room” in order to gauge the acceptability of a planned action taken with the full understanding of colleagues. Psychologists should also attend carefully to cautions from others, whether colleagues, students, clients, or others. Psychologists should resist the temptation to dismiss such cautions as unwarranted and instead to see them as invitations to review the situation in depth through an ethical analysis and consultation.

The following steps are one decision-making system.

• Identify the ethical aspects. Sometimes these are apparent at the beginning of the analysis but may become clearer later in the process. It can be instructive to ask the following:What ethical issues are involved?Are the ethical issues ones of aspirational ethics or enforceable ethics rules? Whatlegal(statutory,caselaw,licensureboardregulations) are involved, if any? What clinical, scientific, or technical issues are involved? (Clinical opinions and strategies are often important in issues of “fact,” as mentioned later.)
• Identify the ethical problems. This is a tentative identification. Be general and specific. Consider whether there is a single problem or multiple dilemmas. What priority do the various problems have?
• Identify relevant ethical and other standards. Are there specific rules that will address all or part of the problem? Consider ethicscodes, licensure laws and regulations, other laws, institutional rules, and professional guidelines.
• Consider whether there is an uncomplicated resolution or whether this is an ethical dilemma in which there are specific conflicting duties or rights.
• Determine the facts. What do you actually know? What additional information is needed to clarify the situation? Consider clinical opinions that, for the purpose of the ethical analysis, are facts. For example, if you are considering the ethics of violating confidentiality to protect a suicidal client, your clinical opinion that he or she is at imminent risk to make a suicide attempt is a “fact” in your ethical analysis. How you formed the opinion is a clinical issue.
• List options for resolving the problem. If the situation is complex, write down the options. For each option, ask whether the option is ethical, practical, and reasonable. Consider consultation to review the options.
• Decide on and evaluate an action plan. Ask whether the means and ends are morally acceptable. Use the “clean, well-lit room” exercise to consider the plan’s acceptability. Consider consultation if it is not already part of the plan.
• Take action. Document the decision process, action, and outcome.
• Evaluate the action. Is the outcome as expected? Were there negative consequences that need to be addressed?

Enforcement of Codes

The APA ethics code is used in various types of disciplinary and corrective actions against psychologists. The APA ethics code is directly enforced by APA and by state or other psychological associations that adopt it and apply it to their members. Such enforcement is limited to members of such groups. The APA ethics code is also enforced by states that incorporate the code into licensure legislation or licensure board regulations as the profession’s code of conduct. In such cases, the ethics code has the force of law and is enforced by the licensure board, or more commonly now, by a professional discipline agency of the state. If the code is used as a standard for psychologists working in settings such as a hospitals or universities, action might be taken against a psychologist on the staff or faculty if the professional is alleged to have violated the code.

In addition to such direct application of a code in reviewing for an ethics or licensure violation, the ethics code is also used as a set of standards of practice in malpractice or other civil litigation. The plaintiff uses the code to show what the standards were that the psychologist did not uphold, just as the defendant psychologist would use it to demonstrate that appropriate procedures were used. An important difference is that an ethics complaint review looks at whether the psychologist complied with the ethics code as such. It need not be shown that the client was necessarily harmed. The profession has an interest in enforcing the ethics code even if no harm was shown because the content of the code is determined based on a belief that not complying with the code is likely to be harmful to the profession and clients. In a malpractice review the plaintiff must show harm by a psychologist who owed him or her a professional duty. Only after that is established is the psychologist’s compliance with the ethics code relevant.

Of course, ethics codes and licensure regulations are not the only bases for review of psychologists’ behavior. A psychologist may be found guilty of having broken an independent (even if related) law. Psychologists may have such action taken against them without having been found to have violated the ethics code or even if it has been shown that they have not violated the code. For example, a psychologist might be charged with insurance fraud based on laws independent of ethics or licensure rules. In such situations, laws may be more stringent than a particular ethics code or licensure provision. For example, there may be situations in which laws against fee splitting may be violated without violating the 1992 APA ethics code provision.

For APA members and others who file complaints against APA members, it is important to understand the APA Ethics Committee’s (1996) Rules and Procedures that govern the process for conducting ethics investigations of members. The current version is typically posted on the APA’s Web site at www.apa.org/ethics, and amendments were adopted in 2001 that were planned for publication in 2002. Changes that may be made to the rules can have a substantial effect on investigations. For example, the 1996 rules revision resulted in new APA student affiliates being subject to jurisdiction of the Ethics Committee. (This jurisdiction is limited to review of activities not under the scrutiny of the student’s graduate program and of affiliates who join after the provision was put in place.) Also, that revision changed the time limit for a member filing a complaint against another member from 1 to 3 years. Beginning with the 1992 revision (APA Ethics Committee, 1992b), the rules include a brief overview that is likely to be included in the future and to be helpful when reviewing future revisions.

The APA procedures provide two types of investigations. One is called a show cause proceeding and provides for review of an APA member if the member has lost his or her professional license, been convicted of a felony, or lost membership in a state psychological association due to unethical conduct. Because another authoritative body has sanctioned the member, the burden is on the member to convince APA that he or she should not be expelled. (The name comes from the member’s being given an opportunity to “show cause” why the member should not be expelled.) In 2001 changes were adopted to provide that such matters would result in an automatic expulsion from APA unless the member appealed the expulsion.

The other type of investigation is based on a complainant’s alleging that the psychologist violated the ethics code. The complaint is usually filed by an individual but may also be filed by the Ethics Committee acting on its own, called a sua sponte review. These complaint investigations allege a violation of the ethics code, and the burden is on the Committee to prove the charges. The complaint is judged by the version of the ethics code in effect at the time the behavior occurred.

In both types of APA investigations, members are not allowed to resign membership in APA (directly or by nonpayment of dues) while under scrutiny of the Ethics Committee. However, changes adopted in 2001 included an option for resignation under investigation.

The Rules and Procedures provide a great deal of detail. For example, there are time limits for filing complaints; nonmembers have 5 years in which to file a complaint, and APA members have 3 years. There are limited provisions for waiving the time limit.

Staying Up to Date

Information about the APA ethics program can be found in the Ethics Committee’s annual article in American Psychologist. This includes information about ethics code and rules and procedures revisions, the Committee’s investigation activities, and educational activities. In recent years the article has carried a table identifying published statements of the Committee. These can be important to interpreting provisions in the ethics code. As noted earlier, the APA Web site is a source of current information.

For example, the Committee issued a statement in 1995 regarding services by telephone or Internet and issued a revised statement in 1997 (APA Ethics Committee, 1998). A primary point of both statements was that even though the Ethics code did not include explicit mention of such services, provisions such as informed consent and confidentiality apply.

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