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While the use of mental health therapies is an important and necessary part of healthcare, a relationship in which a patient reveals extremely personal information to a practitioner by its very nature can involve many ethical challenges. It is therefore important to identify these potential ethical complications and provide examples of best practice to ensure that patients undergoing mental health therapies receive respectful, beneﬁcial, and fair treatment. This research paper draws primarily from the ﬁeld of psychology to examine four primary components of the ethical practice of mental health therapies: (1) competence, (2) informed consent, (3) privacy and conﬁdentiality, and (4) relationships with clients. This research paper also highlights the speciﬁc needs in mental health therapies of various vulnerable populations, including women and girls, older adults, and lesbian, gay, bisexual, transgender, and gender-nonconforming populations. Lastly, this research paper discusses ethical challenges facing mental health professionals that rise in the wake of emerging technologies, particularly, increased use of social media and the Internet.
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The Value And Purpose Of A Code Of Ethics For Mental Health Practice
Ethics codes exist to reﬂect the moral principles underlying the values of a profession, and the practice of mental health therapies is no exception (Fisher 2013). Ethics codes can be aspirational or enforceable, although all must have foundations in moral principles. Ethics codes can take three forms: (1) an aspirational code that outlines broadly worded ideals and principles, but does not attempt to deﬁne precisely right or wrong behaviors; (2) an educational code that combines ethical principles with more explicit interpretations that can assist professionals in making informed decisions in morally ambiguous concepts; and (3) an enforceable code that includes a speciﬁc set of standards describing the behaviors required and proscribed by the profession, designed to serve as a basis for adjudicating grievances (Fisher 2013).
Fisher (2013) identiﬁed four primary purposes for establishing and adhering to an ethics code for professions providing mental health services. The ﬁrst purpose is to establish and maintain the integrity of the profession. Adopting a set of core values that have been reached by consensus among other members of the ﬁeld distinguishes the discipline as a “community of common purpose” and enhances public conﬁdence in those trained in the profession’s ethical standards. This, in turn, encourages members of the profession to focus on their responsibilities as well as the duties of others, as all members of the profession have a stake in acting in compliance with the ethics code. The second purpose of an ethics code is its educational and professional socialization functions. In other words, it provides practitioners with a guide to what they should reasonably expect from themselves and others. Furthermore, by setting out what is considered to be unethical conduct, it serves to deter psychotherapists from engaging in unethical behavior before a problem develops and can assist faculty and supervisors in educating graduate students and recent PhDs with limited professional experience on the values of the profession. The third purpose of an ethics code is to gain public trust by establishing what can be viewed as a contract with society to act in the public’s best interest, thus providing standards against which the public can hold mental health practitioners responsible (Fisher 2013). The ﬁnal purpose of an ethics code is to provide an explicit statement of the behaviors that constitute ethical violations, to assist consumers in making ethics complaints, and to ensure that the complaints can be adjudicated clearly and fairly by the relevant governing authority.
The responsible practice of psychotherapy involves the application of established scientiﬁc or professional behavioral techniques to enhance mental health and reduce mental health disorders. Practitioners provide mental health counseling, assessment, and psychotherapy with an individual client/patient, couples, groups, or families, and their activities are conducted within healthcare organizations or outpatient settings and either in person, by phone, or over the Internet. Ethics codes providing standards for the practice of psychotherapy emphasize four primary components: (1) competence, (2) informed consent, (3) privacy and conﬁdentiality, and (4) relationships with clients. Each of these areas will be addressed in the following sections. The research paper will conclude with a discussion highlighting the ethical issues that arise as a result of the use of emerging technologies in mental health therapies. In many instances, this research paper’s discussion will draw from Fisher’s (2013) widely read text on the American Psychological Association’s (APA 2010) Ethical Principles of Psychologists and Code of Conduct, the most detailed and globally cited ethics code among mental health practitioners.
Boundaries Of Competence
Professional competence is the linchpin enabling psychotherapists to conduct their work responsibly and fulﬁll all other ethical obligations (Fisher 2013). Consequently, to beneﬁt those with whom they work and avoid harm, it is ethically imperative that psychotherapists only practice in areas in which they have received the necessary education, training, supervised experience, consultation, study, and/or professional experience. In addition, for each activity in which they engage, mental health practitioners must be sufﬁciently familiar with current scientiﬁc and professional knowledge to determine whether an understanding of factors associated with the individual characteristics is necessary for effective implementation of their services. This includes continuing training and education if the psychotherapist plans to provide services involving populations, areas, techniques, or technologies new to them. Indeed, psychotherapists who have not had or cannot obtain knowledge or experience necessary must refrain from providing such services and make referrals when appropriate, with the exception of emergencies (APA 2010).
However, situations do arise in which a psychotherapist without the appropriate training or experience is the only professional available to provide necessary mental health therapies, such as in rural areas or small ethno-cultural communities. The APA (2010) Ethics Code permits psychotherapists to perform services in areas in which they do not have the necessary education or experience if (1) they have prior training or experience closely related to the services required, and (2) they make reasonable efforts to obtain the knowledge and skills necessary to provide the services required. Along the same lines, in emerging areas of therapy, in which recognized standards of care do not yet exist, psychotherapists must still take reasonable steps to ensure the competence of their work and protect all parties involved from harm.
Another important aspect of competence for psychotherapists is being aware of how to handle personal problems and conﬂicts that arise during the course of therapy. Psychotherapists should refrain from initiating any services if there is a signiﬁcant likelihood that their personal situations would in any way undermine their competency. If a situation develops in which a psychotherapist becomes aware of personal problems that may interfere with their ability to perform work-related tasks adequately, they must take appropriate measures – such as obtaining professional assistance – and determine whether they should limit, suspend, or terminate their work-related services (APA 2010).
The emotional toll and precarious nature of this work make psychotherapists vulnerable to occupational stress, including emotional exhaustion, depersonalization, and lack of personal accomplishment that lead to burnout, overcompensating efforts to “save” clients/ patients or participants, boundary violations, and other behaviors that impair job performance (Lee et al. 2011). Many ethical dilemmas for psychotherapists working with these patients revolve around decisions regarding maintaining an appropriate balance between personal and professional boundaries. One approach to preventing job burnout and impaired competence in psychotherapy is mindfulness-based stress reduction (MBSR) adapted for the practice of psychology. MBSR is a technique for enhancing emotional competence through attention to present moment inner experience without judgment and has been found to be an effective means of reducing emotional reactions toward and identiﬁcation with clients’/ patients’ problems that can lead to therapeutic deﬁcits (Christopher and Maris 2010).
Multicultural ethical competence in mental health therapies involves a commitment to and awareness of how different cultural attitudes can inﬂuence the treatment process. Multicultural ethical commitment requires emotional responsiveness that prompts the psychotherapist to explore cultural differences and apply ethical standards to each cultural context. It also involves the recognition of harms that psychology can exert on various cultural groups and a willingness to reﬂect on how one’s own culture, values and identity can inﬂuence an individual’s practice of psychology (Fisher 2014).
However, multicultural ethical commitment is not sufﬁcient; psychotherapists also must acquire relevant knowledge about cultural differences and how they impact the ethical decision-making process. This involves remaining up-to-date on advances in multicultural research, theory, and practice guidelines relevant to their work (Salter and Salter 2012). Examples of this include understanding the history of ethical abuses of various minorities and cultural and contextual factors that may facilitate or interfere with psychological well-being or responsiveness to treatment.
While multicultural ethical commitment and awareness are essential, they are not sufﬁcient to ensure the ethical resolution of multicultural challenges. To that end, Fisher’s concept of Goodness of-Fit Ethics (GFE) is applicable when considering multicultural perspectives in therapy. Multicultural ethical competence involves (1) creating a goodness of ﬁt between the cultural context and the psychotherapist’s work setting and goals and (2) engaging in a process of co-learning that ensures that ﬁt, and enables the psychotherapist to learn about how best to treat relevant populations and conditions (Fisher 2014).
Integration Of Religion And Spirituality
In addition to being aware of cultural, societal, gender, and sexual identity differences, practitioners must also take religion and spirituality into consideration when treating clients/patients. Integration of religion/spirituality can be characterized on a secular-theistic continuum (Fisher 2013). On the secular end of the continuum are “religiously sensitive therapies” that utilize traditional treatment while remaining sensitive to the client’s/patient’s religious or spiritual beliefs. The middle of the continuum includes “religiously accommodative therapies,” which do not explicitly promote faith beliefs, but use religious/spiritual language and interventions consistent with the clients’/patients’ beliefs when clinically relevant. On the other end of the continuum are “theistic therapies.” These draw upon the psychotherapists’ own religious beliefs and use religious or spiritual texts and techniques to promote spiritual health.
A psychotherapist’s personal faith and religious experience are neither sufﬁcient nor required for competence (Gonsiorek et al. 2009). However, all psychotherapists should have the training and experience to identify when a mental health issue is related to or grounded in religious beliefs. Religious/spiritual competence in mental health therapy includes (1) an understanding of how religion presents itself in mental health and psychopathology, (2) a self-awareness of a potential religious bias that may impair therapeutic effectiveness, (3) techniques to assess and treat clinically relevant religious/spiritual beliefs and emotional reactions, and (4) familiarity with data on mental health effectiveness of religious imagery, prayer, or other religious techniques (Fisher 2013). In addition to avoiding a secular or theistic bias when treating clients/patients, psychotherapists also should not impose their own set of values – religious or otherwise – on those they treat. Ultimately, the psychotherapist’s primary ethical commitment is to act in each client’s/ patient’s best interest by being well-informed, sensitive, and ﬂexible on religious or spiritual beliefs.
Population-Specific Guidelines In Therapy
Mental health practitioners are increasingly recognizing the unique aspects and needs of speciﬁc populations that seek therapy. While basic ethical standards of practice apply to all clients/patients, psychotherapists should be aware of and familiar with the distinctive needs of various populations, such as women and girls, elder adults, and lesbian, gay, bisexual, transgender, and gender nonconforming individuals (APA 2000). For example, the unique biological, social, and psychological differences of individuals with diverse social identities underline the value of considering how gender and other social and sexual identities may manifest themselves in the expression of a mental disorder (APA 2000, 2007). Furthermore, problems in diagnosis and treatment may arise in situations when the empirical studies conducted in an area had a sampling bias (e.g., only men or women or those of a particular ethnicity) and the results of which are generalized to all clients (APA 2007). It is, however, important to note that demographic-speciﬁc standards are not conﬁned to vulnerable populations. For instance, even though men are not considered a vulnerable or marginalized population, it is important for psychotherapists to be familiar with issues and treatments speciﬁc to the needs of men and boys, such as seeking treatment, risk-taking behavior, and institutional biases. As discussed previously in this section, Goodness-of-Fit Ethics is particularly useful when tailoring a client’s/patient’s treatment based on cultural context and encouraging a scenario of co-learning between the psychotherapist and patient. Moreover, when psychotherapists engage in a GFE co-learning arrangement with clients/patients, it may help to inform their future treatment of other members of that population, based on their unique set of needs (Fisher 2013).
Informed Consent: A Dynamic And Ongoing Process
When providing assessment, therapy, counseling, or consulting services, mental health providers must obtain informed consent from clients/ patients in language that is understandable and accessible to the individuals seeking services. Informed consent should be obtained as early as is feasible in the treatment process and must inform clients/patients of the nature and anticipated course of therapy, fees, involvement of third parties, and limits of conﬁdentiality (APA 2010). In addition, practitioners should provide an opportunity for the client/patient to ask any questions and receive answers about his or her treatment. It should be noted that it might not be possible or clinically appropriate to seek informed consent from clients/patients during the ﬁrst session, as practitioners may need to obtain more detailed information about the diagnostic criteria for service and reimbursement set by a client’s government or private health insurer, or focus on the client’s presenting problems if during the ﬁrst session the client exhibits serious mental distress.
Mental health providers should not assume that all clients/patients are familiar with the nature and practice of psychotherapy and should therefore explicitly provide information on aspects such as the duration of each session, frequency of appointments, and the general objectives of treatment. As early as is feasible, psychotherapists should inform clients/patients of the anticipated course of therapy – including an estimate of the number of sessions expected. This can vary depending on factors such as the client’s/patient’s presenting problem, the type of psychotherapy the practitioner will employ, and the client’s health plan. However, the client/patient should be made aware that informed consent is an ongoing process; as mental health providers work with clients/ patients over time, they become better able to devise a treatment plan speciﬁc to the clients’/ patients’ individual needs (Fisher 2013). The practitioner should also describe any third parties involved with the client’s/patient’s treatment – including legal guardians, health insurance companies, employers, organizations, or legal or other governing authorities – and the role of each third party (e.g., if they are paying for the therapy, if the therapy was an ordered mental health treatment, and/or who is entitled to receive diagnostic information). Lastly, an important part of the informed consent process involves a clear explanation of the extent and limits of conﬁdentiality, which will be discussed in greater detail later in this research paper.
Informed Consent Involving Clients/Patients With Impaired Decisional Capacity And Goodness-Of-Fit Ethics
In some situations, it is not appropriate or sufﬁcient for mental health providers to obtain informed consent from their clients/patients. For example, a psychotherapist working with children and adolescents has the challenging task of balancing ethical obligations to protect the welfare of the client/patient and respecting their developing autonomy and privacy. In situations where the mental health practitioner is legally required to obtain informed consent from a client’s/patient’s legal guardian, he or she must also seek the child’s assent and consider the person’s preferences and best interests (APA 2010). Taking such action respects the client’s/patient’s autonomy by ensuring that they receive developmentally appropriate information regarding the reason for and nature of the treatment and, in some cases, are given the right to refuse treatment. In situations where guardian permission is not legally required, the psychotherapist must take reasonable steps to protect the child’s/adolescent’s rights and welfare. This is accomplished by becoming familiar with research on developmental differences in children’s understanding of consent information and clinical methods to evaluate the consent capacity of individual clients/patients. The consent information must be tailored to the child’s level of understanding of the nature of his or her treatment and rights under the law and ethics guidelines.
Similarly, in situations involving treatment of adults with cognitive disorders, mental health practitioners must balance their ethical obligation to respect the dignity and autonomy of the clients/ patients to make their own decisions, with the obligation to ensure that ill-informed choices do not jeopardize their welfare or leave them open to exploitation. Although assessing the capacity to consent is an important and necessary component of determining whether an individual should be granted or deprived the right to autonomously consent to treatment, it is ethically insufﬁcient. Consequently, Fisher developed Goodness-of-Fit Ethics (GFE) for informed consent, in which she argues that the burden of consent capacity must be shared by psychotherapists and the individuals from whom consent is sought. According to GFE, this is accomplished through just and respectful informed consent processes, where the practitioner not only identiﬁes the strengths and vulnerabilities of the client/patient but also takes responsibility to create tailored consent procedures that minimize vulnerabilities, enhance consent strengths, and provide consent supports when feasible. In addition to adults with impaired decisional capacity, GFE may also be utilized when informed consent is needed for treatment involving children/adolescents (Masty and Fisher 2008).
Informed Consent In Couples, Family, And Group Therapy
Anytime psychotherapists provide treatment to multiple clients/patients either in a relationship (such as partners, or parents and children) or in a group therapy setting, there are additional potential ethical challenges that may arise in the informed consent process. For example, when psychotherapists provide services to individuals who have a relationship, they must take reasonable steps to clarify from the outset: (1) which of the individuals are patients/clients and (2) the relationship the psychotherapist will have with each person, including his or her role and the probable uses of the services provided or the information obtained. Moreover, psychotherapists working with couples and families must be clear about how conﬁdential information will be handled, including any legal obligations to disclose information about instances of potential harm, such as child or domestic abuse, HIV status, and high-risk behaviors of adolescent clients/patients. If a situation arises where a psychotherapist may be called upon to perform potentially conﬂicting roles (such as a family therapist and then a witness for one party in divorce proceedings), he or she should take reasonable steps to clarify and modify or withdraw from roles appropriately (for more details, see APA 2010; Fisher 2013).
In group therapy settings, the psychotherapist must describe the unique roles and responsibilities of all parties involved, as well as the limits of conﬁdentiality. A discussion of the roles and responsibilities of the clients/patients and the psychotherapist could include (1) differences between individual and group therapy; (2) responsibilities of each member of the group, including turn taking and prohibitions against socializing outside sessions; and (3) policies regarding such client/patient responsibilities as acceptance of diverse opinions, abusive language, coercive or aggressive behaviors, or member scapegoating. Group members must be made aware of their right to voluntarily withdraw from the group and the consequences of other members dropping out to the continuation of the group as a whole. Another important part of the informed consent process in group therapy is to ensure that group members understand the limits of conﬁdentiality, speciﬁcally the fact that psychotherapists are professionally obligated to maintain the conﬁdentiality of most material discussed during sessions; however, decisions by group members to disclose personal information are neither bound by professional codes nor subject to legal liability (for additional insights on group therapy, see Bernard et al. 2008).
Confidentiality And Privacy In Psychotherapy
As discussed previously, at the initiation of psychotherapy, clients/patients should be provided information that gives them a working understanding of the extent and limits of their conﬁdential relationship with their psychotherapist.
Mental health practitioners respect the privacy and dignity of their clients/patients by taking all reasonable precautions to protect and maintain their conﬁdentiality. This includes recognizing the extent and limits of conﬁdentiality, which may be regulated by law, institutional rules, or professional or scientiﬁc relationships. In addition, this involves discussing with their client/ patient the foreseeable uses of the information generated as a by-product of their treatment.
Ethical Requirements For Disclosure Of Confidential Information
There are certain situations when psychotherapists have a duty to disclose conﬁdential information to protect clients/patients or others from harm (APA 2010; Quattrocchi and Schopp 2005). Such instances include legal or moral obligations to report to authorities information suggesting child abuse, elder abuse, or the intention of a client/ patient to seriously harm a third party. To determine whether to disclose conﬁdential client/ patient information to third parties, psychotherapists should consider several questions identiﬁed by Younggren (2011) and Fisher (2013). Is there an identiﬁable victim (this includes the client/ patient in cases of potential suicide)? Is the threat immediate? Is there an established scientiﬁc or clinical basis for judging the probability of violence for the speciﬁc case? Can the risk be reduced? Does the psychotherapist have the risk management competencies required? If not, what steps should be taken to ensure that the situation is handled competently?
Confidentiality When Treating Children And Adolescents
Psychotherapists treating children and adolescents must also take into consideration how they will balance conﬁdentiality concerns with parental involvement in the child’s best interests. They must also be aware that parents’ perceptions of conﬁdentiality may differ from those of their children. At the outset of therapy, a consent conference should occur with psychotherapists, parents, and clients/patients at which the nature of conﬁdentiality and rationale for disclosure policies are discussed. If a parent requests information from the psychotherapist not previously considered, the psychotherapist should take special consideration to address the parent’s concern while protecting client/patient conﬁdentiality (Fisher 2013).
In situations where a child or adolescent has disclosed “secret” activities such as sexual activity or alcohol and drug use, the psychotherapist must consider whether conﬁdentiality or disclosure is in the best therapeutic interests of the child. For example, disclosures can lead to protections for children who have eating disorders through increased parental monitoring. Alternatively, disclosure of information to parents also has the potential to place the child in greater risk, for example, the disclosure of high-risk sexual behavior in situations when an LGBTQ child has not discussed their sexual orientation with their parents. Fisher (2013) identiﬁes four steps for psychotherapists to consider when determining whether and how to disclose conﬁdential information to parents when clients/patients are engaging in high-risk behavior: (1) assess and clinically address risk behaviors, (2) consider options if the client/patient is unable or unwilling to terminate or reduce behaviors, (3) prepare the client/ patient for disclosure, and (4) disclose information to the parents.
Relationships With Clients
Boundary Crossing And Multiple Relationships
The process of psychotherapy involves in-depth and reciprocal relationships with clients/patients that run the risk of boundary crossings from professional to personal relationships or overlapping roles that may compromise the effectiveness of psychotherapy. For example, therapists may be asked to attend a client’s/patient’s wedding, be confronted with gift giving or receiving with those with whom one has a professional role, or be tempted to enter a ﬁnancial or social relationship with a client/patient. Incidental encounters with clients/patients at religious services, school events, restaurants, health clubs, or similar places may also risk a blurring of roles. Practitioners should always consider whether the particular nature of a professional relationship might lead to a client’s/patient’s misperceptions regarding an encounter.
Boundaries between psychotherapists and their clients/patients and other subordinates exist in order to prevent a blurring of professional and personal spheres that could jeopardize the psychotherapists’ objectivity and ability to act in their clients’/patients’ best interests. It is the responsibility of the psychotherapist to monitor relationships with clients/patients and ensure that proper boundaries between professional and personal domains exist. For instance, boundary crossings become boundary violations when psychotherapists disclose personal information to their clients/ patients in order to satisfy their own needs. While certain types of nonsexual physical contact are permitted (e.g., showing empathy for an emotional crisis), psychotherapists should be aware that such actions may be the ﬁrst step toward a crossing of boundaries that may lead to an unethical multiple relationship.
A particularly harmful form of boundary violations is when psychotherapists engage in sexual intimacies with current therapy clients/patients. Such relationships destroy the trust in the therapeutic relationship and exacerbate mental health problems in clients/patients. All ethics codes are ﬁrm in their prohibition of such boundary violations (APA 2010). There is no excuse for such behaviors, and the ethical obligation to avoid sexual intimacies lies solely with the psychotherapist–not with clients/patients. Sexual intimacies may impair the psychotherapist’s objectivity to evaluate and treat their client/patient and jeopardize the client’s/patient’s ability to respond to and trust the psychotherapist in a professional role. In addition, such intimate relationships exploit the explicit power differential between psychotherapists and those they treat and the vulnerabilities that led clients/patients to initially seek therapy and may, in some cases, exacerbate symptoms or lead to a more serious mental disorder. Psychotherapists should also not accept clients/patients with whom they have engaged in sexual intimacies in the past. Additionally, psychotherapists should not engage in sexual intimacies with individuals they know to be signiﬁcant others, guardians, or close relatives of current clients/patients; nor should they terminate therapy to circumvent this standard.
Mental health practitioners must be vigilant in identifying situations in which unethical multiple relationships develop. An unethical multiple relationship occurs when a practitioner is in a professional role with a person and (1) simultaneously is in another role with the same person, (2) simultaneously is in a relationship with a person closely associated with or related to the client/patient, or (3) promises to enter into another relationship in the future with their client/patient or someone closely associated with or related to the person (APA 2010).
It is important to note, however, that not all multiple relationships are unethical, speciﬁcally, relationships that would not reasonably be expected to cause impairment or risk exploitation or harm. Situations will also arise with unavoidable multiple relationships, particularly when psychotherapists are working in rural communities or small insulated religious communities, for example. As the members of these communities may not have alternative psychological services available, it is important for the psychotherapist to take all reasonable steps to protect their objectivity and effectiveness and avoid possibilities of exploitation or harm.
Assessing And Avoiding Boundary Crossing And Multiple Relationships
Several authors have established useful decision-making models for determining whether a multiple relationship should be considered unethical, judging them based on a continuum of risk. Fisher (2013) synthesized these models and created a list of situations and actions that makes the ethical appropriateness of a multiple relationship increasingly questionable: (1) increased incompatibility in role functions and objectives; (2) the greater power or prestige the psychotherapist has over the person with whom there is a multiple role; (3) the greater intimacy called for in the roles; (4) the longer the role relationships are anticipated to last; (5) the more vulnerable the client/patient, student, supervisee, or other subordinates are to harm; and (6) the extent to which engaging in the multiple relationship meets the needs of the psychotherapist rather than the needs of the client/ patient.
Conflict Of Interest
Along the same lines, psychotherapists should avoid any situations that would result in a conﬂict of interest, including taking on a professional role when other interests or relationships could reasonably be expected to (1) impair their objectivity, competence, or effectiveness in performing their job as psychotherapists or (2) expose the person or organization with whom the professional relationship exists to exploitation or harm (APA 2010). This includes ﬁnancial or other gains that are given to psychotherapists indirectly through the effect of their decisions on the interests of their family members.
Interruption/Termination Of Therapy
The interruption or termination of therapy may result in additional ethical challenges for psychotherapists. Anytime psychotherapists enter into employment or a contractual agreement with other providers, group practices, institutions, or agencies, they must make reasonable efforts from the outset to provide appropriate resolution of responsibility in the event that the employment or contractual arrangement ends, with paramount consideration given to the welfare of the client/ patient (APA 2010). Psychotherapists may also terminate therapy for reasons other than employment or contractual changes. For instance, under the APA Ethics Code, psychotherapists have an obligation to terminate therapy when it become apparent that the client/patient no longer needs therapy, is not likely to beneﬁt, or is being harmed by continued service. They may also terminate therapy when threatened or endangered by the client/patient or someone with whom they are associated.
Additionally, psychotherapists should be aware that ending therapy with a client/patient without employing an adequate clinically or ethically appropriate process can be construed as abandonment by the client/patient and may be detrimental to their mental well-being. In order to avoid such situations, psychotherapists are encouraged to develop plans for the termination of services at the outset of therapy as part of the informed consent process (Davis and Younggren 2009). Furthermore, when the decision has been made to terminate therapy, the psychotherapist should provide the client/patient with pretermination counseling and ensure that the transition is as efﬁcient as possible, as well as suggest alternative service providers, as appropriate.
New Technologies in Mental Health Therapies
The Internet has changed the nature of communication and gathering information, and mental health practice is no exception. The continued and growing use of the Internet for obtaining and storing data raises ethical issues related to conﬁdentiality and privacy protections and personal/ professional boundaries. Furthermore, as younger generations who never knew life before the Internet may be more comfortable communicating online or via text message rather than in person, it is particularly important for psychotherapists to become familiar with the potential ethical challenges emerging technologies may bring to therapy. This section addresses ethical challenges with the practice of e-therapy, as well as those associated with other aspects of the Internet, such as cybersecurity, social media, and online searches.
Informed Consent And Web-Based Therapies
Web-based or e-therapy is the practice of therapy that involves the psychotherapist and client/ patient interaction occurring via the Internet. This includes both synchronous (simultaneous, e.g., sessions via live video chat) and asynchronous (time-delayed) communication. Although e-therapy does not require a new theoretical approach to psychology, it is important for psychotherapists to discuss the speciﬁcs of this relatively new modality with clients/patients during the informed consent process and address any concerns, particularly regarding conﬁdentiality and immediacy. Beneﬁts of e-therapy should also be discussed, including providing access to qualiﬁed mental health professionals to clients/ patients regardless of geographic location or physical ability to travel. Moreover, psychotherapists must continue to adhere to the ethical guidelines of the practice of therapy discussed previously in this research paper, including ensuring competence (e.g., not providing services in an area in which they do not have training, education, consultation, and experience), a discussion of informed consent (including any policies speciﬁc to e-therapy), maintaining privacy and conﬁdentiality, and avoiding multiple relationships (see also Fisher and Fried 2003 for a more in-depth discussion on the ethics of the practice of e-therapy).
Confidentiality And Web-Based Therapies
Psychotherapists must take all necessary precautions to maintain their clients’/patients’ conﬁdential records, regardless of medium, as cybersecurity at only one end of a communication network is insufﬁcient. For electronic information or data stored using the Internet, this means encrypted data transmission, password-protected data storage, and ﬁrewall techniques. Psychotherapists should discuss cybersecurity with clients/ patients, organizations, students, and others, which may include shared encryption methods and adequate password protection for communications conducted on mobile computing devices such as smartphones and other digital devices (Fisher 2013).
The Internet poses an additional challenge to psychotherapists regarding their control over personal information. As Lannin and Scott (2013) point out, the difference between the practice of therapy and the use of online social media could not be starker, as therapy is rooted in the aspect of conﬁdentiality between psychotherapist and client/patient and social media interactions are broadcast via the Internet to either the public or a selected network. Even if a psychotherapist is careful to limit personal information on professional or personal blogs or websites and has restricted access to their social networks, accidental self-disclosure is possible if clients/patients commission background checks on the psychotherapist, conduct illegal searches of phone records, or use search engines to gather information about the psychotherapist (Fisher 2013). Psychotherapists should discuss their Internet policy with clients/patients during the informed consent process. This includes an explanation of the psychotherapist’s policies on conducting web-based searches on their client/patient, as well as policies regarding interactions on social media and e-mail. Furthermore, there are certain types of speech that should be avoided by psychotherapists online, even if high privacy restrictions or pseudonyms are used, an example of which might include breaches of client/patient conﬁdentiality, speech that is libelous, and speech that denigrates the reputation of psychology (Lannin and Scott 2013).
Potential Multiple Relationships And The Internet
Conversely, psychotherapists must be aware that potentially harmful multiple relationships online are possible when they initiate an Internet search on a client/patient, as doing so without their permission may itself constitute a boundary violation (Lannin and Scott 2013). Clinton, Silverman, and Brendel (2010) put forward six questions that psychotherapists can ask themselves that help frame the decision of whether to conduct an Internet search on a client/patient: (1) Why do I want to conduct this search? (2) Would my search advance or compromise the treatment? (3) Should I obtain informed consent from the patient? (4) Should I share the results of the search with the patient? (5) Should I document the ﬁndings of the search in the medical record? (6) How do I monitor my motivations and the ongoing riskbeneﬁt proﬁle of searching? It is important to note, however, that situations may arise when a psychotherapist using the Internet to search for information on a client/patient is the most ethically responsible course of action, for example, searching for an emergency contact.
Ethics codes for the practice of mental health therapies are important and necessary for a number of reasons. Guidelines are crucial as they explicitly establish the behaviors that are considered ethical and unethical and hold psychotherapists accountable for their actions. They also provide an information base from which clients/ patients can raise ethics complaints. As the practice of psychotherapy is constantly evolving in order to reﬂect the unique needs of various populations, and the use of rapidly advancing technologies, so must the ethical standards for the profession, in order to ensure the safety and welfare of all clients/patients. However, ethics codes are only effective if mental health practitioners have a lifelong commitment to act ethically. Practitioners are not moral technocrats simply working their way through a maze of ethical rules (Fisher 2013). Successful application of the principles and standards of any ethics code involves a conception of mental health providers as active moral agents committed to the good and just practice of their profession. For mental health disciplines, in which codes of conduct dictate the general parameters but not the context-speciﬁc nature of ethical conduct, conscientiousness (the desire to do what is right because it is right), discernment (good and professional detached judgment), and prudence (the ability to apply practical wisdom to ethical quandaries) are requisite virtues. These virtues guide mental health practitioners in providing services that respect the rights and dignity of their clients/patients, provide fair access and treatment to all persons, and enhance the mental health of those who seek their services.
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