Ethics in Psychotherapy

1. Ethics in Psychotherapy Obligatory directives and idealistic virtues

2. Why do we need ethical principles? • Therapeutic relationships are unbalanced, with the therapist typically possessing significantly more power in the relationship. • Therapeutic relationships are complicated, both due to the nature of the relationship itself and the nature of the client’s issues/problems. • Therapy relationships may be characterized by abrupt changes, some of which (e.g., suicidality) may have severe implications for the client’s well-being. • Therapists are human, and humans are fallible. Ethical guidelines provide accountability.

3. What are ethical principles? • Ethical codes are guidelines for what therapists can and cannot do that have been developed by each therapeutic discipline’s organizational body, including the American Counseling Association (ACA) and the American Psychological Association (APA). • Ethical codes are not set in stone. They are principles upon which to guide practice. Each therapeutic situation is unique and sometimes the therapist must interpret the code. • There are two dimensions to ethical decision making: • Principle ethics: Overt ethical obligations that must be addressed. • Virtue ethics: Above and beyond the obligatory ethics and are idealistic.

4. Philosophical Guidelines • Consequentialist Theories • Act utilitarianism • Rule-utilitarianism • Deontological Theories • Act is right or wrong, and we have duty to do what is right • Obligatory, permissible, and forbidden duties • Three best examples of where duties come from • God • Intuition • Kantian “categorical Imperative” –> Universal Law

5. Ethical issues affecting clinical practice • Therapist Competence: Therapists need to only provide services for which they are qualified • Client Welfare: Client needs come before counselor needs and the counselor needs to act in the client’s best interest. • Informed Consent: Counselors need to inform clients as to the nature of counseling and answer questions so that the clients can make an informed decision. • Confidentiality: Clients must be able to feel safe within the therapeutic relationship for counseling to be most effective. • Dual Relationships: When a counselor has more than one relationship with a client (e.g. The counselor is a friend and the counselor.) • Sexual Relationships: Professional organizations strongly prohibit sexual relationships with clients and in some states it is a criminal offense.

6. Competence and malpractice • Therapists need to: • only provide services for which they are qualified, accurate • accurately represent their credentials and qualifications. • continue their education. • keep up on current information of the field, especially in specialty areas. • seek counseling when they have personal issues • Malpractice • occurs when a counselor fails to provide reasonable care that is generally provided by other professionals and it results in injury to the client. • Four conditions must exist: • The counselor has a duty to the client. • The duty of care was not met. • The client was injured in the process. • There was a close causal relationship between the counselor’s failure to provide reasonable care and the client’s injury.

7. Informed consent • All of the following should be covered in order for the client to be able to make an informed choice • The financial costs of counseling • Any special arrangements • The competencies of the counselor • Nature of treatment (experimental Tx should be indicated) • Confidentiality (and its limits)

8. Privileged Communication (confidentiality) • Legal protection of the client which prevents a counselor from disclosing what was said within the counseling session(s) • This right belongs to the client and not the counselor • Laws concerning privileged communication vary from state to state

9. When privileged communication doesn’t apply • Tarasoff vs. Board of Regents of the University of California: A landmark case with the end result being that counselors have a “duty to warn” if a client threatens another person’s life or with significant bodily harm. • When the client is suicidal • When a client needs hospitalization. • When a counselor is performing a court ordered evaluation • When the client sues the counselor • When the client uses a mental disorder as a legal defense • When an underage child (under 16) is being abused

10. The ethics of dual relationships • Is the dual relationship necessary? • Is the dual relationship exploitive? • Who does the dual relationship benefit? • Is there a risk that the dual relationship could damage the patient? • Is there a risk that the dual relationship could disrupt the therapeutic relationship? • Am I being objective in my evaluation of this matter? • Have I adequately documented the decision making process in the treatment records? (the spirit of the law is "If it is not written down, it did not happen.“) • Did the client give informed consent regarding the risks to engaging in the dual relationship?

11. Legal Issues and Managed Care • Counselors have the duty to appeal adverse decisions regarding their client(s). • Counselors have a duty to disclose to clients regarding the limitations of managed care and the limits of confidentiality under managed care. • Counselors have a duty to continue treatment and are not supposed to “abandon” a client just because the client does not have the financial means to pay for services.

12. Practice and Ethics • Practical and ethical issues are inherent in counseling. • Three Phases (DePauw, 1986) • Precounseling • Service Provision • Termination Sperry, Len, John Carlson, & Diane Kjos. Becoming An Effective Therapist. Allyn & Bacon, 2003, pp. 181-199.

13. Pre-counseling Issues • Accuracy of marketing and public communication • Dual relationships • Expertise/competence for given problem/client • Evaluation of threat/crisis

14. Issues with on-going service • Confidentiality • Accurate record keeping • Continuous personal growth • Supervision, training, and/or consultation • Cooperation with other service providers • Proper action when a client poses a clear and imminent danger to themselves or others • Laws regarding child abuse and neglect • Referrals

15. Termination issues • Evaluation • Does the client have the ability to maintain gains made in therapy? • What resources does the client have to manage threats to these gains? • How has the change impacted family members or others? • Be sensitive to the client’s feelings regarding termination. • Initiate termination when the client is not benefiting from services. • Address the client's post-terminations concerns. • Evaluate the efficacy of the counseling services. • Consider referral needs

16. Ethical Quandaries: What to do? • Should I rent an apartment to a current client? • I provided marital counseling to a couple, and they have asked me to serve as the mediator in their divorce. Should I agree to the request? • Should I accept a gift from a client? • Should I buy a car from a dealership owned by a client, when it is the only dealership in town?