Erica H. Wise, Ph.D. Department of Psychology UNC Chapel Hill

1. Infusing Ethical and Multicultural Competencies Into Internship Training:A Participatory WorkshopAPPIC ConferencePortland, OregonApril 17, 2009 Erica H. Wise, Ph.D. Department of Psychology UNC Chapel Hill

2. Overview • Being an ethical role model for our trainees • Ethical and multicultural considerations in supervision and training • Effective strategies for developing ethical and multicultural competencies at the internship level APPIC 2009

3. Serving as an EthicalRole Model • Be familiar with ethical and legal standards • Attend ethics and multicultural workshops • Be familiar with practice guidelines (e.g. Ethics Code, LGBTQ, Multicultural) • Regularly consult with colleagues • Promote ethical and multicultural discourse in your agency APPIC 2009

4. General Ethical Considerations in Supervision and Training • Be familiar with guidelines and standards related to supervision and training • Incorporate these principles into the your training program • Create an atmosphere that fosters discourse about ethics, multicultural considerations and practice APPIC 2009

5. Professional Self-Regulation • Risk management • Aspirational Ethics

6. Philosophical Underpinnings There are two philosophical world views that are commonly drawn from in the study of moral and ethical reasoning: • Deontological • The Moral Imperative • Choices and behavior are inherently right or wrong • Teleological • Utilitarianism or Pragmatism • Choices and behaviors are judged by outcome APPIC 2009

7. Sources of Guidance for the Practice of Psychology • APA Ethics Code • HIPAA and other federal regulations • Psychology Practice Act in your state • Your agency or institution • Guidelines and best practices documents APPIC 2009

8. Ethical Issues in Supervision Major Ethical Issues: • Competence and Client Welfare • Informed Consent • Confidentiality • Supervisee Rights • The Relationship Between Supervisor and Supervisee APPIC 2009

9. Competence and Client Welfare APPIC 2009

10. 2.05 Delegation of Work to Others (excerpt) Psychologists who delegate work to…supervisees…take reasonable steps to…authorize only those responsibilities that such persons can be expected to perform competently on the basis of their education, training and experience…with the level of supervision being provided. APPIC 2009

11. Informed Consent APPIC 2009

12. 10.01 Informed Consent to Therapy • Psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers. • When the therapist is a trainee and the legal responsibility for the treatment provided resides with the supervisor, the client/patient, as part of the informed consent procedure, is informed that the therapist is in training and is being supervised and is given the name of the supervisor. APPIC 2009

13. 10.02 Therapy Involving Couples or Families When psychologists agree to provide services to several persons who have a relationship (1) which of the individuals are clients/patients and (2) the relationship the psychologist will have with each person. This clarification includes the psychologist’s role and the probable uses of the services provided or the information obtained. APPIC 2009

14. What do psychologists say? “Informed consent is a shared decision making process in which the professional communicates sufficient information to the other individual so that s/he may make an informed decision about participation in the professional relationship.” Barnett, PPRP, 2007 APPIC 2009

15. Readability of NPP Forms?The Numbers Game, Washington Post, 2005 0% of patient privacy forms were as easy to read as comics 1% were as easy to read as J.K. Rowling’s “Harry Potter and the Sorcerer’s Stone.” 8% were as easy to read as H.G. Wells’s “The War of the Worlds” 91% were as easy to read as professional medical literature or legal contracts APPIC 2009

16. Etymology of Inform From the Latin Informare; in= causative preposition + formare= to make or to form; to form an idea “To cause someone to form an idea” APPIC 2009

17. Etymology of Consent From the Latin comsentire com= with + sentire=to feel or to sense “To feel together; to feel with; to be of one mind” APPIC 2009

18. Final Thoughts on Informed Consent “To cause someone to form an idea To feel together; to feel with; to be of one mind” How can the Informed Consent process truly serve more than a risk management function? Wise, PPRP, 2007 APPIC 2009

19. Confidentiality APPIC 2009

20. CONFIDENTIALITY • Done or communicated in confidence; told in secret • In the context of an intimate or trusting relationship • Latin: con = with; fidere = trust • General Principle Balance between: public welfare and individual rights

21. CONFIDENTIALITY General Rule • Mandated Exceptions • Permitted Exceptions

22. Definition of Terms • Privacy • Confidentiality • Privilege APPIC 2009

23. CONFIDENTIALITY General Rule • Mandated Exceptions • Permitted Exceptions APPIC 2009

24. General Rule 4.01 Maintaining Confidentiality Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship. APPIC 2009

25. Limits of Confidentiality 4.02 Discussing the Limits of Confidentiality (a) Psychologists discuss with persons (including, to the extent feasible, persons who are legally incapable of giving informed consent and their legal representatives) and organizations with whom they establish a scientific or professional relationship (1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities. (See also Standard 3.10, Informed Consent.) (excerpt) APPIC 2009

26. Disclosure With Consent 4.05 Disclosures (a) Psychologists may disclose confidential information with the appropriate consent of the organizational client, the individual client/patient, or another legally authorized person on behalf of the client/patient unless prohibited by law. APPIC 2009

27. Disclosures Without Consent 4.05 (b) Psychologists disclose confidential information without the consent of the individual only as mandated by law, or where permitted by law for a valid purpose such as to (1) provide needed professional services; (2) obtain appropriate professional consultations; (3) protect the client/patient, psychologist, or others from harm; or (4) obtain payment for services from a client/patient, in which instance disclosure is limited to the minimum that is necessary to achieve the purpose. (See also Standard 6.04e, Fees and Financial Arrangements.) APPIC 2009

28. Supervisee Rights APPIC 2009

29. 7.02 Descriptions of Education and Training Programs Psychologists responsible for education and training programs take reasonable steps to ensure that there is a current and accurate description of the program content (including participation in required course- or program-related counseling, psychotherapy, experiential groups, consulting projects, or community service), training goals and objectives, stipends and benefits, and requirements that must be met for satisfactory completion of the program. This information must be made readily available to all interested parties. APPIC 2009

30. 7.04 Student Disclosure of Personal Information Psychologists do not require students or supervisees to disclose personal information in course- or program-related activities, either orally or in writing, regarding sexual history, history of abuse and neglect, psychological treatment, and relationships with parents, peers, and spouses or significant others except if… APPIC 2009

31. 7.04 Student Disclosure of Personal Information • The program or training facility has clearly identified this requirement in its admissions and program materials or • The information is necessary to evaluate or obtain assistance for students whose personal problems could reasonably be judged to be preventing them from performing their training- or professionally related activities in a competent manner or posing a threat to the students or others. APPIC 2009

32. 7.06 Assessing Student and Supervisee Performance • In academic and supervisory relationships, psychologists establish a timely and specific process for providing feedback to students and supervisees. Information regarding the process is provided to the student at the beginning of supervision. • Psychologists evaluate students and supervisees on the basis of their actual performance on relevant and established program requirements. APPIC 2009

33. The Relationship Between Supervisor and Supervisee APPIC 2009

34. 3.05 Multiple Relationships A multiple relationship occurs when a psychologist is in a professional role with a person and: • At the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or • Promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. • At the same time is in another role with the same person, APPIC 2009

35. 3.05 Multiple Relationships(excerpt) • A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. • Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical. APPIC 2009

36. 3.08 Exploitative Relationships Psychologists do not exploit persons over whom they have supervisory, evaluative, or other authority such as clients/patients, students, supervisees, research participants, and employees. APPIC 2009

37. 7.07 Sexual Relationships With Students and Supervisees Psychologists do not engage in sexual relationshipswith students orsupervisees who are in their department, agency, or training center or over whom psychologists have or are likely to have evaluative authority. APPIC 2009

38. Psychologists in Training90-270.4 Exemptions Example from NC Psychology Practice Act (d) Nothing in this article shall be construed as limiting the activities, services, and use of title designating training status of a student, intern, fellow, or other trainee…preparing for the practice of psychology under the supervision and responsibility of a qualified psychologists…provided that such activities and services constitute a part of his or her course of study as a matriculated graduate student in psychology. APPIC 2009

39. Developing Ethical Competencies in our Trainees… What are we trying to do? APPIC 2009

40. ADPTC Competency Outline #7 Ethical Competencies During the practicum, the student will build on coursework in ethical practice, developing individual, practical knowledge of ethical practice, including linkage of the APA ethics code (APA, 2002) to behavior and decision making in actual clinical settings. In addition, students should increase and apply their understanding of legal standards (state and federal, e.g., HIPAA) and APA practice guidelines. APPIC 2009

41. ADPTC CO Ethical Competencies More specifically, during practicum training the student will work to develop the following ethical competencies: • Knowledge of ethical/professional codes, standards and guidelines; knowledge of statutes, rules, regulations and case law relevant to the practice of psychology. • Recognize and analyze ethical and legal issues across the range of professional activities in the practicum setting. • Recognize and understand the ethical dimensions/features of his/her own attitudes and practice in the clinical setting. • Seek appropriate information and consultation when faced with ethical issues. • Practice appropriate professional assertiveness related to ethical issues (e.g., by raising issues when they become apparent to the student). Evidence commitment to ethical practice. APPIC 2009

42. Competency BenchmarksReadiness for Internship Essential Component: Intermediate level knowledge and understanding of the APA Ethical Principles and Code of Conduct and other relevant ethical/ professional codes, standards and guidelines; laws, statutes, rules, regulations Behavioral Anchor: • Identifies ethical dilemmas effectively • Actively consults with supervisor to act upon ethical and legal aspects of practice • Addresses ethical and legal aspects within the case conceptualization • Discusses ethical implications of professional work • Recognizes and discusses limits of own ethical and legal knowledge APPIC 2009

43. Competency BenchmarksReadiness for Entry to Practice Essential Component: Routine command and application of the APA Ethical Principles and Code of Conduct and other relevant and other ethical, legal and professional standards and guidelines of the profession Behavioral Anchor: • Spontaneously and reliably identifies complex ethical & legal issues, analyzes them accurately and proactively addresses them • Aware of potential conflicts in complex ethical and legal issues and seeks to prevent problems and unprofessional conduct • Aware of the obligation to confront peers and or organizations regarding ethical problems or issues and to deal proactively with conflict when addressing professional behavior with others APPIC 2009

44. Strategies • Didactics and formal seminars • Integrate ethical and multicultural considerations into all agency activities • Supervision • Experiential learning • Socratic questioning APPIC 2009

45. Supervision Considerations APPIC 2009

46. Supervision Defined “An intervention provided by a more senior member of a profession to a more junior member or members of that same profession” (Bernard & Goodyear, 2004) APPIC 2009

47. Supervision… • Is evaluative and extends over time • Enhances professional functioning of the junior person • Monitors quality of professional services to the client • Serves as a gatekeeper for the profession (Bernard & Goodyear, 2004) APPIC 2009

48. Supervision as a Triadic System Client Supervisee Supervisor APPIC 2009

49. The Supervisory Dyad Supervisor Supervisee APPIC 2009

50. A stronger supervisory relationship will facilitate increased trainee disclosure and enhanced examination of multicultural and ethical considerations APPIC 2009