Ethics and Diversity Issues in Psychotherapy

1. Ethics and Diversity Issues in Psychotherapy Al Carlozzi, Ed.D. Professor, School of Applied Health and Educational Psychology Oklahoma State University-Tulsa Licensed Psychologist Licensed Marital and Family Therapist

2. Ethics • Ethics – “the study of standards of conduct and moral judgment; moral philosophy” (Webster) • Ethics and Morals – What is the difference? • Ethics involves reasoning about general principles and using a process of reasoning to determine an appropriate action to take in a given situation • Ethical relativism and ethical absolutism

3. Ethical Decision-Making • Identify the problem or dilemma • Consider any laws, rules, ethical principles and guidelines that might apply • Examine your own sense of right and wrong, your sense of duty and responsibility (the dictates of your conscience) • Generate possible courses of action • Consider the consequences of each course of action • Seek consultation when necessary • Select the best course of action

4. Influences on Ethical Decisions/Actions • Knowledge/understanding of the ethical principles of one’s profession • Personal and professional experiences • Moral maturity/development • Motivation (egoistic self-interest vs. altruistic other-focused) • Intuitive and critical-evaluative processes • Values, attitudes, beliefs (consistency with the values of the counseling profession) • Pressures of the moment • The therapist’s multiple identities

5. Assumptions • Psychotherapy is not value-free. Clients and psychotherapists alike bring their values, beliefs, and multiple identities into the therapeutic relationship. • Clients and the issues they present reflect the diversity in our society (culture, race, ethnicity, gender, age, sexuality, religion, socioeconomic class, and mental and physical ability) • While we have the responsibility to be objective and non-judgmental in our treatment of clients, there remains some risk that our values, beliefs, and biases toward others who are different from us will influence how we respond in certain situations

6. Influence of Therapist Values • Ideal family • Preservation of marriage • Gender roles and double standards • Child rearing • Sexual behavior • Affairs • Age-related biases • Cultural stereotypes and prejudices • GLBT issues • Pro-choice and pro-life • Faith-based values

7. Professional Responsibilities • Act in the best interests of clients (beneficence) • Non-maleficence (do no harm) • Respect for autonomy • Promote justice • Respect, appreciation, and affirmation of diversity • Act consistent with the ethical principles of our profession, and laws pertinent to the practice of psychotherapy

8. Ethical Principles and Therapist Personal Values/Beliefs in Conflict • Respect for client rights and dignity and personal beliefs that certain lifestyles and choices are morally and spiritually wrong and not worthy of respect. • Respect for clients’ rights to make choices and efforts by therapists to influence clients to choose in accordance with their personal beliefs. • Tolerance and respect for human differences and personal discomfort with and culturally insensitive treatment of clients who are different. • Concern for the welfareof others and harmful treatment of others because of personal disagreement with their religious beliefs/practices, lifestyles, and/or choices.

9. More Conflicts • Ensuring that biases, boundaries of competence, and limitations of expertise do not lead to or condone unjust practices and justifying such practices on the basis of an authority higher than the ethical principles of one’s mental health discipline. • Nondiscrimination and therapists refusing services to those whose religious beliefs/practices, lifestyles, and/or choices are inconsistent with their beliefs.

10. APA Ethical Principle E: Respect for People’s Rights and Dignity • Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making.

11. Principle E Continued • Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status and consider these factors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices.

12. What to Do? • Increase awareness of our own multiple identities and values, and our attitudes and biases toward those who are different • Acknowledge how the statused and privileged aspects of our identity might affect others • Educate ourselves about diverse cultures, life-styles, and world views that are different from our own • Cultivate an open mind • Respect and appreciate difference (affirm diversity) • Recognize how while different there is much that unites us a fellow human beings (universality) • Respond to clients with empathy and emotional intelligence • Become culturally competent

13. Culturally Competent Psychotherapy • Recognize sources of discomfort with cultural differences between us and our clients • Acknowledge how our own heritage and identities affect our views about normality/abnormality and the process of psychotherapy • Understand the sociopolitical forces that impact the lives of clients • Seek out multicultural experiences • Respect religious/spiritual beliefs and indigenous helping practices and help-giving networks

14. APA Diversity Guidelines • Recognize that we are cultural beings and that we may hold attitudes and beliefs that can have an adverse impact on individuals who are different from us • Acquire knowledge of and sensitivity/responsiveness to culturally diverse individuals • As educators, employ the constructs of multiculturalism and diversity in psychological education • Conduct culturally sensitive research • Apply culturally appropriate psychotherapeutic practices and be open to the reality that culture-centered interventions may be more effective in certain contexts • Support culturally informed organizational policy development and practices

15. Challenges Are there circumstances when sensitivity to cultural factors can be inconsistent with ethical or legal responsibilities? How do we manage situations when there is conflict between ethical standards and being culturally sensitive and culturally competent? How do we apply ethical decision-making processes to “shades of gray” situations that involve cultural considerations?

16. Case #1 You are working with a couple; she is age 20 from the USA and he is 31 from the middle-east. Her presenting complaint is that he is “extremely jealous” when she talks to other men, and even objects when she glances at or makes eye contact with other men. She says she simply can’t be so restricted. He says that she should not want to look at other men, and that her behavior in the faith tradition in which he was raised is considered improper. How might your values and beliefs affect your working with this couple, and how might you respond were you this couple’s therapist?

17. Case #2 Your client is Mexican American girl, age 13, brought in by her parents who are quite worried about her. She admits that she feels depressed sometimes, has entertained thoughts of killing herself, but cannot bring herself to think too seriously about this because suicide is contrary to her religion. She and her parents are Catholic, and all three attend Mass once or twice per week. The girl discloses that she has been seeing and hearing strange things. She reports that little demons have been taunting her while she lies in her bed just prior to falling asleep and sometimes in the morning about the same time that she is waking up.

18. Case #2 Continued She says that sometimes the demons frighten her, but mostly they just hop around laughing, and then she is not as frightened. Her parents immediately called their parish priest, and begged him to come over to bless the house, the girl, and her bedroom, in order that these demons might be expelled. The girl tells you that the priest complied with their request, and at that time recommended that the girl also get professional help. How would you address your client’s problems with her and her parents in light of the religious and cultural issues involved?

19. Case #3 Your client is a Native American male, age 39, raised on a reservation. He came for counseling at his wife’s insistence for help with stress. After three sessions with him, he tells you that he has little faith in the strictly “logical ways” of psychological practice and prefers methods of spiritual healing. He believes he could be more open to you if you participated with him, as his wife (who is not Native American) has done, in a sweat lodge ceremony. Or, he says, if you are uncomfortable with that, he would like to have a tribal elder present for each therapy session to provide a more spiritual perspective. How might you respond to him?

20. Case #4 Your are working with an African American couple who has sought help after she disclosed that she recently ended an extra-marital affair. She says that she fears her husband might kill the other man. While he admits that he had lost his cool and threatened to kill the other man at first, he says that he has calmed down, will do no harm to anyone, and is willing to do whatever it takes to keep her in the marriage. She complains that he is very controlling and that she wants more freedom, including the freedom to see this other man but only as a friend. He says that he cannot agree to this and becomes quite emotional in the session. She tells you that she is afraid he might lose it when they get home and go for one of his guns. When you ask about the guns, he says he has always kept guns at home for safety reasons because of the neighborhood in which they live, and he again reassures you that he will not harm his wife or the other man. How might you respond?

21. Case #5 Your client is an African American female, age 32, who is married and has a daughter, age 3. She wants help sorting out conflicts she is having between her sexual feelings and her cultural and religious beliefs. She says that she has been troubled for years by intense feelings of affection and sexual attraction toward women, far more than she ever felt toward men. She says that if she ever “came out,” it would shock her family, and she fears that her husband, who she says is good to her and a great father to their child, would be terribly hurt. Still, she feels that she can no longer deny or repress these feelings. How might you respond to her?

22. Case #6 You are working with a gay couple who have been living together for four years. They report that while they love each other, they have had conflicts over their sexual relationship since they first met. One says that he was raised in an evangelical Christian church and that he has always felt that acting on his sexual attraction to men was sinful and nasty. His partner feels no such restriction to the expression of his sexual feelings. As a result, the one has less desire to engage in sexual activity than the other, and when they do have sex, one places strict limits on their sexual activities. The one who is more restrictive is OK only with kissing and oral sex and wants nothing to do anal sex, and the other is upset about this restriction to their love-making. How might you respond?

23. Case #7 A 16 year old girl has been quite open with her friends and with one of her teachers that she has engaged in sexual relations with several boys. Her teacher encourages the parents to seek professional help for their daughter without disclosing information about the girl’s sexual activities. The parents take her in to see you. In her first session with you, she is explicit in sharing the details of her sexual adventures, and makes it very clear that you cannot tell her “religious fundamentalist” parents, because she knows their reaction would be “extreme.” What would you do in such a case?

24. Case #8 A 28 year old female international student from Taiwan is referred to you subsequent to a two week hospitalization for a suicide attempt. The diagnosis she received at the hospital was bipolar disorder with psychotic features, and she was prescribed a mood stabilizer and antipsychotic medications. In her first session with you, she complains that she hates taking these medications, quit taking them as soon as she left the hospital three days earlier, and has scheduled an appointment with a practitioner of traditional Chinese medicine for medical help. She wants you to tell her how she should handle the school and social stresses in her life that she believes contributed to her psychiatric symptoms. How might you respond?

25. Case #9 Your client is a 15 year old female who tells you on the phone when she makes her appointment with you that she is pregnant. She tells you that her parents know that she is pregnant, but she does not want them to know about her seeking counseling related to the pregnancy. You conclude that it is not a violation of the law in your state to see her under these circumstances, and agree to see her. In your first session with her she informs you that the father of the child is one of the leaders of an FLDS community in your state.

26. Case #9 (continued) She tells you that her parents are very happy about the pregnancy and are arranging for her to marry the father, a man for whom they have a great deal of respect. The girl has come for counseling because she is uncertain about whether to marry this man who has two other wives, as their faith (which she is beginning to question) allows. How might you respond?

27. Thank you participating! • Al Carlozzi • Phone: 918-594-8063 • Email: al.carlozzi@okstate.edu