ethical biases
A minimum of 3 scholarly peered reviewed article must be sited using APA format 500 words for each topic 81 and 82
Topic 81
Biases are something we all have, and it is important to be aware of what biases you have in order to monitor them carefully. Biases can be personal or professional in nature and confronting biases can help to overcome them. Discuss some areas on which you hold biases (divorce, domestic violence, death penalty, spanking, etc.)
What are your personal/professional biases? What harm can result from not being aware of them? What standards are violated if they are not acknowledged and addressed?
Topic 82
Dr. Jones has a client who is of a different culture and faith. He is not comfortable dealing with this patient due to past negative feelings from childhood. What are his ethical and legal obligations? Why are these legal and ethical obligations in place?
65
3
ETHICAL GUIDELINES FOR USING
SPIRITUALLY ORIENTED
INTERVENTIONS
WILLIAM L. HATHAWAY
The empirical literature pertaining to clinical practice with religious and
spiritual issues is still at a relatively early stage, but in recent years a substantial
amount of attention has been paid to ethical issues in this domain (Gonsiorek,
Richards, Pargament, & McMinn, 2009; Hathaway & Ripley, 2009; Plante,
2007, 2009; Richards & Bergin, 2005; Sperry & Shafranske, 2005). This liter-
ature has focused on a wide range of ethical concerns, such as protecting against
harmful bias, practicing within one’s boundaries of competence, and exploring
role considerations in working with religious issues.
In this chapter, I begin by bringing attention to how psychologists’ rela-
tive lack of religious commitment has the potential for creating and introduc-
ing biases into treatment. A brief introduction provides readers with common
conceptualizations of spiritually oriented interventions in the recent psycho-
logical literature. This is followed by an examination and application of rele-
vant ethical codes to the use of spiritually oriented interventions. Spiritually
oriented interventions are then discussed from an accountable practice perspec-
tive. Training recommendations are also provided to help facilitate the ethical
application of such interventions. Brief clinical examples and questions are also
offered to help readers delve deeper into thinking about the ethical issues that
To the psychologist the religious propensities of man must be at least as
interesting as any other of the facts pertaining to his mental constitution.
—William James (1997)
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http://dx.doi.org/10.1037/12313-003
Spiritually Oriented Interventions for Counseling and Psychotherapy, by J. D.
Aten, M. R. McMinn, and E. L. Worthington, Jr.
Copyright © 2011 American Psychological Association. All rights reserved.
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must be considered before using spiritually oriented interventions in clinical
practice.
POTENTIAL FOR PROBLEMATIC BIASES
It has been frequently noted that professional psychologists appear to
be atypically irreligious compared with the general North American popu-
lation. Plante (2009), for instance, cited Gallup polls indicating that 95% of
Americans believe in God and 40% of attend religious services on a weekly
basis. Despite a widespread prevalence of religiousness in the general popula-
tion, researchers (Bergin & Jensen, 1990; Delaney, Miller, & Bisono, 2007;
Hathaway, Scott, & Garver, 2004; Shafranske, 2000) have noted that, relative
to the general population, psychologists (a) have double the rate of claiming no
religion, (b) are more likely by a factor of three to report religion being unim-
portant in their life, (c) have a five-fold higher rate of denying belief in God,
and (d) report lower likelihoods of attending religious services, being a member
of a congregation, or engaging in prayer.
The risk is that this lower level of conventional religiousness among psy-
chologists may result in biasing blind spots that lead them to erroneously dis-
regard significant religious issues in clinical practice. Unfortunately, there is
evidence that just this sort of neglect is occurring. Russell and Yarhouse (2006)
found that over two thirds of a sample of training directors at American
Psychological Association (APA) internships never foresaw offering training
in religious and spiritual issues at their sites. Brawer, Handal, Fabricatore,
Roberts, and Wajda-Johnston (2002) surveyed training directors of APA-
accredited doctoral training programs and found that only 17% reported sys-
tematic coverage of religion and spirituality in their programs. There is little
evidence that such findings cause much concern outside of the niche of
psychologists who specialize in the clinical psychology of religion. Imagine
if such lassitude in the profession were the case for any of the other named
diversity domains highlighted for particular attention in the APA (2010)
Ethics Code (hereafter referred to as the Code).
Yet the situation may be even more problematic than just a climate of
indifference. There is evidence that psychologists may be more likely than the
general population to be hostile and prejudicial to conventional religion.
Delaney, Miller, and Bisono (2007) noted that “it appears to be a relatively fre-
quent experience among psychologists to have lost belief in God and disaffili-
ated from institutional religion” (p. 542). They found this experience to be
nearly 7 times more frequent in their sample of psychologists than in the gen-
eral population. In a study of whether antireligious discrimination may be
occurring in admissions to doctoral programs in clinical psychology, Gartner
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(1986) found that a sample of faculty at doctoral programs accredited by the
APA were less likely to grant admission or to have positive feelings about appli-
cants whose admissions protocols contained a conventional religious identifi-
cation than about those whose protocols were otherwise identical except for
the absence of such religious identification.
It seems unlikely that a negative or less receptive atmosphere among psy-
chologists toward conventional religion would not translate into problematic
clinical practice patterns toward this client population or niche. In a random
national sample of clinical psychologists, Hathaway et al. (2004) found that
most psychologists do not routinely assess for clinically relevant spiritual or reli-
gious issues in practice. They also noted that a sizeable portion of their sample
did not feel that religion is more than a slightly important adaptive domain for
such focus.
Although there is no systematic research on the prevalence of apparent
antireligious biases and/or overt discrimination toward conventionally religious
clients by psychologists, numerous anecdotes have been recounted by clini-
cal psychologists (Cummings, O’Donohue, & Cummings, 2009). A doctoral
psychology intern at a respected internship informed me about being instructed
by his supervisor to diagnose a client with a delusional disorder because the
client expressed belief in intelligent design as opposed to evolution. The client
reportedly did not display any other indications of thought disorder, psychotic
process, or life impairment related to her beliefs. The intern expressed concern
about giving this diagnosis, but the supervisor insisted and explained that the
intelligent design belief itself was sufficient to warrant the diagnosis.
Let us assume that naturalism is true and all of the varieties of beliefs self-
identified as intelligent design are false. This would hardly justify a mental
health professional diagnosing a believer in intelligent design with a delusional
disorder. It has become common in the polemics surrounding the new atheism
to declare either theistic or atheistic belief to be a delusion (Dawkins, 2006;
Hart, 2009). In terms of pure logic, either atheism or theism is true, but not
both, so one of the two groups believes something that is false. Yet having a
false belief is not the same thing as having a delusional belief, in a technical psy-
chological sense. Delusional beliefs involve a disordered thought process and
not just acceptance of beliefs that turn out to be factually incorrect (Clarke,
2001). Giving such a diagnosis in the absence of a genuine psychotic process
runs a significant risk of iatrogenic consequences for the client, such as bearing
the stigma of receiving an unwarranted diagnosis of a serious psychiatric con-
dition, potentially having career and life options adversely affected, or being
the recipient of unnecessary treatments. Thus, this practice may constitute a
violation of the cardinal ethical concern of doing no harm.
Although negative or undervaluing biases toward conventional religion
appear to be a common risk among psychologists, problems can also arise from
ETHICAL GUIDELINES 67
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proreligious biases. The American Psychiatric Association (1989) adopted
guidelines warning against a psychotherapist imposing his or her religious val-
ues or beliefs on clients. The ethical principle of nonmalfeasance (i.e., doing
no harm) implies that psychologists should not attempt experimental proce-
dures in lieu of standard proven psychotherapies without clear warrant and
informed consent. I have encountered some psychologists who are personally
religious abandoning standard approaches to common clinical problems for
which well-supported treatments exist in favor of stand-alone explicitly reli-
gious interventions. The stand-alone approaches eschew any other form of
assistance apart from the religious or spiritual practice. Typically, these reli-
gious caregivers have justified the stand-alone spiritual approaches in terms
of their own religious beliefs about what is right for the person. Sometimes
these spiritual-only-approach psychotherapists are licensed mental health
professionals and other times they are not.
Some of their care recipients report benefits from such stand-alone
spiritual-only approaches, but others do not. Their clients are not typically
given any scientific data about likely responses to the approach (e.g., success
rates, rates of nonresponders, adverse risks), although testimonials of success
are frequently shared with the clients. Some persons in our community sought
assistance from nonreligious caregivers after dropping out from these stand-
alone spiritual-only treatments. The stand-alone dropouts indicated that they
were not typically informed by the spiritual-only-approach provider about
standard treatments for their concerns or about the experimental nature of the
approach. In cases in which this care was being provided by a nonmental
health professional, this is perhaps not surprising, but some of these cases
involved licensed mental health professionals.
The stand-alone dropouts typically reported that their presenting issues
had not improved. In fact, they sometimes now had added guilt and shame over
not getting better from the stand-alone spiritual approach. When the lack of
positive treatment response is attributed to God being unable or unwilling to
help, it may deepen recipients’ faith conflicts and emotional pain.
Now, I am not suggesting that such anecdotes prove the stand-alone spir-
itual treatments to be ineffective or noxious. Every treatment, even ones with
good empirical support, has nonresponders and dropouts. Furthermore, there
is a growing body of evidence that spiritually focused and accommodative
approaches that combine spiritual interventions with standard psychotherapeu-
tic techniques and relational skills are benign and helpful to clients (Tan &
Johnson, 2005; Worthington & Sandage, 2002). My concern has more to do
with ethical issues raised by the way the licensed caregivers engaging in the
stand-alone spiritual approaches practiced (Gonsiorek et al., 2009).
These stories call attention to the need for psychologists to adequately
consider the range of relevant ethical principles, standards, and other consid-
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erations that should guide our practice with regard to religious and spiritual
issues (Knapp & VandeCreek, 2006). Hathaway and Ripley (2009) pointed out
that such guidance can be found by reflecting on relevant ethical codes, pol-
icy statements, practice guidelines, legal precedents, exemplar guidance, and
evidence-based practice considerations. Let us now reflect on their relevance
for the explicit use of spiritually oriented interventions by psychologists.
SPIRITUALLY ORIENTED INTERVENTIONS
A growing literature on spiritually oriented interventions provides
detailed descriptions of how to conduct such interventions competently and
ethically (Plante, 2009; Richards & Bergin, 2005; Schlosser & Safran, 2009).
There is no standard language used to identify this group of interventions.
Plante (2009) described them as spiritual practices or tools. Richards and Bergin
(2005) referred to them as either theistic or spiritual interventions (p. 281).
Schlosser and Safran (2009) called them spiritual interventions and techniques
(p. 199). There is considerable overlap among the spiritually oriented interven-
tions enumerated by these authors (see Table 3.1). Although some of these
would likely be readily thought of as spiritual by most individuals (e.g., the use
of prayer), others may be less obvious examples to some of a specifically “spiri-
tual” intervention (e.g., meaning making or relaxation).
Among psychotherapists who seek to incorporate an explicitly spiritual
aspect to treatment, Schlosser and Safran (2009) also distinguished between
two general approaches: “spiritually accommodative approaches typically com-
bined a manualized treatment with practices and beliefs from a particular world
religion, whereas spiritually oriented approaches are typically less standardized
and more inclusive” (p. 200). It should be noted that none of the psychologists
whose work is cited in Table 3.1 is proposing a stand-alone use of spiritual and
religious interventions or techniques regardless of whether they are used in a
spiritually accommodative or spiritually oriented manner.
RELEVANT ETHICAL GUIDANCE
The Code provides psychologists with a list of ethical aspirational princi-
ples and enforceable standards that are either explicitly or implicitly relevant
to the use of spiritually oriented interventions in clinical practice. An example
of an explicitly relevant principle from the Code is Principle E, titled “Respect
for People’s Rights and Dignity.” The principle states the following:
Psychologists respect the dignity and worth of all people and the rights
of individuals to privacy, confidentiality, and self-determination.
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Psychologists are aware that special safeguards may be necessary to pro-
tect the rights and welfare of persons or communities whose vulnerabil-
ities impair autonomous decision making. Psychologists are aware of and
respect cultural, individual, and role differences, including those based
on . . . religion . . . and consider these factors when working with mem-
bers 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. (APA,
2010, p. 1063)
The earlier discussion of the role of bias in psychological practice with
religious issues directly and explicitly intersects with Principle E. Psychologists
should be diligent and intentional in preventing relevant biases from affect-
ing religious or spiritual issues in treatment. The simplistic characterization of
70 WILLIAM L. HATHAWAY
TABLE 3.1
Three Lists of Spiritually Oriented Interventions
Theistic/spiritual Spiritual interventions
interventions and techniques Spiritual practices or tools
Richards & Bergin (2005) Schlosser & Safran (2009) Plante (2009)
Therapist prayer
Teaching spiritual
concepts
Reference to Scripture
Spiritual self-disclosure
Spiritual confrontation
Spiritual assessment
Religious relaxation
or imagery
Therapist and client prayer
Blessing by therapist
Encouragement for
forgiveness
Use of religious community
Client prayer
Encouragement of client
confession
Referral for blessing
Religious journal writing
Spiritual meditation
Religious bibliotherapy
Scripture memorization
Dream interpretation
Prayer (therapist or client
guided)
Teach spiritual concepts
Forgiveness
Reference sacred writings
Meditation
Spiritual self-disclosure
Encourage altruism and
service
Spiritual confrontation
Spiritual assessment
Spiritual history
Spiritual relaxation and
imagery
Clarify spiritual values
Use Spiritual community
and spiritual programs
Spiritual journaling
Experiential focusing
methods
Encourage solitude and
silence
Use spiritual language
and metaphors
Explore spiritual elements
of ereams
Spiritual genogram
Prayer
Meditation
Meaning, purpose, and
calling in life
Bibliotherapy
Attending community
services and rituals
Volunteerism and charity
Ethical values and
behavior
Forgiveness, gratitude,
and kindness
Social justice
Learning from spiritual
models
Acceptance of self and
others (even with
faults)
Being part of something
larger than oneself
Appreciating the sacred-
ness of life
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a client’s belief in intelligent design as a delusional disorder illustrates the inap-
propriate operation of such a bias. However, the desire of a proreligious psy-
chologist to promote a spiritual activity in psychotherapy when the spiritually
oriented intervention is not chosen in deference to an informed client’s own
beliefs, values, and preferences would also be example of such bias.
The Code’s second standard on competence has both explicit and implicit
relevance to the use of spiritually oriented interventions. Standard 2.01a states,
“Psychologists provide services, teach, and conduct research with populations
and in areas only within the boundaries of their competence, based on their
education, training, supervised experience, consultation, study, or professional
experience” (APA, 2010, p. 1063). Thus, a psychologist who is not trained to
appropriately use spiritually oriented interventions would be wise in avoiding
their use until he or she takes steps to ensure competency and avoidance of
client harm. Until such training is received, it would be appropriate to make
a referral for a client who requests explicit use of spiritually oriented inter-
ventions or who presents with prominent religious and spiritual issues.
Yet this does not mean that psychologists should be content simply to
avoid this domain indefinitely. Standard 2.01b further states the following:
Where scientific or professional knowledge in the discipline of psychol-
ogy establishes that an understanding of factors associated with . . .
religion . . . is essential for effective implementation of their services or
research, psychologists have or obtain the training, experience, consulta-
tion, or supervision necessary to ensure the competence of their services, or
they make appropriate referrals. (APA, 2010, pp. 1063–64)
The relatively ubiquitous nature of religion and spirituality renders it pro-
pitious for general practitioners to obtain at least a basic competence in this
domain. Standard 2.01c states that “psychologists planning to provide services,
teach, or conduct research involving populations, areas, techniques, or tech-
nologies new to them undertake relevant education, training, supervised
experience, consultation, or study” (APA, 2010, p. 1064). Given that formal
training in this domain is the exception for most psychologists as part of their
prelicensure preparation for practice, seeking out continuing education, con-
sultation, and a supervisor to obtain a religious and spiritual practice compe-
tency would be a commendable priority for many psychologists. For those
psychologists who do have a proficiency in working with religious and spiritual
issues, continued consultation and professional development is advised, partic-
ularly when encountering clients whose spirituality diverges from one’s prior
preparation.
APA’s Division 36 (Psychology of Religion) appointed an ad hoc com-
mittee that has formulated preliminary practice guidelines for clinical work
with religious and spiritual issues (Hathaway, 2005). The guidelines were
developed by identifying common shared recommendations offered by over
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20 exemplar professionals in the clinical psychology of religion. Guidelines
related to assessment, intervention, and relevant multicultural competency
issues in the domain were formulated. The subset of preliminary guidelines
specifically addressing the use of religious and spiritual interventions can be
found in Exhibit 3.1. The full set of preliminary guidelines can be found in
Hathaway and Ripley (2009).
As part of the ad hoc committee’s ongoing work, I presented a set of five
principles that undergird the preliminary practice guidelines (Hathaway, 2009).
The Division 36 preliminary guideline principles are presented in Exhibit 3.2
and include awareness, respect, routine assessment focus, clinically congruent
roles, and competence. These themes converge with those noted as relevant for
clinicians seeking to appropriately incorporate spirituality and religion into
practice by Plante (2004, 2007, 2009) and others (Gonsiorek et al., 2009).
Plante has summarized the relevance of five ethical principles derived from the
Code for guiding psychologists in the use of spiritually oriented interventions
in practice under the acronym RRICC (i.e., Respect, Responsibility, Integrity,
Competence, and Concern).
ETHICAL USE IS APPROPRIATE CLINICAL USE
Many of the spiritual and religious practices listed in Table 3.1 are fre-
quently used in nonclinical contexts and for other purposes. For instance, the
use of directed prayer or scripture reading could be used as an evangelistic tool
designed to cultivate or instill faith. If these practices were used in an evan-
gelistic context, such use would be congruent with the explicit purpose of the
context. However, if they were being used for this purpose in the context of
professional psychological practice, it would likely violate numerous ethical
principles and standards.
Principle B of the Code states the following:
Psychologists establish relationships of trust with those with whom they
work. They are aware of their professional and scientific responsibilities to
society and to the specific communities in which they work. Psychologists
uphold professional standards of conduct, clarify their professional roles
and obligations. (APA, 2010, p. 1062)
A professional psychologist operates within a publically and legally granted
fiduciary space (Reaves, 1996). As licensed professionals, psychologists agree to
practice congruent with applicable scope of practice, standards, legal precedent
and other structures arising from relevant regulatory codes.
To appropriately use spiritually oriented interventions, licensed psychol-
ogists must do so congruent with their clinical role and regulating standards.
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ETHICAL GUIDELINES 73
EXHIBIT 3.1
Division 36 Preliminary Religious and Spiritual Intervention Guidelines
1. Psychologists obtain appropriate informed consent from clients before incorpo-
rating religious/spiritual techniques and/or addressing religious/spiritual treat-
ment goals in counseling.
2. Psychologists accurately represent to clients the nature, purposes, and known
level of effectiveness for any religious/spiritual techniques or approaches they
may propose using in treatment.
3. Psychologists do not use religious/spiritual treatment approaches/techniques of
unknown effectiveness in lieu of other approaches/techniques with demon-
strated effectiveness in treating specific disorders or clinical problems.
4. Psychologists attempt to accommodate a client’s spiritual/religious tradition in
congruent and helpful ways when working with clients for whom spirituality/
religion is personally and clinically salient.
5. Religious/spiritual accommodations of standard treatment approaches/protocols
are done in a manner that (a) does not compromise the effectiveness of the
standard approach or produce iatrogenic effects, (b) is respectful of the client’s
religious/spiritual background, (c) proceeds only with the informed consent of
the client, and (d) can be competently carried out by the therapist.
6. Psychologists are mindful of contraindications for the use of spiritually/
religiously oriented treatment approaches: (a) Generally, psychologists
are discouraged from using explicit religious/spiritual treatment approaches
with clients presenting with psychotic disorders, substantial personality
pathology, or bizarre and idiosyncratic expressions of religion/spirituality.
(b) Psychologists should discontinue such approaches if iatrogenic effects
become evident.
7. When psychologists use religious/spiritual techniques in treatment, such as
prayer or devotional meditation, they (a) clearly explain the proposed technique
to the client and obtain informed consent, (b) do so in a competent manner that
is respectful of the intended religious/spiritual function of the technique in the
client’s faith tradition, and (c) adopt such techniques only if they are believed to
facilitate a treatment goal.
8. Psychologists appreciate the substantial role faith communities may play in the
lives of their clients and consider appropriate ways to harness the resources of
these communities to improve clients’ well-being.
9. Psychologists avoid conflictual dual relationships that might arise in religious/
spiritually oriented treatment or in adjunctive collaborations with faith
communities.
10. Psychologists set explicitly religious/spiritual treatment goals only if (a) they
are functionally relevant to the clinical concern, (b) can be competently
addressed within the treatment, (c) can be appropriately pursued within the
particular context and setting in which treatment is occurring, and (d) are
consented to by the client.
11. Psychologists commit to a collaborative and respectful demeanor when
addressing aspects of a client’s religion/spirituality the psychologist deems
maladaptive or unhealthy. The preferred clinical goal in such cases is to pro-
mote more adaptive forms of the client’s own faith rather than to undermine
that faith.
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This can be illustrated by considering one such spiritually oriented intervention.
Moriarty and others have been investigating interventions to alter God image
(Moriarty & Hoffman, 2007), defined as “the complex, subjective emotional
experience of God” (p. 2). A variety of strategies have been deployed in an effort
to alter God image, including bibliotherapy, appropriate use of cognitive psy-
chotherapy strategies, group psychotherapy, and integrative–psychodynamic
approaches. Certain types of God image are more associated with depressed
states and others with less depressed states. Let us suppose that God image psy-
chotherapies are successful at fostering a shift toward God images that are less
associated with depression. When would such an intervention be appropriate?
Several factors that are highlighted in Exhibit 3.1 would impinge on determin-
ing whether such an intervention is ethical. Did the client provide informed
consent from the intervention? Did the information provided to the client prior
to this consent “accurately represent to the client(s) the nature, purposes, and
known level of effectiveness” (see Exhibit 3.1, item 2) for the God image inter-
vention? Was the God image intervention used adjunctively and not in lieu of
other interventions that have higher levels of demonstrated effectiveness for
treating the clinical concern (unless the God image intervention has been
demonstrated to be equally effective as a stand-alone treatment through ade-
quate research)? Is the God image intervention being used in a manner that is
respectful of the client’s religious and spiritual tradition? If the God image inter-
vention is being used adjunctively with another established treatment, is it
being done in a manner that does not compromise the effectiveness of the stan-
dard treatment? Can the psychologist using the God image intervention do so
in a competent manner? A negative answer to any of these considerations
would contraindicate that use of the God image intervention.
The fourth Division 36 preliminary practice guideline principle states,
“When engaged in spiritually oriented practice activities, psychologists should
do so congruently with their clinical roles” (see Exhibit 3.2, item 4). So in
74 WILLIAM L. HATHAWAY
EXHIBIT 3.2
Division 36 Preliminary Practice Guideline Principles
1. Awareness: Psychologists aspire to cultivate deliberate and nuanced awareness
of relevant religious and spiritual issues in practice.
2. Respect: Psychologists seek to maintain a respectful demeanor towards the
religious and spiritual domain in clinical practice.
3. Routine assessment focus: Psychologists strive to routinely and intentionally
assess for relevant religious and spiritual considerations in practice.
4. Clinically congruent roles: When engaged in spiritually oriented practice activities,
psychologists should do so congruently with their clinical roles.
5. Competence: Psychologists seek to maintain ongoing competence in their
spiritually oriented practice activities.
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addition to the clinical manner of deploying the God image intervention, it
would be important to reflect on whether its use is congruent with the psychol-
ogist’s clinical role.
Psychologists address many issues facing their clients that overlap with
those addressed by religious caregivers (Pargament, 2007, 2009). Some have
attempted to distinguish the approach taken by psychologists and religious
caregivers in terms of differing epistemologies that operate in each sphere. I
served on an APA Presidential Working Group (2008) that drafted a policy
statement on “resolution on religious, religion-based, and/or religion-derived
prejudice.” The resolution offers guidance about issues and bias and prejudice
associated with religion and about what should be the proper response of psy-
chology to these issues. Some members of the working group initially proposed
language asserting that psychology proceeds from a qualitatively different epis-
temology than religion and consequently that religious considerations were
irrelevant to the clinical or scientific decisions made by psychologists in the
course of their professional and disciplinary activities. But we soon realized
that the issue is not that simple. Pargament (2009) noted the following:
Religion and science are not totally separable. Although we can draw con-
trasts between contemporary psychology and religious traditions, these
contrasts can be overdone. . . . Values, subjectivity, and judgment are an
intrinsic part of science. . . . On the other hand; religion does not reject
critical reflection or evaluation of the external world. (p. 391)
The final version of the APA (2008) resolution admitted some distinctive
epistemic tendencies but no watertight separation between psychological
and religious knowledge claims.
Professional role differences offer a more promising distinction between
religious and psychological approaches to spiritual practices than does a focus
on epistemic differences. The same spiritual practice may function differentially
as a form of religious care or psychological care depending on the contextual,
role-, and goal-related factors under which it is deployed. Religious caregivers
tend to encourage religious and spiritual practices for explicitly and intrinsically
religious goals (Hathaway, 2009). Such caregivers often operate with a religio-
legal authority that is alien to the psychologist’s professional identity. It is com-
monly the case that the traditional role of a religious professional allows him or
her to speak prescriptively to care recipients about what should be the proper
form of spiritual life.
In contrast, a psychologist who attempts to operate from such a position
of religious authority would be engaging in role-incongruent value imposition
on the client. For instance, a client may have religious convictions about the
sanctity of marriage that leads him or her to persist in an unhappy marriage with
a personality disordered spouse even after clinical options for improving the
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situation have been exhausted. A psychologist might be tempted to make an
authoritative religious pronouncement such as “God would not want you to
continue to suffer when there is no real hope for change.” I have unfortunately
encountered psychologists making just these sorts of statements to their clients.
Such a claim is outside of the psychologist’s proper role and competence, as
noted in APA (2008) policy: “Psychologists are encouraged to recognize that
it is outside the role and expertise of psychologists as psychologists to adjudi-
cate religious or spiritual tenets” (p. 433).
The APA (2008) policy clarifies, however, that “psychologists can appro-
priately speak to the psychological implications of religious/spiritual beliefs or
practices when relevant psychological findings about those implications exist”
(p. 433). So it may be appropriate for the psychologist to point out to the client
that the sorts of difficulties that arise within such a relationship are likely to per-
sist. To be fully compliant with the principles in the Ethics Code, the psychol-
ogist would need to convey this observation in a manner that is fully respectful
to the client and his or her religious beliefs.
Let us return to the issue of the propriety of a God image intervention.
The foregoing discussion about professional roles suggests that it would be
inappropriate to attempt such an intervention with the explicit goal of help-
ing the client change their God image in a direction that the psychologist
deems theologically superior simply because this is the religious judgment of the
psychologist or a tenet from the psychologist’s personal religious tradition. The
Division 36 preliminary practice guidelines on interventions indicate that
psychologists should set such explicitly religious treatment goals only if they are
“functionally relevant to the clinical concern” and “are consented to by the
client” (see Exhibit 3.1, item 10). If altering a God image can be done in a man-
ner that comports well with the earlier guidelines and is being done to improve
clinical functioning with client informed consent, then such an explicit spiri-
tually oriented intervention would be prima facie appropriate (Pargament,
2009). Does feeling this way rather than that about God allow the client to find
relief from his or her depression?
Still, what if the client is primarily concerned about the impact of his or
her depression on religious or spiritual functioning? The client may come into
treatment asking for help in feeling differently about God, reengaging their
faith community, or performing religious activities that reportedly have been
adversely impacted by his or her psychological difficulties. When such altered
spiritual functioning is the result of a clinical disorder, a religious caregiver may
be less able to offer effective assistance. Assuming the psychologist has the rel-
evant clinical competencies, self-awareness, and relational skills needed to
engage such goals, when might it be appropriate for the psychologist to take on
a case with such explicitly spiritual or religious treatment goals rather than refer
it out to a religious caregiver?
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I have elsewhere argued that religious and spiritual functioning can be a
significant adaptive domain that can be adversely impacted by psychological
disorders (Hathaway, 2003). If the religious and spiritual domain is salient to
the client, the domain is adversely affected by a psychological difficulty and the
client desires treatment of the psychological difficulty to alleviate the clinically
significant religious impairment, then having an explicit goal of altering the
client’s religious experience or functioning may be within the bounds of the
professional psychologist role. This sort of clinical focus may require a higher
level of niche competence than simply using spiritually oriented interventions
to assist with more standard treatment goals (Hathaway, 2008). Close collabo-
ration with religious professionals may also be wise in such cases.
ACCOUNTABLE PRACTICE
The fiduciary space and oversight afforded by the regulatory bodies that
govern our practice provide an important mental frame within which psychol-
ogists should conceptualize the ethical use of spiritually oriented interventions.
During graduate training, doctoral psychology students receive extensive men-
toring and close supervision to inculcate practice virtues, skills, and competen-
cies. Once a psychologist becomes licensed for independent practice, most of
his or her practice activities will be free of this direct external scrutiny. Yet psy-
chologists are always subject to potential review by state licensing boards, cre-
dentialing bodies, courts, or other controlling authorities (Reaves, 1996). Even
when such review does not in fact occur, well-trained psychologists would
habitually practice with a communal consciousness that is always mindful of the
potential audience that is attending to one’s performance. Thus, a psychologist
should always be prepared to offer cogent and appropriate rationales for any
approach, treatment decision, action (or nonaction) in one’s practice:
Any mental health professional should practice in a professionally self-
aware manner, with an internalized community of wise peers. When a pro-
fessional treats a client, the client should be treated not merely with his
or her psychotherapist’s innate skill and the body of objective scientific
knowledge but also from the implicit communal wisdom and calibration
that emerges from myriad dialogues about analogous cases in supervision
sessions, published cases, and professional peer interactions. When such
internalized voices are not sufficient, ethical professionals invite still
other professionals into the conversation through ongoing consultation.
(Hathaway, 2009, p. 111)
A prudent goal of maintaining ethical awareness in practice might be to
avoid malpractice liability from incompetent practice or to prevent commis-
sion of an ethical violation that could result in loss of licensure and livelihood.
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The more overriding concern for such awareness should be to maximize our
benefit to our clients and minimize the chance of their harm.
Given that spiritually oriented practice competencies may not be
widespread in professional psychology, it might be tempting to continue to
avoid this area as risk management strategy. But such a strategy would likely
only lead to continued neglect of this important domain that may be of cen-
tral salience for clients in dereliction of our broader ethical aspirations as
profession (Hathaway et al., 2004).
CONCLUSION
There are now many resources, such as this volume, that provide training
at various competency levels in spiritually oriented treatments. At least since
the 1990s the APA has offered continuing education workshops by leading
clinical psychologists of religion in this practice area. Such workshops are also
frequently offered at state psychological associations and in other venues. The
APA has several psychotherapy training videos focusing on spiritual issues.
Becoming self-aware of the needs for practice competency in this domain is the
first step toward ethical practice with spiritually oriented interventions. The
next step is to make appropriate referrals based on client presentation and pref-
erence to others who have achieved the competency until one acquires the skill
or can practice under sufficient consultation to ensure competent practice.
There is an entire division of the APA (Division 36) dedicated to the psychol-
ogy of religion that has many niche practitioners in this domain among its
members.
Fisher (2003) noted the following:
The Ethics Code is not a formula for solving . . . ethical challenges. The
Ethics Code provides psychologists with a set of aspirations and broad gen-
eral rules of conduct that must be interpreted and applied as a function of
the unique scientific and professional roles and relationships in which they
are embedded. (p. 237)
For many of our clients, this relational embedding will include religious and
spiritual forms of life. In regard to appropriate professional roles in this practice
niche, a thought experiment may provide such guidance: Imagine giving an
account of practice habits with religious and spiritual issues and in using spiri-
tually oriented interventions before a licensing board or some other body. Can
the practitioner think through a clear rationale for how and why a specific spir-
itually oriented intervention was used with a particular client? Were all of the
relevant ethical considerations well managed? What was the outcome? The
ability to offer such a cogent rationale may be a helpful clue about one’s readi-
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ness to pursue this practice niche as well as a guide for whether such an inter-
vention would be ethical.
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11
7
INFORMED CONSENT
7
The overarching ethical principle of showing respect for patients’
autonomous ability to make their own decisions is reflected in the American
Psychological Association (APA, 2010) Ethics Code through standards that
require psychologists to provide information to, and secure consent from,
consumers of psychological services (e.g., Standard 3.10). The doctrine of
informed consent stems most directly from General Principle E: Respect for
People’s Rights and Dignity, which urges psychologists to respect the self-
determination of others.
Respect for patient decision making has influenced the wording and
content of other standards in the APA Ethics Code. For example, advertising
should be guided by transparency and accuracy so that prospective patients
can make informed choices as to whether to seek services from a particular
psychologist. In addition, respect for patient autonomy guides the selection of
treatment goals. In this chapter, we review difficult ethical problems for which
http://dx.doi.org/10.1037/14670-008
Ethical Dilemmas in Psychotherapy: Positive Approaches to Decision Making, by S. J. Knapp, M. C. Gottlieb,
and M. M. Handelsman
Copyright © 2015 by the American Psychological Association. All rights reserved.
118 ethical dilemmas in psychotherapy
respect for patient autonomy is especially important. Other issues dealing
with respect for patient autonomy are considered in Chapter 9.
WHAT TO PUT IN ADVERTISEMENTS
In Standard 5.01b, the APA Ethics Code identifies certain activities
that are unethical in advertising:
Psychologists do not make false, deceptive, or fraudulent statements con-
cerning (1) their training, experience, or competence; (2) their academic
degrees; (3) their credentials; (4) their institutional or association affilia-
tions; (5) their services; (6) the scientific or clinical basis for, or results or
degree of success of their services; (7) their fees; or (8) their publications
or research findings.
Other than additional restrictions on testimonials (Standard 5.05), the APA
Ethics Code says little else about advertising. From the standpoint of positive
ethics, psychologists want to do more than just refrain from violating 5.01,
5.05, and other relevant standards. Instead, they want their advertisements
to help patients make informed decisions about services. Nonetheless, and
especially given the ubiquity and “freedom” of the Internet, separation strate-
gies may include the idea that advertising is an ethics-free zone if additional
prohibitions are not mentioned in the APA Ethics Code. At that point, eco-
nomic self-interest, business frames for advertising, or other factors unrelated
to psychology ethics determine their course of action.
Positive ethics, of course, provides additional guidance in the form of over-
arching ethical principles, virtues, and values. For example, would it be ethical
for a psychologist to advertise himself as “The Sportsman’s Psychologist,” with a
picture of himself holding a gun and wearing a hunting outfit? Would it be ethi-
cal for a psychologist to indicate on her website that her hobbies are hiking and
playing tennis? Some questions to ask include, Are these advertisements consis-
tent with professional values, such as respecting patients’ autonomous decision
making by giving patients accurate and useful information to help them decide
whether to seek services from a particular psychologist? Are the messages mis-
leading in some way? Looking at advertising from the perspective of trying to
help prospective patients, it may be appropriate for a psychologist with expertise
in sports psychology to note, for example, that she was a collegiate tennis cham-
pion; such information may be relevant to the decisions of prospective patients.
It may be appropriate for a psychologist with an interest in treating religious
patients to note that he or she is an ordained member of the clergy.
Reasonable psychologists may disagree on whether certain disclosures
can be linked to overarching ethical principles. One psychologist noted that
informed consent 119
he had lived in the city all his life. Although some readers may view this as
an unnecessary self-disclosure, he considered it an indication that he was
aware of the community’s values and local resources. He also judged that the
information was unlikely to cause harm (nonmaleficence).
Other forms of self-disclosure in advertising appear more problematic.
One psychologist worked part time as a singer and, on her professional website,
included a link to samples of her recordings. This practice raises the issue of
whether psychologists should place unrelated secondary occupations on their
professional website. Although it may not be an explicit violation of the APA
Ethics Code to include such information, doing so enhances the opportunity
for potentially contraindicated boundary crossings and multiple relationships.
A preferred integration strategy would be “boundary bolstering” (Anderson
& Handelsman, 2010, p. 83), such as the one adopted by a colleague of ours
who buys and sells classic guitars. He maintains two separate websites: one for
his practice and one for his business. Neither site gives any hint of the other.
Psychologists using separation strategies may disclose information as
they would to friends or social acquaintances in which mutual self-disclosure
is a norm. But some behaviors that are acceptable or even desirable in social
relationships may be contraindicated in professional ones in which self-
disclosure needs to be selective and focused on patients’ needs. A psycholo-
gist whose professional website contains a link to her singing web page also
may be using a marginalization strategy to the extent that she would be happy
with the sale of a couple tunes, even if it ran the risk of decreasing the effec-
tiveness of her clinical services.
Ethical fading (Bazerman & Tenbrunsel, 2011), that is, when the ethical
dimensions of a situation become overshadowed by practical, monetary, or
other nonethical concerns, can occur in decisions about advertising. If psy-
chologists think about advertising only in terms of how to maximize referrals
(a business frame), then the ethical implications of advertising (an ethical
frame) may fade away in the decision-making process. Psychologists can
reduce the risk of ethical fading by keeping ethical principles in mind from
the beginning of their deliberations.
RESPECTING PATIENT DECISIONS
CONCERNING TREATMENT GOALS
Beginning at the outset of treatment, psychologists need to have
informed consent discussions to ensure that patients understand a variety
of relevant information, including “the nature and course of therapy, fees,
involvement of third parties, and limits of confidentiality” (Standard 10.01,
Informed Consent to Therapy). Psychologists who value respect for patient
120 ethical dilemmas in psychotherapy
autonomy and practice positive ethics will want to involve patients—at the
start of the relationship and at points throughout the course of treatment—in
as many treatment decisions as is clinically indicated.
Agreeing on Treatment Goals With Children and Adolescents
Standard 3.10b of the APA Ethics Code requires psychologists to “seek
the . . . assent” of those who cannot legally consent to treatment. In Chapter 2,
we discussed the need to balance respect for the autonomy of the child or
adolescent receiving treatment as a matter of beneficence (the welfare of the
child) with respect for the autonomy of the parents who must authorize treat-
ment. Often, disagreement about goals can involve highly sensitive informa-
tion. This example expands on that theme:
Sexual Orientation Issues With an Adolescent
An adolescent presented for treatment with symptoms of depression.
The psychologist decided to see the boy in individual therapy, and over
time it became clear that he was struggling with feelings of attraction to
individuals of the same sex. The parents, who were conservative Chris-
tians, would likely view same-sex attraction as a moral failing and would
expect the psychologist to work to rid their son of these feelings. The
psychologist was gay affirmative and would not agree to do so.
Should the psychologist continue to see the boy and accept payment from the
parents, even though she is working on issues different from what the parents
expected and is accepting behaviors or feelings that the parents would likely
find offensive? Beneficence would suggest that the psychologist should con-
tinue to treat the boy with a therapeutic stance that allows him to express
his sexual feelings freely. Also, respect for patient autonomy would suggest
that the adolescent has the right to choose the topics he wishes to explore.
However, consider the potential for conflict of interest: Seeing the adolescent
would be in the psychologist’s self-interest in that the patient would continue
in treatment, and seeing him would mean additional income. Because the
psychologist is gay affirmative, seeing the boy will advance the public accep-
tance of the therapist’s views and agenda on sexual orientation. On the other
hand, meeting the boy’s needs most likely conflicts with the parents’ goals and
interests; if so, they may refuse to pay for further therapy and may terminate
treatment, even though it may not be in their son’s best interest.
In this case, many psychologists would agree that the importance of
having the adolescent explore his sexual feelings trumps respect for the par-
ents’ rights (beneficence trumps respect for autonomy). This alternative
could be viable if the psychologist’s informed consent process included the
provision that he could give the parents accurate but incomplete information
informed consent 121
concerning the nature of their son’s treatment. For example, the adolescent
and the psychologist could agree on what to tell the parents about the nature
of therapy and the manner in which the parents are told (e.g., a phone call
between the psychologist and parents or a face-to-face meeting that included
the psychologist, boy, and parents). The psychologist could, for example,
accurately describe general symptoms, such as anxiety and depression, as
reasons for continued sessions. Out of concern for the anticipated effect on
the parents and the boy, the psychologist could discuss with him whether to
reveal that there are other sensitive topics that he chooses not to share. If
specifically asked what they are, the psychologist, based on his consultation
with the teen, can decide whether to reveal more information, and if so,
how much.
The psychologist also could consider how the parents may have inter-
preted the informed consent information. For example, even though the
psychologist informed the parents that he would not share certain sensitive
information, neither he nor the parents could have anticipated that this issue
would arise and that the parents may consider this much more than just
another “sensitive topic.” If so, and the parents learned of their son’s sexual
concerns and that they had not been informed of them, they may react with
feelings of betrayal, regardless of how thorough the informed consent process
may have been.
The psychologist would do well to consider how his emotions and other
nonrational factors may influence his deliberations. He may ask himself, Am
I stereotyping the parents and their religious beliefs? If so, is there a risk of
confirmation bias on my part? Am I placing too much importance on my
patient’s sexuality—relative to other issues—because of my own political
beliefs and personal experiences with discrimination? How might my own
experience with issues of sexual preference, and my experience with religious
patients, be short-circuiting my assessment of the relevant ethical principles
and alternatives? Do I fear loss or embarrassment, and are these feelings lead-
ing me to misjudge the risk associated with the alternatives I am consider-
ing? What System 2 questions might I be missing by focusing on System 1
concerns?
We know one psychologist with a long background of promoting fair-
ness for sexual minorities who consciously monitors his thoughts on the value
of coming out when he deals with patients who are questioning their sexual
orientation. Although he sees the social value that occurs when gay men pub-
licly discuss their sexual orientation, he is aware that his primary obligation
as a psychologist is to help patients make their own decisions. The failure to
take such a position could be considered intrusive advocacy (Pope & Brown,
1996), wherein the political agenda of the psychologist trumps the patient’s
autonomous decision making.
122 ethical dilemmas in psychotherapy
Agreeing on Treatment Goals With Adult Patients
Most of the time, psychologists can agree on treatment goals with their
adult patients. However, respect for patient autonomy may conflict with
other values. Consider the following example involving a seriously depressed
patient:
The Unwilling Prostitute
A psychologist worked with a 21-year-old college student who was
involuntarily involved in prostitution; she initially got involved volun-
tarily, but soon found herself trapped in a coercive relationship. Her par-
ents knew that their daughter was upset, and they paid for therapy, but
they did not know the reason for her distress. The patient believed that
she would be beaten or maimed by her pimp if she were to stop, and she
appeared highly traumatized.
The psychologist wanted to uphold beneficence by alleviating the symptoms
of depression and helping the patient extricate herself from her situation.
However, the patient saw herself as hopelessly trapped, and if the psychologist
fully respected patient autonomy, she would not have challenged the patient’s
acquiescence to her circumstances. However, the psychologist judged that
the situation was not in the patient’s best interest and that she could not
make an informed or autonomous decision while in such a compromised state.
Consequently, she proceeded with treatment of depression and trauma, but
also gently insisted that a social worker with experience in helping women
involved in prostitution join them for a session of therapy to discuss ways in
which the patient could extricate herself from “the life.”
Because of the potential for harm to the patient, the psychologist acted
paternalistically; that is, she trumped what the patient believed to be in her
best interest, even though it meant raising an option that the patient did not
want to consider at the time. Although, in general, the psychologist respected
her patient’s autonomy, she concluded that in this situation beneficence dic-
tated trumping autonomy to protect her patient from a situation in which she
seemed unable to act on her own behalf. Some may consider this weak or soft
paternalism (Feinberg, 1986) because the patient’s ability to make decisions
about the focus of treatment was partially compromised, and thus the infringe-
ment on autonomy was minimal, and the intervention served to increase the
patient’s ability to make independent decisions.
On the other hand, the psychologist could have done nothing to address
the issue of prostitution and not invited the social worker to become involved.
That option may represent an assimilation strategy, albeit an overly simplistic
one: “I’m here to serve the goals of the patient. She’s legally competent, so I’ll
informed consent 123
do as she asks.” Another factor driving this alternative may have been igno-
rance or unrealistic fear on the psychologist’s part. What the therapist knew
about prostitution came from TV programs that portrayed violence. Because
of the availability heuristic, the psychologist may have based her decision on
the information that was available to her and overestimated her own vul-
nerability to violence as a matter of self-interest, and she avoided the issue
altogether.
At the other end of the continuum, the therapist could have insisted
that the social worker get involved and that the patient remove herself
immediately from prostitution before initiating therapy, presuming that no
treatment would be effective under the circumstances. This alternative could
represent a separation strategy in which the therapist overrode her profes-
sional respect for autonomy and concern for the patient with her personal
agenda in a way that was incompatible with her therapeutic role.
Consider a similar situation:
A Victim of Blackmail
A young woman had been abused by a neighbor as a teenager. Later,
this man blackmailed her into having sex with him, threatening to tell
her husband about this history if she did not accede to his demands.
She agreed, believing she had no choice, and quickly became seriously
depressed. She felt ashamed and debased by her actions; she greatly
feared that her husband would leave her if he found out.
Although the patient was seriously depressed, she was able to participate
meaningfully in treatment once she had been stabilized on medication. The
psycho logist was supportive and nurturing, but she refused to accept the patient’s
premise that the blackmail was inevitable and that her patient had no alterna-
tives. The therapist pursued the goal of changing the patient’s blackmail situ-
ation, judging that respect for patient autonomy did not mean failing to offer
alternative ways of viewing the situation.
This situation is another example of ethical gradualism (Francis, 2009; see
also Chapter 2, this volume). The psychologist knew that goals can change
over the course of psychotherapy and that goal setting often is an evolutionary
process. Thus, the psychologist could agree to work on the patient’s depression
in the short term and defer work on the blackmail. She had strong personal
values about honesty and knew in her heart that psychotherapy would (or at
least should) take a course that included alternatives to the blackmail. She
also knew that not telling the patient about her (the therapist’s) long-term
goals did not feel good to her. However, she recognized that complete hon-
esty at such an early stage in treatment would be a separation strategy. When
she considered her value of honesty in light of the value of compassion, the
124 ethical dilemmas in psychotherapy
virtue of benevolence, and the relative weights of beneficence and respect for
autonomy, she was able to adopt the integration strategy of working honestly
on the goal of lifting the depression and deferring a more detailed and difficult
discussion of long-term goals.
Adopting such a strategy was not easy for the psychologist. As a femi-
nist, she was personally outraged by her patient’s situation and was tempted to
pursue intrusive advocacy. As she thought about it, she realized that, had she
done so, she would have been acting more from her own goals than those of
her patient. Fortunately, the psychologist was able to take her emotional tem-
perature (i.e., monitor her emotional reaction to the situation; Gino, 2013),
step back, and reflect on the clinical facts of the case, and then proceed in
accordance with a reasonable treatment plan.
Here is another example:
A Polyamorous Life
During the course of therapy, a patient reported that he and his wife
had an open marriage and freely engaged in sexual relationships with a
range of partners. As treatment proceeded, the patient wanted to spend
much of the time trying to convince the psychologist of the acceptability
of his polyamorous lifestyle. The psychologist continually had to redirect
the therapy into more clinically relevant issues, but soon the patient
informed the psychologist that he was trying to convince his 18-year-old
daughter of the values of such a lifestyle.
The psychologist felt a conflict among ethical principles. He respected the
patient’s lifestyle as long as it did not involve harm to others. However, he
knew that teenagers are at increased risk of exploitation and harm, and this
situation could be especially problematic, because it was her father who was
suggesting she do this. Consequently, the psychologist believed that general
beneficence (protection of the daughter’s welfare) required him to address this
issue with the patient, and he assertively discussed with him the importance
of allowing the daughter to make her own decisions. Presenting alterna-
tives to the patient does not necessarily mean trumping his autonomy; how-
ever, given the age of the girl and her risk for exploitation, the psychologist
believed that trumping the patient’s autonomy was justified.
What factors might have led the psychologist to a different course? If
the patient’s daughter were 25, then he might assume that she was less vul-
nerable to exploitation, and his concern for her would be reduced. If the
psychologist had strong religious beliefs opposed to the patient’s views or
strong political beliefs in agreement with the patient’s, then he would need
to monitor his behavior so that he did not appear to be engaging in intrusive
advocacy or, on the other hand, allowing his similar beliefs to blind him to
potentially problematic behaviors.
informed consent 125
PURSUING INFORMED CONSENT
IN UNUSUAL CIRCUMSTANCES
Sometimes patients are in situations in which they do not anticipate
what questions to ask, and they may be vulnerable to making ill-advised or
ill-considered decisions. Consider this example:
Appearing on a Talk Show
A psychologist was called by a producer of a TV talk show to see if she
would be willing to treat a patient with obsessive–compulsive dis order
(OCD). The treatment would be paid for by the TV show, with the
understanding that the patient and psychologist would agree to appear
to talk on camera about the treatment.
What factors should the psychologist consider in evaluating this request?
One factor is the nature of the TV show. The show may exploit people with
mental illness by focusing on bizarre or unusual symptoms in a sensational-
istic fashion. On the other hand, if the program took a more even-handed
approach, their appearance could educate the public about OCD and avail-
able treatments, thereby contributing to general beneficence. Fortunately, this
particular talk show had a reputation of presenting mental health informa-
tion in a helpful and respectful manner.
A second factor, given the unusual circumstances, is the likely effect of
the therapy on the patient. Some talk show interventions have been poorly
planned. One talk show offered enough money for 10 sessions of therapy, but,
given the severity of her problems, the patient needed long-term treatment,
medication, and probably a social worker to help her handle multiple agency
problems. In that case, the show’s offer was clearly inadequate.
Talk show hosts have had guests with dramatic life situations, such as a
patient with serious hoarding problems. In such situations, it is reasonable to
ask whether the attention given to the patient’s problem could be harmful.
Will being on the show consolidate the patient’s identity as a sick person?
The requirement for the patient to appear on the program again to talk
about the treatment raises other important questions. Will the patient appre-
ciate the loss of privacy involved in appearing? Would reappearing on the
show create additional pressure that could disrupt the therapeutic progress
the patient may have made otherwise?
A third factor to consider is the competence of the therapist, both to
perform the therapy and to perform on TV. In one situation we know of, a
psychologist who was asked to treat a “television patient” was skilled in the
treatment of OCD, had presented at national conferences, and had partici-
pated in national organizations that included professionals and consumers.
He also believed strongly in the importance of educating the public about the
126 ethical dilemmas in psychotherapy
disorder and had experience doing so via lectures and the media. He also did
not agree to appear on the show until he had personally evaluated the patient
to determine if he could be of assistance, and if the patient was fully informed.
Other psychologists may have more difficulty making a judgment about
their competence. For some, the self-interest involved in appearing on TV,
whether motivated primarily by money, the chance to educate the public, or
other self-serving factors, may alter choice making by influencing psycholo-
gists to discount arguments against competence. Alternatively, fear of appear-
ing on TV may lead them to discount their competence and relinquish an
opportunity.
TV has its own cultural values and traditions. Thus, the ethical accul-
turation task for psychologists may be more complex. For example, consider
informed consent. In the therapy room, psychologists can take steps to assess
how free patients feel to refuse services, and either therapist or patient can
take steps to refer, end therapy, or change the nature of the interaction. Such
options may not be available in the studio, which may be sufficiently coercive
(for both therapist and patient) that the process of informed consent does not
get the attention it deserves. A separation strategy may involve insisting that
the informed consent process be identical to the one the psychologist uses
in the office. Such a strategy may entail blindly assuming that if the patient
agreed, he must know what he is getting into—after all, people getting therapy
appear on TV all the time.
The informed consent process is also important in dealing with confi-
dentiality. Clearly, confidentiality issues are different when therapy occurs in
front of cameras and an audience. Therefore, the ethical obligation (APA,
2010; Standard 4.02) to discuss confidentiality arrangements early in the
relationship becomes especially important.
To deal with these factors, the psychologist in the preceding case used
quality enhancement strategies. He reflected on his motivations—both noble
and base—for an appearance. Although he wanted to educate the public
regarding OCD, he realized that appearing on national TV was self-serving
in that it would be a marketing opportunity that could enhance his national
stature. After the intake interview that confirmed the OCD diagnosis and
advisability of treatment, he consulted with a trusted colleague. As part of the
consultation, the psychologist asked his consultant to review the intake to
determine whether he was missing any significant factors. After the consul-
tation, he spoke with the patient and focused heavily on empowering her to
make her own decisions.
In the course of this discussion, the psychologist reviewed, in some
detail, the limits to confidentiality as they applied to the patient. He candidly
reviewed the manner in which a TV appearance might influence the patient’s
motivation and the resulting risks to treatment effectiveness. He reviewed the
informed consent 127
general nature of the treatment with the producer to make advance arrange-
ments about the conditions of his acceptance. He also sought to clarify the
financial arrangements. For example, would the show pay for additional treat-
ment costs and referral to a psychiatrist for medication, if necessary? If so, how
much would they pay and for what period of time? The psychologist was able
to integrate the important values of his profession with the traditions of the
TV industry and his own personal morality.
One may think that this advance planning was strictly a matter of risk
management for the psychologist; he pursued these issues in such detail,
though, because he knew that the patient might not be aware of the potential
pitfalls. As a result, his additional efforts also were a matter of beneficence.
SHOULD PSYCHOLOGISTS CONDUCT INTERNET
SEARCHES ON THEIR PATIENTS?
Sometimes patients will ask a treating psychologist to look at their
Facebook page or other Internet sources to help the psychologist better under-
stand their life circumstances. A review by Kolmes and Taube (2014) reported
wide ranges (between 18% and 95%) in the results of studies that looked at
the percentage of psychotherapists who reported conducting Internet surveys
on their patients. However, should psychologists conduct Internet searches
routinely on patients without their knowledge or consent? (For further read-
ing, see Kaslow, Patterson, & Gottlieb, 2011.) It is no more illegal to conduct
an Internet search on a patient than it is to watch them walk down the street;
after all, information on the Internet is public. But the fact that doing so is not
illegal does not mean that it is ethically or clinically indicated. The overarch-
ing principle of respect for patient privacy would suggest that psychologists
not seek any additional information without the patient’s consent, except
under highly unusual circumstances. Information gained from the Internet
has never been necessary to conduct treatment before, and no research has
suggested that using it now will enhance treatment effectiveness. Thus, it
becomes hard to argue that Googling patients without their consent would
promote their well-being. Furthermore, there is no guarantee that the infor-
mation found on the Internet will be accurate, representative, or current.
Therefore, proceeding based on such information risks unnecessary harm.
If psychologists use information obtained from the Internet as a basis
of their treatment plans or case conceptualization, a question arises as to the
extent to which patients were informed and involved in determining the
nature of their treatment goals. In addition, a psychologist whose treatment
plan depends on information obtained without the patient’s consent would
have to document this information and its source in the patient’s treatment
128 ethical dilemmas in psychotherapy
record. Consequently, patients who access their records may feel betrayed
when they see a treatment plan based on information they had decided not
to share with the psychologist and that may have been inaccurate.
On the other hand, imagine unusual situations in which trying to obtain
information on a patient via the Internet may be beneficial. For example, we
learned of one situation in which a psychologist greatly feared for the well-
being of a highly suicidal patient and, without the patient’s knowledge, looked
at his social media postings to gain a better understanding of his degree of risk.
Finding even more troubling information there, he moved to intervene more
aggressively to protect his patient.
A policy of routinely and surreptitiously searching for patients can be
considered from the standpoint of the overall manner in which the psycholo-
gist addresses Internet use consistent with overarching ethical principles. For
example, Tao (2014) noted that most young adults use social media exten-
sively. She discussed how psychologists need to evaluate its use to understand
the social connectedness of their patients. She also pursued the issue of the
effect of social media on the psychological well-being of patients and whether
that should be addressed.
Because the use of social media is a topic for exploration and perhaps for
intervention, it makes sense that psychologists should make inquiries regard-
ing its use. At the same time, they need to ask themselves if an unauthorized
searches of their patients would undercut unique standards of professional
psychology, such as the principle of patient autonomy, which, among other
things, means that patients disclose private information at their own pace;
beneficence, in the sense that patients may learn of the search and perceive it
as a violation of trust, or psychotherapists could become “lazy” in their intake
because they figure that they can always get the background information
through an Internet search; or justice, in the sense that psychologists may
choose to search some (types of) patients but not others.
Therapy is most effective when psychologists create an atmosphere of
trust so that patients feel free to disclose personal information. Psychologists
who wish to use the Internet to learn about their patients could, for example,
apply the principle of respect for autonomy by including such information
in their informed consent forms and have a conversation with their patients
in which they discuss the risks and benefits of doing so. In this way, patients
could determine what kind of information therapists may seek and for what
purposes. The treatment plan and chart, then, would reflect this understand-
ing and the relevance of the information obtained.
Of course, unusual situations may arise in which searching without
patients’ consent may be justifiable, such as when one is being threatened or
harassed by them. As a general proposition, however, we believe that respect
for patient autonomy/beneficence (trusting relationship) and patient profes-
informed consent 129
sional relationships (fidelity) trump presumptive beneficence (accurate infor-
mation). Googling one’s friends is common and is considered an acceptable
way of keeping up. However, treating patients the same way that one treats
friends in this way could be an example of a separation strategy.
TERMINATING THERAPY WITHOUT PATIENT CONSENT
Difficult situations occur when patients want to continue treatment
even if they no longer need it, are not benefiting and are unlikely to benefit
from it, or are being harmed by treatment. Therapy can be helpful even if
patients are not improving if, for example, treatment helps stabilize patients
or prevents deterioration. But in some circumstances, therapy can make
patients worse. However, psychotherapy may also become a “social habit”
without clearly defined goals (Younggren & Davis, 2012, p. 428).
In addition to the ethical issues that arise when fulfilling the obligation
to terminate treatment with non-life-endangering patients who are not ben-
efiting, especially without their consent, psychologists need to be especially
aware of the emotions and potential cognitive errors engendered by their own
thoughts. Psychologists do not enter the mental health field to make patients
worse or to help them mark time. Hence, it is bad enough to terminate or
refer when both the patient and psychologist feel that therapy is not working;
however, when patients and therapists disagree, the situation can become
much more complex. For example, O’Reilly (1987) described what he called
the transfer syndrome, which includes feelings of guilt, depression, and relief
on the part of the practitioner. To make matters worse, ethical judgment may
be skewed by “fears of evaluation by peers or supervisors, anxiety concerning
what the patient might expose about him or her, and anxiety about the new
placement” (Rice & Follette, 2003, p. 162).
On the other hand, some patients become reliable sources of income,
arrive on time, and are pleasant to work with. In these cases, psychologists
need to understand the boundaries and purposes of therapy. It is easy to con-
tinue to see such patients, presuming that they would not be coming if they
were not benefiting in some way. In such cases, self-interest could influence
psychologists to not closely evaluate the patient’s progress. Failing to termi-
nate may not lead to extremely adverse consequences for the patient, but it
will not necessarily do him or her much good, either.
At the other extreme are burdensome patients who present problems
when it comes time to terminate. Often these patients are doing poorly in life.
They may be manipulative, engage in self-mutilation or suicidal gestures, and
alienate others within their social circles. As a consequence, they have little
outside social support and can become excessively dependent on the therapist.
130 ethical dilemmas in psychotherapy
Of course, such difficult patients may still benefit from treatment, and
being difficult is not in itself adequate grounds for termination. Our discussion
here focuses on those difficult patients who are not benefiting from treatment
and who display behaviors that significantly diminish the likelihood of prog-
ress, such as missing appointments and being nonadherent. In more extreme
cases, if psychologists suggest termination due to lack of progress, patients may
threaten suicide, a licensing board complaint, or the posting of hostile com-
ments about the therapist on the Internet. Here is one such case:
A Difficult Patient
A patient had developed an extreme transference to the therapist; she
continually solicited her love and became angry when the psychologist
got pregnant and had a child (“You love them more than me”). Despite
instructions to call only during emergencies, the patient began calling
the psychologist at her home at all hours of the day and night for trivial
reasons. Frequently, she would miss therapy sessions. The patient also
rescinded the release of information form that allowed the psychologist
to exchange information with the treating psychiatrist. The patient
currently owes more than $1,000 in unpaid bills.
These types of situations may involve a sequential use of proximal qual-
ity enhancement strategies and the principle-based ethical decision-making
model. Distal quality enhancement strategies are relevant here: Psychologists
should try to anticipate that such situations can occur. Several authors have
stressed the importance of raising early in the treatment the issues surround-
ing termination (e.g., Anderson & Handelsman, 2010; Rice & Follette,
2003; Swift & Greenberg, 2014; Younggren & Gottlieb, 2008). Among other
things, as part of the informed consent process, psychologists should discuss
what they expect from the patient in treatment and how those expectations
relate to termination. The failure to cooperate with the basic elements of
treatment, such as arriving on time, not committing a boundary violation,
cooperating in therapy, paying bills, and completing homework, should
be the basis for discussing the termination of treatment, and, if necessary,
reevaluating the treatment plan.
Sometimes psychologists do not like to admit failure and may not be as
alert to red flags as they need to be early in therapy. Such early warning signs
that treatment may be imperiled include patients who refuse to pay bills or
otherwise become nonadherent to treatment recommendations. Such behav-
ior can prompt feelings of resentment in the practitioner that may foster non-
rational decision making, such as moving to terminate prematurely without
adequate exploration of the reasons for the nonadherence.
In Chapter 3, we noted the option of using the four-session rule: If a
patient has not improved by the fourth session, or if a good working rela-
tionship does not exist, the psychologist can use a prompt list to reevaluate
informed consent 131
the goals and procedures of therapy. Although some psychologists may wait
several more sessions before they consider that a treatment plan needs to
be reevaluated, we urge a strategy of reevaluating the goals and procedures
of therapy early and when the patient is not responding to treatment. The
prompt list is an opportunity to consider the four quality enhancement strat-
egies: Psychologists may talk to the patient about the lack of progress and
solicit input on how to engage the patient in a better way (empowered collab-
oration), seek consultation from another professional on the case, document
their decision-making process, and seek additional sources of information to
determine their progress (redundant protection). It may seem obvious, but
the success of these strategies may be greater if they occur earlier in treatment.
If these quality enhancement strategies do not work, psychologists can
move to ethical decision-making strategies and weigh patient benefit against
the harm of continuing treatment. In the preceding vignette, the patient is
not benefiting and even may be suffering harm, but such a conclusion and
the termination of treatment may appear to conflict with respect for patient
autonomy. The therapist can minimize harm to the offended moral principle
by attempting to involve the patient in the discussions “as a matter of respect
for the patient’s autonomy and informed consent, to obtain his or her per-
spective on the treatment process” (Younggren & Gottlieb, 2008, p. 501).
The psychologist in this case may be influenced by feelings such as anger
at the patient, disgust at the patient’s behavior, or anger at herself for not hav-
ing enough expertise to help this patient or not knowing better than to have
accepted her in the first place. Among the nonrational factors that may exist,
the therapist may wish to terminate, but, based on loss aversion, she may
act too hastily and fail to follow appropriate professional procedures. Ideally,
she would be aware of her feelings and would address problematic patient
behavior (including the unpaid fees) early in treatment, instead of allowing
resentments to build to a point at which she can no longer stand the patient
and begins to worry that she may explode or otherwise act inappropriately
toward the patient.
Of course, the situation could be even worse. Consider this example:
A Suicidal Patient
A patient was nonadherent to treatment recommendations and was
not making progress when the psychologist raised the option of discon-
tinuing treatment. The patient said that this would be so upsetting for
her that she would consider suicide. The patient had a long history of
passive suicidal ideation but had never threatened to kill herself before.
Here, the psychologist must weigh the ethical principles of beneficence (ben-
efit to the patient) with nonmaleficence (avoiding harm to the patient) and
respect for patient decision making. One question is whether the threat of
suicide is so imminent and serious that terminating the treatment would be
132 ethical dilemmas in psychotherapy
contraindicated. This situation requires a cost-benefit analysis. The psycholo-
gist may determine that the threat of suicide is so high that termination should
be avoided, at least while the patient is acutely ill. If so, the psychologist may
postpone termination to minimize harm to the offended moral principle by
continuing treatment as long as the patient meets her obligations, such as
keeping appointments, following recommendations, and using on-call ser-
vices appropriately. However, the psychologist may determine that the threat
of suicide is low enough that the potential benefits of termination and referral
are worth the risk of a suicide attempt. In documenting the decision to termi-
nate, the psychologist should not deny or minimize the threat of suicide but
record the other considerations that balance out the threat.
FINAL WORD
There is no question about the importance of providing informed con-
sent to patients. It is legally required, ethically indicated, and it represents
a good quality enhancement strategy. Yet some psychologists seem to resist
performing this task or taking advantage of all its potential advantages. Some
may resent what they consider to be needless legalisms; others may feel that
having to address such issues breaks the therapeutic frame and intrudes on
the process. Although we understand how some of our colleagues may feel,
we hope this chapter shows that attending to informed consent can not only
meet legal standards but can also be a matter of excellent clinical care.
Volu
m
e 35¡Number ll]anuary 2OI3lPages 15-
28
Informed Consent, Confidentiality, and
Diagnosing: Ethical Guidelines for
Counselor Practice
Victoria E. Kress
Rachel M. HofTman
Nicole Adamson
Karen Eriksen
Informed consent and confidentiaKty are discussed in the context of counselors’ use of the DSM
diagnostic system. Considerations that can facilitate counselor diagnostic decision-making
related to informed consent and confidentiality are identified in a case application. Suggestions
that can enhance ethical diagnostic practices are provided.
The Gouncil for the Accreditation of Gounseling and Related
Educational Programs (GAGREP,
20
09) requires that all trainees be instructed
in ethical principles (GAGREP, Section II.G.I.j). The GAGREP standards
also require that clinical mental health counselors and addictions counselors
be trained in the use of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR, hereafter DSM; American Psychiatric Association
[APA], 2000; GAGREP Standards for Glinical Mental Health Gounseling
Section K. 1 and Standards for Addiction Gounseling Section K.I). With
regard to the intersection of ethics and diagnosis and in relation to informed
consent, the American Gounseling Association (AGA) Gode of Ethics (2005)
states “Gounselors take steps to ensure that clients understand the implications
of diagnosis” (A.2.b.). The American Mental Health Gounselors Association
(AMHGA) Gode of Ethics (2010) asserts that “Informed consent is ongoing and
needs to be reassessed throughout the counseling relationship” (B.2.d.).
The DSM contains 297 diagnoses (APA, 2000), which will be explored
with generally equal breadth and depth in the next DSM iteration (APA, 2011).
It may therefore be difficult for counselors to fully understand the myriad eth-
ical considerations that need to be addressed when applying DSM diagnoses
(Eriksen & Kress, 2005). Galley (2009) stated that because they are elusive
Victoria £. Kress is affiliated with Youngstown State University: Rachel Hoffman with Meridian Services,
Youngstown, OH; Nicole Adamson with the University of Narth Carolina at Greensboro, and Karen
Eriksen with the Eriksen Institute. Delray Beach, Florida. Correspondence about this article should be
addressed to Victoria E. Kress, Beeghly Hall, Department of Counseling and Special Education,
youngstown State University, Youngstown, OH 44555. E-mail: victoriaekress@gmail.com.
Journal of Mental Health Counseling
aspects of counselors’ personal and professional behavior, ethics must be
explicitly addressed if they are to be fully integrated into professional practices.
Explicit discussions of DSM ethics-related issues are thus important if coun-
selors are to be deliberate and ethical in their practice (Galley, 2009).
There is a need for context-specific applications of ethics related to
informed consent, confidentiality, and the DSM (Eriksen & Kress, 2005; Kress,
Hoffman, & Eriksen, 2010). A lack of professional exchange about this topic
could give the impression that it is not of importance. Gonversely, more
detailed discussions should facilitate ethical practices related to the DSM, con-
fidentiality, and informed consent (Galley, 2009). Although professional codes
of ethics focus on appropriate use of the DSM (AGA, E.5.a.-E.5.d.; AMHGA,
D.1.-D.3.) and GAGREP requires counselor training in its use, the literature
offers minimal guidance on how to. use the DSM ethically. Only a few articles
have touched specifically on the topic of client-informed consent and confi-
dentiality as related to the DSM (e.g., Bassman, 2005; Kress et a l , 2010;
Walker, Logan, Glark, & Leukefeld, 2005).
Ghent diagnosis has risks, and clients are often not fully apprised of them.
This lack of transparency compromises the counseling values of beneficence
and nonmaleficenee (because client well-being may be jeopardized), and
autonomy (because the client is not given all the information needed for an
informed deeision). Galley (2009) suggested that counselors consider complex
ethics issues comprehensively, explicitly identifying problems and relating
them to the principles of beneficence, nonmaleficenee, justice, and fidelity.
Galley suggested there is value in examining all ethical codes that apply to a
particular dilemma and identifying how the standards are being executed.
According to Galley (2009), if upon consideration a counselor is unable
to conclude that ethical codes are being upheld, it is necessary to explore the
issue in greater depth. Galley suggested consulting resources to help identify
desirable ethical standards and how they can be applied to a given ethical
dilemma. This article disseminates a new way of demonstrating that ethical
codes are upheld when diagnosing clients.
Because the literature provides no guidance, it is important to explore the
multiple ethical dimensions of diagnosing, informed consent, and confiden-
tiality (Galley, 2009). Thus we discuss confidentiality and informed consent as
related to counselors’ use of the DSM, offer specific suggestions for optimizing
ethically-sensitive diagnosis, and describe a case study application.
INFORMED CONSENT CONSIDERATIONS AND DIAGNOSIS
Diagnosis is often not discussed as part of the informed consent process
(Gampbell, 2000; Eriksen & Kress, 2005; Fisher, 2002; Kress et a l , 2010). At
a minimum, clients should be informed that they may receive a diagnosis and.
16
Informed Consent, Confidentiality
once given a diagnosis, they should be told what it is (Kress et al., 2010).
A diagnosis allows for reimbursement by third-parfy payers (i.e., health
insurance companies or agency grant funders; Braun & Gox, 2005). Insurance
companies require a medical diagnosis for reimbursements. Further, in organi-
zations that obtain government or other funding to treat specific diagnoses
(e.g., addictions), only clients diagnosed with those problems may receive ser-
vices. Thus, DSM diagnoses give clients opportunities to attain needed ser-
vices, which is particularly important given the high costs of treatment. From
a psychological perspecfive, another potential strength is that some clients find
relief and validafion in having a label to describe their difficult experiences
(Goodwin, 2009; Marzanski, Jainer, & Avery, 2002; Mitchell, 2007).
Moreover, diagnosis can be used to guide counselor interventions and treat-
ment plans. Ideally, counselors use diagnoses to select treatments that have
proved to be successful.
The well-documented risks of diagnosis (e.g., Eriksen & Kress, 2005,
2006; Ivey & Ivey,
19
98, 1999; Zalaquett, Fuerth, Stein, Ivey, & Ivey, 2008)
should also be conveyed to clients. Ghents with mental health diagnoses may
be stigmatized at school or work and viewed and treated negafively (Eriksen &
Kress, 2006). They may come to think of themselves as “less than” or perhaps
as permanently “ill” with little possibilify of becoming or seeing themselves as
“well.” Those diagnosed may take on the identify of a “sick” person and find it
difficult to separate themselves from the label (Eriksen & Kress, 2005).
Glients who are not aware that not all DSM diagnoses are reimbursable
may agree to incur the risks of receiving a diagnosis but not receive the finan-
cial benefit (Braun & Gox, 2005). Although the Paul Wellstone and Pete
Domenici Mental Health Parify and Addiction Equify Act of 2008 (the Federal
Mental Health Parify Act; U.S. Department of Health and Human Services,
2008) prohibits providing discrepant benefits for mental health and substance
abuse treatment, third-parfy payers are not required to reimburse for mental
disorders that are not biologically based (U.S. Department of Health and
Human Services, 2008). In other words, treatment for those mental illnesses
(i.e., many illnesses other than schizophrenia, schizoaffecfive disorder, major
depressive disorder, bipolar disorder, paranoia and other psychotic disorders,
obsessive-compulsive disorder, and panic disorder) is considered supplemental,
and insurance companies have discrefion about whether to reimburse (U.S.
Department of Health and Human Services, 2008). Also, under the Parify Act,
employers can choose which non-biologically-based mental health and sub-
stance use diagnoses they will reimburse—there is no coverage mandate.
Glients should be informed that though a diagnosis may be required for third-
parfy reimbursement for services, some diagnoses may not be eligible.
The counselor’s challenge is to find a balance between adequately
explaining the potential harms associated with diagnosis and the benefits (see
17
Hinkle, 1999, for a broader discussion of these issues; Kress et a l , 2010).
Because even trained counselors may struggle to do this, it is especially impor-
tant to gain an objective view to help clients get an impartial picture of DSM
advantages and disadvantages.
Veracity is also highly valued in the health professions (Hill, 2003).
Veracity is the commitment of a professional to be open and honest with a
client, despite the discomfort that might occur. Because the well-being of the
client is at the heart of the relationship, it is imperative that the counselor be
truthful and realistic. In the short term, it might seem more beneficent to give
clients information that will encourage them to receive the services they seem
to need, but for some clients the long-term consequences of diagnosis may out-
weigh the treatment benefits. Thus, fully informing clients of the potenfial risks
as well as benefits of diagnosis allows counselors to uphold the traditional coun-
seling values of beneficence, nonmaleficence, and autonomy (Galley, 2009).
Some counselors, feeling uncomfortable discussing diagnostic informa-
tion with clients, may avoid full disclosure (Hill, 2003), and when counselors
fully explain the risks of diagnosis, clients might choose not to receive services.
The value of veracity suggests that counselors should nevertheless discuss
uncomfortable topics like diagnosis because that will promote long-term ben-
efits for counselors and clients (Hill, 2003).
Martin, Garske, and Davis (2000) found that an open and honest
exchange is a key predictor of therapeutic success regardless of many other fac-
tors, such as the difficulties associated with diagnosis. Glients should have the
opportunity to freely determine whether they will agree to receive a diagnosis.
Gounselors might provide the following information to present an objective
view of the diagnostic process: (a) whether the client’s third-party payer or a
prospective and desired program will require a diagnosis; (b) the most common
problems associated with a diagnosis; (c) the benefits of a diagnosis; and (d)
what the options are should the client choose not to receive a diagnosis or not
to have a third-party payer involved. As most counseling employers require a
diagnosis by the end of the first session, discussions related to diagnosis need to
be part of informed consent discussions early in that meeting.
CONFIDENTIALITY CONSIDERATIONS
Ethical practice requires that counseling professionals provide informa-
tion about diagnosis and confidentiality as part of the informed consent
process. Gonfidentiality-related information helps to ensure that client agree-
ment to participate in counseling is adequately informed (AGA, 2005;
AMHGA, 2010; Kaplan et al., 2009; Ponton, 2009). Thoughtfully and thor-
oughly conveying that information to clients assures clients that counselors will
keep them apprised of important information while keeping the counseling
Informed Consent, Confidentiality
experience confidential. Glients have a right to discuss and understand the
risks and benefits of counseling before agreeing to participate.
The AGA (2005) and AMHGA (2010) Godes of Ethics state that clients
have the right to confidentiality and to have its limitations explained. There are
risks involved with the unanticipated—sometimes inadvertent—release of
diagnostic information, and clients have a right to know of them.
Grover (2005) commented that “consent may not be truly informed in
that the full implications of having the diagnosis and of having it communi-
cated to others may not be adequately understood by the client at the time he
or she proffers consent” (p. 78). For example, a client who signs a release on a
job application that allows an employer to check into counseling history may
be harmed, and the employer may not employ people with certain diagnoses
(e.g., the military; Gouture & Penn, 2003). Parents of young clients may sign
releases for mental health professionals to communicate with schools (U.S.
Department of Health and Human Services, 2010), perhaps making a diagno-
sis part of the ehild’s permanent school record, which can result in stigmatiza-
tion as long as the client is a student.
Mental health records and diagnoses may also be used against clients dur-
ing legal battles and in court hearings (Dentón, 1989; Kress et a l , 2010; Scott,
2000; Woody, 2000); the result can range from stigmatization and embarrass-
ment to a loss in a legal batfle. Diagnoses become a permanent part of client
mental health records, which offen must be released in civil or criminal cases
(Luepker, 2003; Scott, 2000; Woody, 2000). Although privileged communica-
tion is a responsibility of counseling professionals, the law does not always sup-
port such ethical considerations (Fisher, 2003). Gounseling information-
including diagnoses —may have to be disclosed in court and might lead to a
client not being awarded custody of a child (Glosoff, Herlihy, & Spence, 2000).
Although it is routinely mentioned during the initial informed consent conver-
sation that a judge’s written order can overrule confldentiality, clients may not
foresee the impact this could have on them.
Gonfidentiality is further complicated in group or family counseling,
where diagnostic information may be shared; the legal system offen does not
acknowledge privileged communication in such situations (Woody, 2000).
There are also risks in releasing diagnostic codes to insurance companies
(Ackley, 1997; Gampbell, 2000) that clients need to be made aware of (Braun
& Gox, 2005). A client’s diagnosis becomes a permanent part of the insurance
record affer one reimbursed service using the ascribed diagnosis is billed
(Privacy Rights Glearinghouse, 2011). This information can then be classified
as a preexisting condition that can be accessed by future employers and insur-
ers. Depending on state laws and how long ago the client was diagnosed (U.S.
Department of Labor, 2009), clients may lose job or insurance opportunities
based upon past mental health diagnoses.
19
Employers may also determine that some clients are not suitable employ-
ees because their mental health needs are severe or from fear that they will
raise employer insurance premiums. What complicates the issue is that such
clients may have difficulfy obtaining their own health insurance due to docu-
mented preexisting conditions (Ackley, 1997; Gampbell, 2000). If they are able
to secure insurance, services for preexisting conditions may not be reimbursed
immediately, if at all. Therefore, clients who lose their health insurance may
have to pay for their own counseling or suffer with untreated difficulties.
Glients may also consent to diagnoses being released without fully under-
standing what they are consenting to. In other words, clients may not grasp the
long-term implications of sharing diagnoses (e.g., the client wants information
shared with disabilify services, yet the information may be defamatory, such as
a diagnosis of malingering). Glients may not understand that when diagnoses
are released to other professionals, they may become a permanent part of those
files, too. Einally, clients should understand that some diagnoses are retained
indefinitely. Eor example, a person diagnosed with alcohol dependence will
always—according to the DSM—be diagnosed with alcohol dependence, even
though the disorder may be qualified as “in remission” (APA, 2000).
Eurther complicating this issue of confidentialify and informed consent is
the fact that clients may only be made aware of their diagnosis when, or even
after, the information has been shared (Grover, 2005). Glients are often given
a diagnosis at the initial session, and if that session is reimbursed, it automati-
cally becomes part of the client’s permanent mental health record (Privacy
Rights Glearinghouse, 2011). Therefore, clients fypically only have the length
of one session to determine if they want a diagnosis. Even if the informed con-
sent discussion is thorough, clients may not have enough time to process the
information and make an informed decision before their health records are
affected and the associated risks are incurred.
CASE APPLICATION
The following composite case based on the authors’ experiences illus-
trates some of the ethical problems that may arise in relation to diagnosis, con-
fidentialify, and informed consent.
Gase Study
Madison, 28, is a mother of three who recently separated from her hus-
band of five years. She has reported feeling sad and lonely since, and she also
reported a history of “significant periods of sadness and depression.” She stated
that the separation has already become contentious and was fearful that her
husband would make the divorce proceedings difficult.
Madison has also been using alcohol to cope; she estimated that she
20
Informed Consent, Confidentiality
drinks three to four times a week. Although she said that she has not experi-
enced any negative effects of her alcohol use, she was aware that using alcohol
was not a good way of coping with her sadness. On the advice of a friend,
Madison decided to seek counseling to get help with her alcohol use and sad-
ness at a local agency that offers services on a sliding fee scale. As part of the
informed consent process, the counselor, Rita, explains to Madison that she
may receive a mental health diagnosis and informs her that the purpose of the
diagnosis is to help determine the best treatment for her problems.
Rita incorporated information from Madison’s intake assessment and ini-
tial interviews to formulate a diagnosis. The client’s primary complaint was her
feelings of sadness and depression, and Rita considered a primary diagnosis of
adjustment disorder with depressed mood. However, Madison reported having
had depressive symptoms before the separation. This information supported
the primary Axis I diagnosis of Depressive Disorder N.O.S. The additional con-
cern about alcohol use did not warrant a secondary Axis I diagnosis of alcohol
dependence, but the full criteria for alcohol abuse were met.
Madison was forthcoming about her impending divorce, her struggles
with alcohol use, and her feelings that she was not an effective parent. She
completed about 20 sessions of counseling before choosing to discontinue
treatment because she “felt better.” Rita felt that Madison had made good
progress and was supportive of her decision to discontinue treatment. About
two months later, Rita received a subpoena from family court. Madison and
her husband were involved in a custody dispute and the Family Gourt Judge
had appointed a guardian ad litem to help determine the best living circum-
stances for the children. Rita was subpoenaed to testify about Madison’s func-
tioning, her diagnosis, and her progress in treatment. Rita is concerned that
Madison’s diagnosis (depressive disorder NOS and alcohol abuse) may be
taken out of context in the custody determination; she believes that Madison
may be unnecessarily penalized for her decision to seek treatment.
Case Discussion
Although Madison was aware that she would be assigned a mental health
diagnosis as part of the counseling process, she was not explicitly informed that
this information might be subpoenaed in the divorce proceedings. Rita
obtained consent from Madison for her diagnosis and treatment but did not
explain that Madison’s diagnosis might be used as an indication that she was
unable to be an effective parent. This is particularly noteworthy because Rita
was aware that the divorce would be acrimonious.
Rita might have taken the initiative to expand upon the limits of confi-
dentiality, exploring with Madison situations that often result in mental health
records being subpoenaed. Informing Madison that her diagnoses might be
revealed in court would have given her enough information to decide if she
21
was comfortable with the risk of receiving a diagnosis. It would also have been
helpful for Rita to explore with Madison how the diagnosis might be used
adversely in the court case. Exploring with Madison how mental health disor-
ders may be (incorrectly) perceived by others as negative could have helped
prepare her for possible disclosure of potentially damaging informafion.
Preparing Madison for possible disclosure might also have altered how
forthcoming she was with personal information. Rita might have discussed the
possibilify of Madison electing to be treated without a formal diagnosis, which
would probably have resulted in her, rather than a third parfy, paying for the
services. Although not legally required, these discussions might have helped
Madison make a more thoughtful informed consent decision.
PRACTICE SUGCESTIONS
Even when counselors are aware of and willing to discuss informed con-
sent issues related to diagnosis, finding a therapeutic balance in describing the
risks and benefits takes skill (Martin et al., 2000). The realities of deciding how
and when to provide this information and how much information needs to be
revealed to facilitate, rather than harm, counseling efforts are complicated. For
example, even when clients are informed, many may decide that they have no
choice but to accept these risks, because without reimbursement they would be
unable to pursue counseling (Wittig, 2000).
The ethical principle of beneficence requires that counselors strive to
improve the qualify of their clients’ lives (Remley & Herlihy, 2007). A compre-
hensive understanding of the benefits and risks of giving diagnoses could
potenfially conflict with the counselor’s ascription to beneficence. In fact.
Mead, Hohenshil, and Singh (1997) found that over 60% of clinicians were
aware of instances of intentional over- or under-diagnosis. That is, some clini-
cians reported giving a less serious diagnosis than was warranted or putting only
the least serious diagnosis on the client’s permanent record to avoid labeling or
stigmatizing the client (Mead et a l , 1997). Glinicians also reported giving or
continuing to use an unwarranted Axis I diagnosis so that the client could
receive third-parfy reimbursement for mental health services.
Although altering diagnoses might seem to allow counselors to uphold the
values of beneficence and nonmalfeasance, it is not only ethically unsound, it
is illegal (Mezzich, 1999; Welfel, 2002). Not only can under- or over-diagnos-
ing clients prevent them from receiving the care that they need, it also inter-
feres with their right to autonomy (Remley & Herlihy, 2007). The value of
veracify also compels counselors to be honest with clients (Hill, 2003). The
authors cited suggest completely describing the benefits and risks of accurate
diagnosis and allowing clients to make the final decision on diagnosis—and
emphasizing that diagnoses will not be inappropriately ascribed.
m
Informed Consent. Confidentiality
A best practice approach to informed consent and diagnosis may be to
openly discuss the facts that are likely to impact clients and offer assistance and
information as they weigh their choices (Kaplan et al., 2009). Eriksen and
Kress (2006) suggested that the medical model for making mental health diag-
noses can coexist with a multifaceted counseling approach. Gounselors should
take care to understand symptoms and cures in terms of the client’s worldview,
social Stressors, and interpersonal history (Eriksen & Kress, 2006).
Once sure that a diagnosis is accurate, the counselor can explain the
probable counseling duration, process, and outcome to the client, and process
with the client the benefits and any possible unhelpful consequences (Eriksen
& Kress, 2006; Hill, 2003). Using basic counseling techniques that promote
introspection and problem-solving skills, clients can be empowered to assess
their ability to overcome the potential risks of diagnosis.
Glearly, not all situations carry significant diagnosis-related risks, and a
counselor should determine when risks are more likely. When working with
clients at particularly high risk of a negative effect of receiving a diagnosis (e.g.,
those involved in custody hearings), counselors should provide more thorough
and detailed education about the risks and benefits during the intake session
and may discuss how clients might manage these risks (Fisher, 2002; Jepson &
Robertson, 2003; Luepker, 2003; McGivern & Marquart, 2000).
When they are educated about the risks, clients are better able to decide
whether they want to receive a diagnosis. In helping clients establish what they
will do to manage possible risks, it may be useful to encourage them to garner
additional information to inform their decision. Depending on the situation, a
client might benefit from a better understanding of the implicafions of receiv-
ing a diagnosis. For example, if involved in a custody dispute, clients might
choose to speak to their attorneys before continuing counseling. They might
also ask their attorneys about what counseling records can and cannot be
shared with third parties, and what disclosure might mean for them.
In terms of managing risks, clients might also be invited to consider what
information they disclose to the counselor. Glients may elect to share some but
not other information. For example, a client who is seeking counseling for
depression issues might elect to withhold a past substance abuse history. For a
client seeking, say, to enter the military, that might be a prudent decision.
Electing to not receive a diagnosis may place the financial burden of treat-
ment on clients who may not be able to afford counseling, but it also provides
clients who do have greater financial means with more opportunities to avoid
being diagnosed. However, most counseling agencies have policies that require
that clients complete a DSM multi-axial assessment, so clients wishing to avoid
formal diagnosis may have no choice but to seek counseling in private practice
settings. Gonversely, clients who do not have the means to seek private practice
counseling may be forced to receive diagnoses and thus be subjected —
23
arguably unfairly—to the risks of diagnostic labeling (Erikson & Kress, 2005).
There are also be intervention and treatment issues when counselors diag-
nose some, but not other, clients. Theoretically, counselors working from a tra-
ditional model may rely on a diagnosis to guide treatment interventions; these
counselors may not feel comfortable withholding a diagnosis. Gounselors
electing to not provide a diagnosis might instead select interventions and treat-
ment approaches that are rooted in the client’s stated presenting concern. For
example, instead of diagnosing a client with depression and applying a
Gognitive Behavioral Therapy (GBT) approach, a counselor might instead
identify the treatment goals clients want specifically to address (e.g., finding
more joy in life) and use GBT approaches to help them do so.
Gomplicating informed consent discussions is the fact that informed con-
sent is generally acquired before counseling services are provided; thus, it is
often difficult to determine how much detail to cover in the discussion. Rather
than conceiving of informed consent as an agreement to be reached before
counseling (i.e., a one-time event), such discussions should be part of the full
assessment and counseling process. As the counseling process unfolds, coun-
selors need to exercise discretion in deciding when and how to fully inform
clients (Fisher, 2002; Jepson & Robertson, 2003).
Gounselors also need to guard against informing clients too late in coun-
seling of the potential limitations of diagnosis; if clients have agreed to the
counseling relationship on the basis of incomplete information, information
provided too late may damage a therapeutic alliance (Fisher, 2003). Moreover,
counselors may want to inform clients about the possibility that an initial DSM
diagnosis may change, given new information gathered over the course of
several sessions. In other words, clients should be informed that DSM diag-
noses are dynamic rather than static; they may change with a client’s symptom
presentation. If the diagnosis does change during counseling, the elient should
be informed about the rationale for the change. Related to this issue, client
improvements or changes (e.g., remission, severity indicators) should also be
documented in client records, including discharge/termination summaries.
Gounselors’ theoretical models generally shape their relationships with
clients and may also influence the degree to which they discuss with clients the
risks and benefits of diagnosis. Some schools of thought (e.g.. Feminist
Gounseling Theory) place counselors in more egalitarian roles with clients;
others encourage counselors to promote a more authoritarian relationship
(Gorey, Gorey, & Gallahan, 2007; Marzanski et al., 2002). However, whether
they embrace or shun the power assoeiated with their therapeutic role, coun-
selors should be aware of the power they have related to use of the DSM within
the counseling relationship. Thoughfful reflection on how power influences
the diagnosis or informing clients about diagnoses may be helpful in making
decisions related to informed consent and the diagnostic process.
24
Informed Consent, Confidentiality
In summary, counselors are responsible for evaluating the consequences
of issuing diagnoses, following jurisdictional laws, and upholding ethical stan-
dards. At minimum, we recommend that clients be fully informed, both in
wrifing and orally, of potential benefits and risks of a DSM diagnosis. Although
there is no one-size-fits-all approach, here is an example of a statement that a
counselor might use orally or in informed consent documents:
A formal assessment will be conducted in order to help me gain an understanding of your current It is important that we review several possible limitations of mental health diagnosis. First, if you use Lastly, please be aware that your mental health diagnosis—and any accompanying records — may be This discussion should occur before any assessment, and follow-up con- The authors have found that using this statement with clients invites DISCUSSION
A thorough discussion of informed consent and confidenfialify issues as 25 diagnosis should be addressed, and unique client life circumstances (e.g., get- Glients need to be informed about the diagnostic process, including (a) Gounselors need to be aware of the potential power differential inherent REFERENCES
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situation; it is possible tbat you will receive a diagnosis. The purĵ ose of the diagnosis is to help us
and other mental health professionals identify the problems you are experiencing and the counsel-
ing procedures that may be most helpful in treating those problems. In some cases, a diagnosis may
also be required in order to receive third-party reimbursement for services counselors provide.
Certain diagnoses (e.g., partner or parent
a third-party payer to pay for your services, your diagnosis, or diagnoses, will be revealed to the insur-
ance company as part of the reimbursement request. It is your responsibility to contact your insur-
ance company to identify the organization’s specific method for storing and sharing confidential
information. If you are concerned about this, we can discuss alternative options, ineluding out-of-
pocket pay, pro bono services, or referral to other service providers. Also, if you are involved in any
type of litigation, such as a child custody situation, your counseling records, including your mental
health diagnosis, may be subpoenaed by the courts and released during eourt proceedings.
revealed if you sign a release of information for disclosure of your medical records to any other
agency or individual (e.g., school, probation office, family physician).
versations may be required. Specifically, informed consent should be seen as a
confinuing process that occurs before any major event in the counseling rela-
fionship (e.g., giving or changing a diagnosis, releasing records, bringing a sig-
nificant other into a session).
healthy dialogue. Glients who have been to numerous other mental health
providers have expressed surprise that they had previously received a diagnosis.
Some clients express gratitude for making them more aware of the benefits and
risks associated with sharing certain information. Glients appear to most value
specific examples of how confidenfial informafion could cause harm.
related to the DSM should occur early in the counseling process. Before coun-
selors ascribe a diagnosis, clients should be informed that they may receive one
and, once a diagnosis is made, they should be informed of it. After reviewing this
information, a thorough discussion of the possible repercussions of a formal
ting a divorce, renegotiating child custody, planning to enlist in the military)
that could be impacted by a diagnosis should be explored.
what DSM diagnoses are in general and their own specific diagnosis; (b) how
diagnoses are made and when they are changed; (c) that clients may receive
one or more diagnoses; (d) the role the client will play in formulation of the
diagnosis; and (e) the risks and benefits of receiving a diagnosis. The extent to
which a client is given information about informed consent issues needs to be
based on the treatment setting, the presenting client concerns and needs, and
the personal ramifications to the client receiving the diagnosis. Decisions
related to the depth to which informed consent issues and diagnosis are dis-
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are ethically bound to ensure that this judgment is informed.
in the diagnostic process. Although DSM diagnoses are currently a necessity,
counselors must intentionally balance the process of diagnosing with the foun-
dational values (e.g., strength-based, wellness-oriented) of the counseling pro-
fession. However, by providing information about DSM diagnosis and being
transparent about the diagnostic process, counselors can help establish a posi-
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