Ethics in Psychotherapy and Counseling (Pope et al., 2021)

Question 1

utilitarianism

Answer 1

a guiding principle of ethics that involves choosing whatever brings the most happiness and produces the least pain to the majority

–> focuses on results and consequences rather than an intent
–> although, figuring out what promotes the most happiness in every situation may present more of a challenge than following a set of rules

Question 2

Kantian ethics

Answer 2

focuses on will and intention; “emphasizes that action should be motivated by goodwill and duty, and the morality of an action is not measured by its consequences but by the motivation of the doer”

–> we must always treat others as an end in themselves and never as simple a means to an end

Question 3

Feminist ethics

Answer 3

all feminisms offer an ethical position that accompanies a political, activist agenda to achieve social justice and to improve women’s lives

Question 4

American Indian Ethics

Answer 4

Indigenous people have a holistic and inter-relational view of health. This means that the Western-based concepts of body, emotions, mind, spirit, community, and land cannot be separated from their relationships, including the generations before them and the generations to come. There are no distinctions between physical health, mental health, and spiritual health, which also means that my physical health, mental health, and wellbeing are related to yours (“we are all related”).

Question 5

trust

Answer 5

it is at the core of therapy (therapy relies on this); what patients tell us in confidence carries the potential to be therapeutic or harmful depending on how we use that info and/or whether we violate the client’s ___ by breaking the sacredness of confidentiality

Question 6

power conferred by the state

Answer 6

power is given to us by the state, in which licensed professionals can do things that people without a license cannot. For example:

-holding private information about our client gives us power
-we have the power to make decisions (subject to judicial view) about our clients’ civil liberties
-we have the power to determine whether an individual constitutes an immediate danger to the life of someone else & should be held against their will for observation/treatment

Question 7

power to name and define

Answer 7

diagnosing someone is exercising power, and diagnosis and other forms of clinical naming have the potential power of affecting how we view people

-power of naming and defining has been particularly harmful to BIPOC and other oppressed social groups

Question 8

power of testimony

Answer 8

we possess the authority to change the course of lives when we testify as experts in the civil and criminal courts and through similar judicial or administrative proceedings

e.g., our testimony can convince a jury that the plaintiff is an innocent victim of needless trauma who is suffering severe and chronic harm or is a chronic liar, gold digger, or malingerer

Question 9

power of knowledge

Answer 9

our research, writing, and our very words have the power of providing language and validation to experiences that have been marginalized, made invisible, silenced, and disregarded

–> maintaining a constant, respectful awareness of the power flowing from knowledge and expertise is essential to avoid the subtle ways of manipulating and exploring clients through our interaction with them or through our clinical documentation (treatment plans, progress notes, assessment reports) and scholarship

Question 10

power of expectation

Answer 10

the client’s investing in the therapist with the power to help bring about change can become a significant part of the change process itself (e.g., placebo effect); the therapist’s expectations, including optimism and belief in the client’s capacity to change, are powerful as well

Question 11

therapist-created power

Answer 11

for example, the therapist decides the time, place, and circumstances of the therapy session

Question 12

inherent power differential

Answer 12

a defining attribute of the profession is the recognition, understanding, and careful handling of the considerable power - and the responsibility for that power - inherent in the role; regardless of how genuine, mutual, or egalitarian a therapist may choose to be, some degree of power difference is UNAVOIDABLE

Question 13

caring and healing

Answer 13

caring about the client’s well-being and working to not just help cope or adjust to intolerable circumstances but actually helping clients heal their pain; protecting the public interest above advancing the profession’s self-interest

Question 14

competence

Answer 14

a process through which an individual gains sufficient knowledge, judgment, and skills to carry out a task without doing harm

Question 15

intellectual competence for therapy

Answer 15

-learning which clinical approaches, strategies, or techniques show evidence or promise of effectiveness, and for whom do such techniques work
-learning what approaches have been shown to be invalid or perhaps even harmful
-admitting what we do not know
-knowing how to do certain clinical tasks

Question 16

emotional competence for therapy

Answer 16

reflects our awareness and respect for ourselves as unique, fallible human beings; includes self-knowledge, self-acceptance, and self-monitoring

-we must know our own emotional strengths and weaknesses, our needs & resources, and our limits for doing clinical work
-includes the process of constantly questioning ourselves
-leaves little room for denying, discounting, or distorting how we respond emotionally to the challenges of clinical work

Question 17

cultural competence

Answer 17

a continuing, life-long process of learning and relearning about ourselves and others as complex and layered cultural beings. involves:
1. developing awareness of one’s own cultural values, traditions, and biases
2. learning about the cultural values, traditions, and worldviews of others
3. developing a set of culturally informed interpersonal skills

Question 18

What are the 3 ways in which culture shapes clients?

Answer 18

Shapes how clients:
1. narrate and make sense of their presenting problems, describe the causes, signs, and symptoms of their problems
2. discuss what they believe heals or prevents the problems from getting worse
3. envision their relationship with their healthcare providers, including their therapist

Question 19

What are the FIVE domains of culture?

Answer 19

1. ontology: nature of reality (how is reality defined? Who defines what is real?)
2. axiology: value system (what are your values? what are your non-negotiables?)
3. cosmology: relationship to the divine (how was the universe created? Is there a higher power? If so, who are they?)
4. epistemology: system of knowing and believing what is the truth (describe the ways you believe knowledge is created?)
5. praxis: systems of human interaction (how do you connect and build relationships with others?)

Question 20

White and Henderson’s Multicultural Competency Building Model (2008)

Answer 20

includes an actionable plan to develop and maintain cultural competency throughout our mental health careers and beyond. divided into 4 levels:
1. conceptual/theoretical/intellectual: underscores the importance of learning about our client’s culture at the deep structural level (obtained by reading textbooks & journals, attending lectures & courses, watching movies/documentaries)
2. engaging in challenging cross-cultural dialogues - that provide the opportunity for emotional growth through active participation in difficult dialogues around individual differences
3. behavioral engagement: emphasizes the importance of immersing ourselves in the context/community of the people we serve
4. building practical skills that enhance the therapeutic relationship: focuses on developing healing approaches that are tailored to the unique and complex needs of our clients

Question 21

What is an active approach involving 3 steps that can help ground us in the current science and avoid using theories, studies, and approaches that have been discredited?

Answer 21

1. actively seek out new theory, research, and practices relevant to our work
2. actively read and listen to critics of our own current beliefs and practices
3. actively question new claims - this is as important as seeking them out

Note: when integrating known theories into our work, it is important to read the ORIGINAL source rather than rely on secondary sources (the description and interpretation of others)

Question 22

ethics placebos

Answer 22

switching the process from finding and taking the most ethical path to finding ways to justify what we WANT to do –> we find ways to do what we want to do by turning down the volume on our conscience and dulling our ethical awareness

–> emphasizes that we have a responsibility to do what is BEST for our clients and not just what is easier, simpler, more popular, or what fits our personal needs, schedule, and individual preferences

Question 23

human rights

Answer 23

basic inalienable rights of freedom, inherent dignity, and equal and inalienable entitlements of all humans

Question 24

oppression

Answer 24

cultural, economic, and political subjugation and degradation of people due to their membership in a social group considered inferior by those with power in a given society
–> experienced across time and context

Question 25

Socialization and Oppression in Psychotherapy (SOP) Framework

Answer 25

Part 1 - Historical Context and Socialization: recognizing and incorporating the role of history in our work as therapists; “human actions are embedded in a context of time, space, culture, and the local tacit rules of conduct” and valid assessment and choice of intervention for a specific client depend on recognizing this relevant context
Part 2 - Overlapping Forms of Oppression: intersectionality theory describes the ways in which systems of inequality based on gender, race, ethnicity . . . ‘intersect’ to create unique dynamics and effects on these individuals who hold membership in multiple socially constructed groups –> recognizing issues in the therapeutic context prompts us to question whether oppression is causing, maintaining, making, or exacerbating our client’s presenting problems
Part 3 - The Therapeutic Context: we become more open, alert, and skilled at recognizing the ways systemic and institutional oppression can influence development, stunt flourishing, foster maladaptive behaviors, cause suffering and distress, and, if unrecognized by the clinical, send both assessments and interventions off course

Question 26

What are 5 actions that may be helpful in improving our skill at addressing and naming oppression in therapy and putting that skill to use in the service of the client and the therapeutic process?

Answer 26

1. Pause and pay attention to your emotional reactions
2. Contextualize the exchange
3. Decide how best to proceed
4. Take care of your wellness
5. Consider consultation

Question 27

What are four principles of Black psychology that can assist us all in engaging and committing to SOCIAL JUSTICE in our work with all people?

Answer 27

1. creating and maintaining a psychology that represents the voices of the people whose lives it seeks to improve
2. producing psychological knowledge that is accessible to laypersons (i.e., avoiding the use of professional jargon)
3. make psychological knowledge available to the public
4. use a strengths-based lens rather than a deficit-based perspective to make sense of clients and communities

Question 28

7 Guidelines for Integrating Social Justice in Ethics (Hailes et al., 2020)

Answer 28

1. reflecting critically on relational power dynamics
2. mitigating relational power dynamics
3. focusing on empowerment and strength-based approaches
4. focusing energy and resources on the priorities of marginalized communities
5. contributing time, funding, and effort to preventative work
6. engaging with social systems
7. raising awareness about system impacts on individual and community well-being

Question 29

boundary crossing benefits

Answer 29

-can reshape how the patient views the therapist
-can strengthen and deepen the working relationship
-can heal rifts, speed growth, and break through an impasse (dead end)
-can make a patient feel less alone, less hopeless, more understood and at times less suicidal

Question 30

boundary crossing risks

Answer 30

done in the wrong situation, at the wrong time, or with the wrong person, it can:
-knock the therapy off track
-sabotage the treatment plan
-offend, exploit, or harm the patient

Question 31

4 considerations for therapists when making self-disclosure decisions (Gutheil & Brodsky, 2008)

Answer 31

1. some degree of self-disclosure by a therapist is inevitable, but such disclosures can become boundary violations when they are not made for the benefit of the client
2. different schools of therapy involve different levels of disclosure, which in turn serves the needs of different patients
3. self-disclosures of a personal nature that do not have a clinical purpose . . . may not be helpful and may violate boundaries
4. decisions about the therapeutic use of self-disclosure need to be made on a case-by-case basis and in the context of the type of therapy offered

Question 32

bartering

Answer 32

allowed under certain conditions, but a number of therapists oppose this; however, for those who choose to use it, ethical guidelines should be followed to avoid the risk of exploitation of the client

APA: “Psychologists may bargain only if (1) it is not clinically contraindicated, and (2) the resulting arrangement is not exploitative”

Question 33

7 common cognitive errors made by therapists when making boundary decisions

Answer 33

1: what happens outside the psychotherapy session has nothing to do with the therapy

#2: crossing a boundary with a therapy client has the same meaning as doing the same thing with someone who is not a client
#3: our understanding of a boundary crossing is also the client’s understanding of the boundary crossing
#4: a boundary crossing that is therapeutic for 1 client will also be therapeutic for another client
#5: a boundary crossing is a static, isolated event
#6: if we ourselves don’t see any self-interest, problems, conflicts of interest, or potential downsides to crossing a particular boundary, then there are not any
#7: self-disclosure is, per see, always therapeutic because it shows authenticity, transparency, and trust

Question 34

non-sexual physical contact with clients

Answer 34

considerations for the therapist:
1) maintains a theoretical orientation for which therapist-client contact is not opposed
2) has competence (education, training, and supervised experience) in the use of touch
3) then decides on whether or not to make physical contact with a client –> must be based on a careful evaluation of the client’s clinical needs at that moment in the context of any relevant cultural and other contextual factors

Question 35

Steps in Ethical Decision Making (i.e., when facing an ethical dilemma)

Answer 35

1. State the question, dilemma, or concern as clearly as possible.
2. Anticipate who will be affected by the decision.
3. Figure out who, if anyone, is the client.
4. Assess whether our areas of competence - and of missing knowledge, skills, experience, or expertise - fit the situation.
5. Review relevant formal ethics codes and standards.
6. Review relevant legal standards.
7. Review the relevant research and theory.
8. Consider whether personal feelings, biases, or self-interest might shade our ethical judgment.
9. Consider whether social, cultural, religious, or other similar factors affect the situation and the search for the best response.
10. Consider consultation.
11. Develop alternative courses of action.
12. Think through the alternative courses of action.
13. Try to adopt the perspectives of each person who will be affected.
14. Decide what to do, review or consider it, and take action.
15. Document the process and assess the results.
16. Assume personal responsibility for the consequences.
17. Consider implications for preparation, planning, and prevention.

Question 36

informed consent

Answer 36

the process of describing to patients the purpose, risks, and benefits they will receive
–> provided to ensure that clients know, understand and are able to make an informed decision on whether they want to participate in services or refuse
–> should be clear and straightforward about all info (e.g., fees, like limitations imposed by 3rd party payers; relevant conflicts of interest; ethical responsibilities of psychologists)
–> a process of communication and clarification, not a static ritual
–> level of acculturation can influence how the client understands and makes sense of the process
–> therapist must decide if patient is competent enough to exercise __________ _______

Question 37

Schloendorf v. Society of New York Hospital

Answer 37

U.S. legal 1914 case that determined the patient, not the physician, had the right to decide whether or not to undertake a specific treatment approach –> “every human being of adult years and sound mind has a right to determine what shall be done with his own body”

Question 38

Natanson v. Kline

Answer 38

1960 Kansas case which exemplifies the community standard rule, such that informed consent procedures must adhere only to what the general community of doctors customarily do (also reflects the strong value of autonomy and self-determination underlying Western law, policy, and ethical decision-making)

Question 39

Canterbury v. Spence

Answer 39

1972 legal case which determined that it is the physician’s responsibility to provide the necessary info the patient needs to make an informed decision –> docs are prevented from withholding or neglecting to provide relevant info because a patient did not ask; “True consent to what happens to one’s self is the informed exercise of a choice.”

Question 40

Cobbs v. Grant

Answer 40

1971 CA Supreme Court case which determined that a patient needed only the relevant info to make an informed decision but needed it in clear, straightforward language

Question 41

Truman v. Thomas

Answer 41

1980 CA Supreme Court case which reaffirmed principles previously set forth in Canterbury v. Spence and Cobbs v. Grant but also affirmed that patients have a right to informed refusal of treatment as well as a right to informed consent to treatment

Question 42

benefits of informed consent

Answer 42

can benefit the therapeutic process and outcome
-can enhance therapeutic alliance
-using informed consent procedures makes it more likely that patients will:
1. become less anxious
2. follow the treatment plan
3. recover more quickly
4. be more alert to unintended negative consequences of the treatment

Question 43

pitfalls that can lead to violations of confidentiality

Answer 43

1. referral sources
2. public consultation - e.g., speaking with colleagues in hallway about a client
3. gossip
4. case notes and patient files
5. phones, faxes, and messages
6. home office
7. sharing with loved ones
8. post-death confidentiality - confidentiality extends beyond the grave
9. communications in group or family therapy
10. failure to obtain written consent to release confidential info
11. managed care and other organizations
12. failing to disclose confidential info for mandated reporters only to the extent required by law
13. publishing case studies
14. distractions may lead to violations of confidentaility
15. focusing on legal responsibilities to the exclusion of ethical responsibilities

Question 44

suicidal risk factors

Answer 44

1. Direct verbal warning
2. Plan
3. Past attempts
4. Indirect statements and behavioral signs
5. Depression
6. Hoplessness
7. Alcohol use and abuse
8. Marital separation or divorce
9. Clinical syndromes
10. Sex (males higher)
11. Age
12. Race and ethnicity (highest for Native Americans)
13. Religion (highest for Protestants)
14. Living alone
15. Bereavement
16. Unemployment
17. Health status
18. Impulsivity
19. Rigid thinking
20. Stressful events
21. Release from hospitalization
22. Isolation, lack of a sense of belonging, or loneliness

Question 45

Steps to Approaching Clients who may be Suicidal

Answer 45

1. Screen all patients for suicidal risk during initial contact and remain alert to this issue throughout the therapy.
2. Check the literature or consult with an expert in this area to see if current research and practice offers any approaches that might be particualrly effective with a particular situation or population.
3. Work with the client to arrange an environment that will not offer easy access to whatever the patient might use to commit suicide.
4. Work with the patient to create an actively supportive environment.
5. While not denying or minimizing the patient’s problems and desire to die, also recognize and work with the patient’s strengths and desire to live.
6. Make every effort to communicate realistic hope.
7. Explore any fantasies the client may have regarding suicide.
8. Make sure communications are clear and assess the probable impact of any interventions.
9. When considering hospitalization as an option, explore the drawbacks as fully as the benefits, the probable long-term and the immediate effects of this intervention.
10. Be sensitive to negative reactions to the patient’s behavior.
11. Perhaps most important, communicate caring.

Question 46

Five Special Pitfalls for Teletherapy

Answer 46

1. It is not just therapists who are both fallible and vulnerable; so are our computers. An important part of using computers and tech in a therapy practice is evaluating carefully when and how they can fail and preparing for those failures and the worst-case scenarios.
2. There are hazards to not understanding the implications of participating in cyber activities, such as joining lists or providing info on websites. Many of us become used to reflexively clicking “agree” without reading all the dull boilerplate and legalese of policy statements when we install new software. That reflex takes over when we journey around the web. And even if read every statement before agreeing, we may not fully understand the ambiguous or technical legal language used, and many of them may not cover material that is crucial for us to make informed decisions and avoid disasters.
3. Patients may record you without your permission and edit/make videos misconstruing what you said. Being unaware of how the tech you used can change the nature of your practice and affect the privacy of what you said and did as a therapist in your own office, and give tools to your patients that could be used in ways in which you have not imagined.
4. Being unaware of how your social media posts actually shape how people view you. Your reputation you create in cyberspace might play a role in how future employers and members of hiring committees view you as a job candidate.
5. Focusing too much on the wonders of website and videoconferencing technologies can lead you to overlook the responsibilities they bring with them. Failing to notice that the webcam’s power to let you work with patients in distant states and provinces means you need to be familiar with and comply with the relevant laws and regulations. Working within the framework of videoconferencing may distract you from doing the kind of careful assessment you no doubt would conduct if you were working in person.