Psychotherapists endeavor to be ethical in all their professional roles and interactions. Yet, being ethical is not always easy. While there are regularly occurring situations that are clearly ethical or unethical, many of situations we may face constitute ethical dilemmas. These are situations with no readily apparent, clearly appropriate or inappropriate course of action. These are situations where the answer to the question “What should I do in this situation” often is “it depends.”
The “it depends” implies that there may be numerous factors and nuances to the situation that need to be considered in deciding how to proceed. Psychotherapists need guidance and support when confronted with ethical dilemmas. What follows five specific actions to take when facing ethical dilemmas. These are intended to provide guidance on how to be an ethical psychotherapist and hopefully will be of value for psychotherapists.
Make Sure it is an Ethics Issue
Many of the dilemmas and challenging situations psychotherapists face are not actually ethical dilemmas; often, these are legal issues (Younggren, Fisher, Foote, & Hjelt, 2011). An important first step in pursuing ethical practice is to determine if the challenge being faced is an ethics one or a legal one (or both). If the challenge is a legal one, for example, “does this situation meet the requirements for making a mandated report to the appropriate state agency?”, then relevant laws and regulations should be carefully reviewed and consultation with legal experts should occur.
When making such decisions, always consider the regulatory environment. Each practice setting brings with it a range of laws, regulations, rules, and policies that must be considered when making decisions about our obligations. For example, the laws, regulations, rules, and policies may vary somewhat when practicing in a Federal prison, a state hospital, a county mental health center, and a private practice.
Follow the Ethics Code
To practice ethically, we must be familiar with your profession’s ethics code. Each of the mental health professions has an ethics code that is easily accessed online. For example, one may find the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (APA, 2010) at http://www.apa.org/ethics. While this ethics code provides us with a great start to being ethical psychotherapists, it has its limits. The Ethics Code includes a number of enforceable ethics standards, yet it cannot tell us specifically what to do in every situation that may arise during the course of our careers. We do need to follow the Ethics Code and not engage in actions that fall below the stated standards, but the Ethics Code is broad and general by design, and leaves a lot open to interpretation, allowing us to apply our own values, thought process, and decision-making.
Attend to the General Principles
An important aspect of the APA Ethics Code is the aspirational General Principles section. These general principles of ethics are intended to guide our decision-making when confronted with ethical dilemmas. In essence, these general principles are the underlying values of our profession that should be reflected in all we do. They are based on Beauchamp and Childress’s (2013) principles of biomedical ethics. These include:
- Beneficence: The need to do good, be helpful, and provide benefit to others in our professional interactions with them.
- Nonmaleficence: Taking steps to minimize or avoid exploitation of, and harm to, those we serve.
- Fidelity: Meeting our obligations to others, whether they are stated specifically in the informed consent agreement or implied based on reasonable expectations of us based on our professional roles.
- Autonomy: Only taking actions that promote our clients’ autonomous functioning over time and not engaging in behaviors that promote clients’ dependence on us.
- Justice: Providing all individuals equal access to needed treatment and treating clients fairly and not singling anyone out for preferential or substandard care.
To these, it is recommended that one additional underlying value be added (Barnett, 2008; Wise & Barnett, 2016):
- Self-Care: Failure to adequately take care of ourselves will contribute to a degradation in our ability to effectively implement the preceding five values and can, over time, result in impaired ethical judgement and decision-making.
Each of these values can be utilized to assist us in making good decisions when faced with ethical dilemmas. For example, we can ask ourselves: “If I engage in this behavior will this be of benefit to my client?”, “If I take this action will my client be at increased risk of exploitation or harm?”, “Will this decision be in keeping with my obligations to my client?”, “Will this action promote my client’s independent functioning or their dependence on me?”, “Am I treating this client differently than I typically treat others?”, and “Have I been adequately attending to my own wellness and are there any factors in my life that may be adversely impacting my objectivity and judgment?” (Barnett, 2008).
Utilize a Formal Decision-Making Model
Asking the questions above can provide us with a good starting point for thinking through ethical dilemmas and clarifying our overarching obligations in these situations. But, to assist us further, there are a number of models for ethical decision-making that are readily available. They provide a comprehensive, step-by-step process for thinking through ethical dilemmas. See for example Cottone and Claus (2000) for a review of many available ethical decision-making models and the website of the Markkula Center for Applied Ethics (2017) for a wealth of helpful information on ethical decision-making and different approaches and models that are available. While the decision-making models cannot tell us what to do, they can be very helpful to us in thinking through the relevant issues to help us to reach the best possible decision.
Some decision-making models are quite broad and others are more specific. For example, Younggren and Gottlieb (2004) developed an ethical decision-making model that is specifically focused on boundary and multiple relationship situations. A more general type of ethical decision-making model described by the Markkula Center for Applied Ethics is the practice-based model. This type of model guides us through a series of steps to systematically work through the dilemma. These typically include:
- Recognize the ethical issues.
- Get the facts.
- Evaluate alternative courses of action.
- Make a decision and test it.
- Act and reflect on the outcome.
As a representative example, Barnett and Johnson’s (2008) practice-based model for ethical decision-making includes the following steps:
- Define the situation clearly, gathering as much relevant information as is possible and clearly articulating the dilemma or conflict present that must be addressed.
- Determine who will be affected, considering the potential impact of potential actions on all individuals involved, being mindful of your obligations to each of them.
- Refer to both underlying ethical principles and the standards of the APA Ethics Code, keeping in mind specific enforceable standards as well as more fundamental ethics obligations.
- Refer to relevant laws/regulations and professional guidelines, being mindful of both ethics and legal issues and obligations.
- Reflect honestly on personal feelings and competence, considering any factors that may impact your judgment and decision-making.
- Consult with trusted colleagues, honestly sharing all information relevant to the situation.
- Formulate alternative courses of action, considering the full range of possibilities.
- Consider possible outcomes for all parties involved, paying attention to potential risks and benefits.
- Make a decision and monitor the outcome, modifying your plan as needed on an ongoing basis.
Consult with Colleagues
While this recommendation is a component of most ethical decision-making models, it is important to mention it separately due to its great importance. Ethical decision-making should not be a solitary activity. While psychotherapists often are used to practicing their profession in isolation, we all know that clinical supervision and peer consultation help us to be more effective psychotherapists. The same is true with ethical decision-making. Even with implementing the four steps above, it is easy to make mistakes when we do not include others’ perspectives. We can get stuck in seeing a situation from one perspective and not be able to think of others. Yet, a thoughtful consultation with a colleague can provide us with input that we might not have considered on our own. While we are not required to follow the guidance our colleagues provide, these consultations may assist us to make the best decisions possible, providing us with additional issues and perspectives to consider as we go through our decision-making process.