Ethics for psychotherapists is a given; it’s a fact of life for mental health clinicians. It is a required course in graduate school, likely included in comprehensive exams, and is addressed to some extent in clinical supervision (at least when problems arise). It also is an area of emphasis on licensure exams, making sure future psychotherapists possess at least the minimal knowledge about ethics to practice independently.
But, what is ethics?
Is it a long list of do’s and don’ts listed in the American Psychological Association’s Ethics Code (APA, 2010)? If we just memorize the Ethics Code and attempt to follow its specific standards will we be guaranteed to always be ethical? Perhaps it is the list of professional practice standards in our state’s licensing law. Many of us had to memorize these standards to pass our state licensure exam. Does this memorization guarantee ethical practice?
Data indicate that psychotherapists who have successfully passed their state licensure exam (thus demonstrating their basic knowledge of ethics) come to the attention of their state licensure board or professional association’s ethics committee each year. These groups receive, review, investigate, and adjudicate ethics complaints on an ongoing basis. Thus, one can reasonably ask “how can this happen?” After all, it seems reasonable to assume that those who enter into the mental health professions do so with the intention of practicing ethically and assisting, and not harming, those they serve.
Perhaps the first and most important issue to consider about ethics in psychotherapy is that ethics is so much more than memorizing a list of standards and laws.
The reality of ethics codes, laws, and regulations is that they can only establish basic requirements for ethical conduct. Knapp and VandeCreek (2006) describe this as the ethical floor; the minimal expectations our profession has for each of us. But, these standards cannot address every possible situation that may arise during the course of our professional work.
As Pope and Keith-Spiegel (2008) so appropriately point out:
Codes and standards, however, inform rather than determine our ethical decisions. They cannot substitute for thinking and feeling our way through ethical dilemmas, and cannot protect us from ethical struggles and uncertainty. Each new client, regardless of similarities to other clients, is unique. Each therapist is unique. Each situation is unique and constantly evolves. (p. 640)
Thus, an important element of what ethics is involves the ability to think and reason ethically. This includes ethical awareness that enables us to know when an ethical dilemma is present.
Even more importantly, this ongoing sensitivity to ethics that we hopefully will have at the forefront of our minds should enable us to anticipate ethical dilemmas and the potential for ethically challenging situations. Once we do so, it is hoped that we will be guided by the underlying virtues, or ethics principles, of our profession and use them in an active decision-making process.
Underlying virtues of the field of psychology
As articulated by Beauchamp and Childress (2009) these underlying virtues of our profession include:
Beneficence: To help others and only act in ways that are of benefit to them.
Nonmaleficence: To avoid harming or exploiting others; acting to minimize the risk of harm to those we serve.
Fidelity: Acting in keeping with our obligations to others, both explicit and implicit, to include being truthful and avoiding violations of trust.
Autonomy: Promoting clients’ independent functioning over time and avoiding actions that would promote their dependence on us.
Justice: Treating all individuals justly and equally, not singling anyone out for better or worse treatment.
In addition, the APA Ethics Code (2010) includes self-care: The need to give adequate attention to our own ongoing wellness and the prevention of burnout. Failure to do so can jeopardize our ability to successfully implement the other five virtues described above (Barnett, Baker, Elman, & Schoener, 2007).
Attention to these underlying virtues is a great start when seeking to be an ethical psychotherapist. Each virtue can lead to a series of questions we can ask ourselves when faced with an ethical dilemma, defined as a situation with no immediately evident right or wrong course of action, and one for which the ethics code does not provide clear guidance. These questions, such as “If I engage in this action will it be in my client’s best interest?” can form the foundation of an ethical decision-making model.
Ethical decision-making is a vital component of ethical practice. Since ethics codes cannot provide us with all the answers, we need to be able to think and reason through the many situations likely to arise throughout our careers in which no “right answer” or correct course of action is immediately evident. A wide range of ethical decision-making models are readily available. Cottone and Claus (2000) provide a useful overview of many available ethical decision-making models.
Ethical decision-making models are available to assist psychotherapists in their efforts to achieve the highest ideals of our professions. Rather than seek to just meet the ethical floor (the minimal standards set in ethics codes, statutes, and regulations), ethical decision-making will hopefully help guide us to doing our best for each of those we serve. Handelsman, Knapp, and Gottlieb (2009) describe this as positive, or aspirational, ethics. This involves constantly striving to do the best we can for those we serve as psychotherapists.
In addition to utilizing ethical decision-making models to assist us when faced with challenges and dilemmas, we must be constantly vigilant about these issues, self-aware and self-reflective about our own needs and issues that may contribute to these situations, and we must actively integrate colleagues into this process.
It is vital that we not isolate ourselves professionally, attempting to work through these issues on our own. We should actively reach out to, and use, our colleagues to assist us to promote the highest possible standards of ethical conduct and practice (Johnson, Barnett, Elman, Forrest, & Kaslow, 2012).
In many ways, ethics in psychotherapy is a team activity. While self-awareness and self-reflection are important first steps, they are not sufficient for ethical practice.
In some ways ethics is an attitude, an outlook, a perspective, and a way of thinking.
But, perhaps most importantly, it is a way of being; something we integrate into who we are. We must live and act in ways that are consistent with the underlying values of our profession, honestly reflecting on any biases, risk factors, and blind spots that may exist for us. Then, we must actively utilize our colleagues to assist us in our ongoing efforts to achieve the highest ideals of our profession.
Several representative ethical decision-making models may be found here.
Regardless of the specific model chosen, once a decision is made it is important to monitor outcomes. If the results are not what was hoped for, or if circumstances change over time, we should go through the ethical decision-making process again to strive for achieving the most desirable outcome possible.
Conclusion and Summary
Some ethics challenges may be avoided with appropriate planning and forethought. Examples include instituting a comprehensive informed consent process in your practice and ensuring that all client records are stored securely. But, when ethical dilemmas arise, it is our engagement in a thoughtful ethical decision-making process that is based on the values of our profession and that includes active consultation with colleagues that should be of greatest help to us.