As licensed professionals, psychologists are obligated to serve in their professional roles and to carry out their professional duties and responsibilities in an ethical manner. We have a fiduciary duty to our clients that requires that all decisions made, and all actions taken, are motivated by and in keeping with our clients’ best interests (Jorgenson et al., 1997). The Ethical Principles of Psychologists and Code of Conduct (Ethics Code, APA, 2017) provides aspirational general principles and enforceable ethical standards to provide both “guidance for psychologists and standards of professional conduct” (p. 2). Yet, the Ethics Code cannot provide clear and unambiguous answers for what to do in every challenging situation a psychologist may face in the course of their career.  

Ethical Dilemmas and the APA Ethics Code

Psychologists may regularly be confronted by ethical dilemmas; situations where no one correct answer is immediately evident or where multiple possible courses of action exist, each of which may have potential risks and benefits associated with them. Psychologists may also face situations where ethics and law conflict (see Ethical Standard 1.02), where ethics and organizational demands conflict (see Ethical Standard 1.03), where the ethics code does not address the challenge being experienced, and when the psychologist is confronted by conflicts between the general principles. Additionally, the ethics code may at times seem vague in the guidance it provides when using modifiers such as “reasonably, appropriate, potentially” (p. 2). The use of these terms acknowledges that “a set of rigid rules” could “be quickly outdated” (p. 2) as the profession evolves and previously unexperienced and unanticipated dilemmas arise for which psychologists must use their professional judgment to determine the most appropriate course of action.  

When faced with an ethical dilemma it would be nice to be able to look up the one correct answer for how to proceed, but the Ethics Code can only provide this specific guidance for addressing ethical problems, which can be defined as situations with clear acceptable and unacceptable courses of action. These standards set what Knapp et al. (2017) describe as the ethical floor, defined as the minimal standard that must be met and “prohibited acts” (p. 13) that must be avoided. Conduct that falls below this ethics floor violates the ethics code and constitutes unethical behavior. Examples from the Ethics Code (APA, 2017) include “Psychologists do not engage in sexual harassment” (Ethical Standard 3.02, p. 5), “Psychologists do not engage in sexual intimacies with current therapy clients/patients” (Ethical Standard 10.05, p. 14), “Psychologists do not misrepresent their fees” (Standard 6.04c, p. 9), and “Psychologists do not present portions of another’s work or data as their own…” (Standard 8.11, p. 11).  

Yet, many standards are more broad and general, requiring the application of one’s professional judgement and thoughtful decision-making. Examples from the Ethics Code (APA, 2014) include: 

 “Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service” (Standard 10.10a, p. 14). How does one determine when this is reasonably clear, at what point in time should this decision be made, might this vary based on each client’s individual needs and circumstances, and where does one find guidance to help in making these decisions?  

“A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists” (Standard 3.05a, p. 6). Are impaired objectivity, competence, and effectiveness all-or-nothing phenomena? If not, what is the threshold for making this determination? Can psychologists accurately make such determinations independently or do they need input and guidance from colleagues? Would it make a difference if the client is in crisis? Would living and working in a small and isolated community with limited resources for referrals impact one’s decision about what is reasonable? Does reasonable vary by setting and circumstances? How does one decide? 

The Need for an Ethical Decision-Making Process

It is evident that the guidance of just follow the Ethics Code will be found to be lacking in these and so many other situations. Additionally, responding impulsively and trusting one’s instincts or gut has been shown to be a poor substitute for a logical decision-making process. The use of a decision-making process can help psychologists to avoid fast, instinctive, intuitive, and emotional decision-making that is flawed by personal biases and blind spots, and instead to engage in slower, more deliberate active reasoning, and more logical thinking and decision-making that involves “focused cognitive effort to actively evaluate problems, weigh evidence, and make rational decisions” (McManus, 2021, p. 155), what Kahneman (2011) have described as Type 1 and Type 2 thinking, respectively.  

When faced with an ethical dilemma an important first step is to consider the foundational general principles on which each of the enforceable ethical standards are based. These underlying values of the profession of psychology may be utilized to help clarify one’s obligations when faced with an ethical dilemma. These principles as articulated by Beauchamp and Childress (2012) are: beneficence, non-maleficence, fidelity, autonomy, and justice.   

Ethical Decision-Making Models

K. Johnson et al. (2022) provide a comprehensive review of available decision-making models. Further, the Markkula Center for Applied Ethics at Santa Clara University is an excellent resource about ethical decision-making. Its website may be accessed at: https://www.scu.edu/ethics/. Some very specific decision-making models are available such as Gottlieb’s (1993) and Younggren and Gottlieb’s (2004) decision-making models for deciding about post-treatment multiple relationships, Barnett and Johnson’s (2011) decision-making model to assist clinicians to make decisions about integrating religion and spirituality into psychotherapy, and Kellen et al.’s (2015) ethical decision-making assists clinicians to make decisions regarding participating in social media in our professional roles.  

One representative general ethical decision-making model, articulated by Barnett and Johnson (2008) involves the following steps: 

Stage 1: Define the Situation Clearly

• Articulate the exact nature of the situation. 
• Gather as many relevant facts and details as possible. 
• Pinpoint the primary quandary or conflict(s). 
• Begin to consider the potential ethical issues and your obligations. 

Stage 2: Determine Who Will be Impacted

• Identify the primary clients as well as any secondary clients. 
• Consider the full range of persons who might be impacted by your decision. 
• Articulate your professional obligations to and the rights of each person and group involved. 
• Be especially sensitive to the potential for harm to any person involved. 
• Reflect on your obligation to promote the best interests of those involved. 
• Begin to consider the potential impact of various decisions on those involved. 

Stage 3: Refer to both Universal Ethical Principles and the Standards of Your Profession’s Code of Ethics

• Ask yourself the following principle-based questions: 
  • How can I contribute to my client’s welfare (beneficence)? 
  • How can I avoid harming my client and others (nonmaleficence)?
  • How can I promote my client’s independence (autonomy)? 
  • How can I remain loyal to my client (fidelity)? 
  • How can I ensure equitable treatment of clients (fairness)? 
  • How can I protect my client’s disclosures (privacy)? 

• Review Your Profession’s Code of Ethics. 
• Identify the standards and universal principles most germane to your situation. 
• When specific standards are ambiguous regarding your question, consider the more fundamental obligations conveyed in the universal ethical principles.
• Consider consulting one or more current ethics texts or articles on ethics in professional journals for additional guidance or case examples. 

Stage 4: Refer to Relevant Laws/Regulations and Professional Guidelines

• Review legal statutes and regulations bearing on counseling in your jurisdiction. 
• Consider agency and institutional policies  
• Identify and review any relevant counseling guidelines bearing on the situation, client type, problem, and type of service. 
• Consult with a lawyer to determine your legal obligations and the legal consequences of various courses of action. 
• Consult with colleagues or ethics organizations concerning potential conflicts between ethical and legal obligations. 

Stage 5: Reflect Honestly on Personal Feelings, and Competence

• Take time to reflect honestly about the thoughts and feelings aroused by the situation. 
• Consider whether feelings aroused about yourself (e.g., shame, diminished esteem) or others (e.g., anger, anxiety, sexual attraction) involved may negatively impact your decision-making. 
• Honestly consider whether you have the requisite competence—defined by education, training, and supervised experience—to effectively handle the situation. 

Stage 6: Consult with Trusted Colleagues

• Carefully select one or more colleagues whom you know to have experience, good judgment, solid familiarity with ethical and legal issues, and preferably, experience in the area of concern. 
• Seek consultant referrals, if needed, from local or national counseling organizations. 
• Select consultants who are honest, forthright, and respectful of confidentiality. 
• Prepare carefully for the consultation by summarizing key facts, apparent ethical issues, personal concerns, and possible courses of action. 

Stage 7: Formulate Alternative Courses of Action

• Take time to think about the full range of possible responses to the situation. 
• Consider all of the ways you might proceed in light of the facts at hand (e.g., full array of interventions, research designs, methods of confronting a student or colleague). 
• Consider the feasibility and ethical/legal implications of each approach. 

Stage 8: Consider Possible Outcomes for All Parties Involved

• Evaluate the probable impact—for each client and stakeholder—of each course of action considered. 
• Enumerate possible outcomes for those involved paying particular attention to potential risks and benefits.  
• Assess the implications of each approach in light of your ethical and legal obligations. 
• Document this reasoning process. 

Stage 9: Make a Decision and Monitor the Outcome

• Based on the first 8 stages and all relevant information available to you at this time, select the best option and implement it. 
• When possible, discuss your decision and your rationale with stakeholders. 
• Always take full responsibility for the decision. 
• Clearly document each stage of your ethical decision-making process. 

Stage 10: Engage in an Ongoing Assessment and Modification

• Carefully monitor—to the extent possible—the effects of your course of action on those involved.  Modify your plan as needed and continue this process until the best possible outcomes are achieved. 
• Engage in ongoing monitoring and feedback.  
• Adjust actions as needed. (pp. 177-180) 

Key Points and Recommendations

While psychologists are faced with numerous ethical dilemmas throughout their careers, it is not always possible to engage in a comprehensive decision-making process. A client may ask their psychotherapist a question that requires disclosing personal information, they may ask their psychotherapist for a hug at the end of a session, or they may give their psychotherapist a gift as an expression of thanks. At times, psychotherapists must make quick decisions and use their best judgment in the moment. But, even in these situations if the clinician has thought about such issues in advance and has a context for evaluating possible courses of action, they will be better prepared for responding to these situations in a thoughtful and appropriate manner.  

There will be common dilemmas that psychotherapists may anticipate and thus be better prepared for when they arise. Having written procedures to follow when requests for treatment records are received and having a clear policy in place to address the use of social media and how to respond to client requests for online interactions are possible examples.  

Finally, there will be occasions when psychotherapists can take the time to go through the steps of a decision-making process to determine the most appropriate course of action that is consistent with the general principles of the Ethics Code, that is consistent with the client’s treatment needs, and that feels comfortable for the clinician. Examples include being invited to a client’s special occasion such as a graduation ceremony, deciding if it would be appropriate to evaluate or treat a family member or someone known to a current client, and deciding when one possesses sufficient competence to treat a certain client whose treatment needs fall outside one’s usual areas of practice.  

Perhaps most importantly, it is essential to be able to recognize when one is faced with an ethical dilemma and is prepared to consider options in a thoughtful manner that is consistent with our obligations to our clients. It is also of paramount importance that we each realize that consultation with expert colleagues and the thoughtful use of their input will invariably assist us to make better decisions in the face of ethical dilemmas.  

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Jeffrey E. Barnett, Psy.D., ABPP

Jeffrey E. Barnett, Psy.D., ABPP is a Professor in the Department of Psychology at Loyola University Maryland and a licensed psychologist who is board certified by the American Board of Professional Psychology in Clinical Psychology and in Clinical Child and Adolescent Psychology. Additionally, he is a Distinguished Practitioner in Psychology of the National Academies of Practice. Among his many professional activities, Dr. Barnett is a past chair of the ethics committees of the American Psychological Association, the American Board of Professional Psychology, and the Maryland Psychological Association. He previously served on the Maryland Board of Examiners of Psychologists and has been a consultant to licensing boards across a range of health professions. His numerous publications and presentations focus on ethics, legal, and professional practice issues in psychology. Dr. Barnett is a recipient of the APA’s outstanding ethics educator award.