The Ethical Practice of Psychotherapy: Easily Within

Our Reach

m

Jeffrey E. Barnett

Independent Practice, Arnold, Maryland and Loyola College

in Maryland

Psychotherapists confront a myriad of ethical dilemmas as they

endeavor to provide effective services. This issue of the

Journal of

Clinical Psychology: In Session

on Ethics in Psychotherapy provides

psychotherapists with thoughtful reviews, case examples, and

practical guidance in the major areas of ethics. Following this brief

introduction, the subsequent seven articles cover Informed consent;

confidentiality, privilege, and their limits; treatment of minors and their

families; business matters of practice (e.g., money, fees, bartering,

advertising); clinical competence and scope of practice; boundaries

and nonsexual multiple relationships; and termination and abandon-

ment. This issue is designed to promote ethical practice, to provide

guidance on common ethical dilemmas, and to prevent ethical

challenges before they occur.

&

2008 Wiley Periodicals, Inc. J Clin

Psychol:In Session 64: 569–575, 2008.

Keywords: ethics; psychotherapy; ethical practice; dilemmas; profes-

sional conduct

The practice of psychotherapy can be highly rewarding, yet quite challenging. Despite

their extensive training and best efforts, psychotherapists often find themselves ill-

prepared for the wide range of ethics dilemmas that face them. This issue of the

Journal of Clinical Psychology: In Session

brings together distinguished experts in

mental health ethics to educate and guide practitioners in successfully navigating some

of the most common and challenging ethical dilemmas in psychotherapy. Respected

authors address seven of these challenges: Informed consent; confidentiality, privilege,

and their limits; treatment of minors and their families; business matters of practice

(e.g., money, fees, bartering, advertising); clinical competence and scope of practice;

boundaries and nonsexual multiple relationships; and termination and abandonment.

Correspondence concerning this article should be addressed to: Jeffrey E. Barnett 1511 Ritchie Highway,

Suite 201, Arnold, MD 21012; e-mail: drjbarnett1@comcast.net

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 64(5), 569–575 (2008)

&

2008 Wiley Periodicals, Inc.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20473

The overarching aim of the issue is to assist psychotherapists in rendering the most

ethical and effective services possible.

In this brief introduction, I offer a practical approach to ethical practice that

addresses the complexities of psychotherapy practice, the many forces that create

ethics challenges, and that can be integrated easily into each psychotherapist’s daily

practices. Then I introduce the following articles in this issue and the essential

aspects of ethical practice each addresses.

The Ethical Practice of Psychotherapy

Psychotherapists can adopt several strategies in their efforts to practice ethically.

These include positive or aspirational ethics, risk management, and defensive

practice (Barnett, 2007).

Positive ethics

focuses the psychotherapist on constantly

striving to achieve the highest ethical standards of our profession. It is guided by a

series of aspirational virtues that we strive to achieve throughout our careers. These

virtues provide both important direction and a conceptual framework. These virtues

include:

*

beneficence: doing good and providing maximum benefit to those psychothera-

pists serve

*

nonmaleficence: avoiding exploitation and harm of clients and those associated

with them

*

fidelity: being faithful to the explicit and implicit obligations psychotherapists

have to their clients

*

autonomy: promoting each client’s independence of us over time and not creating

increased dependence on us through our actions

*

justice: providing fair and equal treatment, and access to treatment, to all

individuals

*

self-care: providing adequate attention to our own physical and psychological

wellness so that we are effectively able to implement the preceding virtues

(Beauchamp & Childress, 2001).

These virtues can generate a series of questions that may be of assistance

when facing dilemmas. For example, ‘‘Will taking this action be in my client’s

best interest?’’ ‘‘Will engaging in this behavior increase the likelihood of exploitation

or harm of my client?’’ ‘‘Is acting in this way consistent with my obligations to my

client and consistent with my client’s expectations of me?’’ ‘‘Will proceeding with this

course of action promote greater dependence on me by my client?’’ ‘‘Am I singling

out this particular client for unique or special treatment in some way?’’ ‘‘Are there

personal factors that I have overlooked that may be contributing to my decision to

engage in this planned course of action?’’

Positive or aspirational ethics strive to achieve the highest ideals of ethical and

professional conduct in all our interactions with clients (Knapp & VandeCreek,

2006). It eschews efforts to do the minimum to get by or to just avoid negative

outcomes. Further, positive ethics focuses on the best possible outcome for the client.

Risk management

shares the goal of positive outcomes for clients, but it is more

specifically focused on minimizing risks for the psychotherapist that may result in

ethics complaints or malpractice claims. Risk management attends to data on the

most likely causes of complaints against psychotherapists and utilizes them to

develop practice models to reduce the probability of these pitfalls. Effective risk

management most frequently addresses informed consent, effective documentation,

570

Journal of Clinical Psychology: In Session, May 2008

Journal of Clinical Psychology: In Session

DOI: 10.1002/jclp

and consultation (Bennett et al., 2006). While reducing the risk of an ethics

complaint or malpractice claim is obviously of great importance to all psychothera-

pists, as will be seen in the following articles, effective ethical practice embraces risk

management, but retains its focus on the client’s best interests rather than on

protecting the psychotherapist.

Defensive practice

focuses on the direct protection of the psychotherapist. It

involves making decisions based on reducing the possibility of adverse outcomes for

the psychotherapist (Barnett, 2007). For example, a practitioner may restrict the

range of clients worked with and refuse to work with certain types of clients, such as

those with suicidal ideation or severe personality disorders, out of fear that they

materially increase risk (Wilbert & Fulero, 1988). As highlighted in the articles to

follow, overzealous efforts to avoid all possible risk can actually result in greater

harm to clients. For example, an absolute refusal to cross certain boundaries in

psychotherapy, such as self-disclosure and touch, can result in poorer treatment

outcomes and may not be in the client’s best interests (Williams, 1997; Zur, 2001).

The authors of articles in this issue consistently emphasize positive ethics.

Focusing on the client’s best interests and aspiring to the highest ideals of our

profession are most likely to achieve the best treatment outcomes, to assist

psychotherapists in effectively responding to the inevitable ethics challenges we

confront, and incidentally, to minimize risks to the psychotherapist.

The Regulatory Environment

The regulation of healthcare practice creates it own set of complications to positive

ethics. The regulatory environment refers to one’s practice setting and the many

standards, regulations, laws, and policies that regulate the practice of psychotherapy.

All psychotherapists must follow the ethics code of their profession, such as the

Ethical Principles of Psychologists and Code of Conduct

(Psychological Association,

2002; hereinafter referred to as the ‘‘Ethics Code’’), and state laws and regulations

relevant to their status as a licensed professional. Additionally, depending on one’s

practice setting, other policies and regulations must be considered. Psychotherapists

working in institutions such as state hospitals, federal prisons, county schools, and

the like will find a plethora of documents that regulate how they conduct themselves

in their professional roles.

Psychotherapists also must be aware of prevailing professional standards in certain

areas. Knowledge of the professional literature in one’s area of practice is an ethical

duty for keeping aware of changes in practice patterns and recent developments that

may alter accepted practices. Psychologists, for example, should familiarize

themselves with American Psychological Association’s (APA) various practice

guidelines that reflect the current consensus of experts in a number of specific

practice areas such as the treatment of older adults, girls and women, and ethnically

diverse populations. These may be accessed at www.apa.org/practice/prof.html.

Ethical Decision Making

When faced with ethical dilemmas, psychotherapists will seek information from the

law, professional publications, and colleagues to guide them in their decision

making. Consider the following two illustrative examples:

A psychotherapist receives a telephone call from an individual identifying

herself as the noncustodial parent of one of the psychotherapist’s clients.

571

Ethical Practice of Psychotherapy

Journal of Clinical Psychology: In Session

DOI: 10.1002/jclp

The client is a minor, and the psychotherapist correctly had the custodial

parent consent to the child’s psychotherapy. But the psychotherapist is

unsure of how to respond to this request since the noncustodial parent has

not been involved in the treatment and the custodial parent does not want

her involved.

The first thing the psychotherapist did was review the Ethics Code and its sections

on informed consent to psychotherapy. While the psychotherapist did follow these

standards, the issue of the noncustodial parent’s access to treatment information had

not been addressed. The psychotherapist next sought consultation with a colleague

with expertise in ethics and legal issues in psychotherapy. The colleague referred the

psychotherapist to a particular section of law in their state that authorizes all

noncustodial parents to have access to all treatment information concerning their

children. While they cannot consent to their children’s treatment, they do have the

legal right to all information about the treatment and to participate in it if desired.

Then, after reading several articles in the professional literature, the psychothera-

pist learned more about preventive practices with regard to the treatment of minors

and the involvement of their parents in treatment. Based on recommendations in the

literature, the psychotherapist scheduled a meeting with both parents, reviewed

relevant Ethics Code standards and the relevant statute, and then together they

modified the original informed consent agreement to the satisfaction of all involved.

The minor client’s psychotherapy then proceeded successfully.

A male psychotherapist is providing treatment to an attractive female client.

Over the course of treatment, the psychotherapist realizes he is becoming

attracted to the client. He understands his obligation to focus on his client’s

best interests, but is unsure of how to deal with his feelings and how to

proceed.

The psychotherapist reviews relevant sections of the Ethics Code, including

standards on multiple relationships, avoiding exploitation and harm, and attention

to one’s personal functioning and how it may impact client welfare. He then reads

relevant professional literature on personal feelings toward clients, boundary issues

and multiple relationships, self-care, the use of consultation and personal

psychotherapy, and when to restrict or limit one’s scope of practice.

The psychotherapist then consulted with an experienced, trusted colleague and

discussed the situation openly and honestly. As a result of this consultation and

upon self-reflection, the therapist realized that he has been under stress in his

personal life lately and that this may be impacting his professional conduct. With the

support of his colleague, he seeks personal psychotherapy and begins to address

these concerns with his psychotherapist. With what he learns and now understands

better, he is able to continue his clinical work with this client and do so in an ethical

and appropriate manner.

As can be seen in these case examples, a primary source of guidance when faced

with ethics dilemmas is the ethics code of one’s profession. The Ethics Code provides

both general principles that are aspirational in nature (based on and applied like the

virtues) and a code of conduct comprised of enforceable minimal expectations for

professional conduct. Each is important for considering how to provide psychother-

apy in the most ethical manner possible. But, the Ethics Code makes it clear that it

cannot specifically address every situation or dilemma that a psychotherapist may

face. Further, it states that psychotherapists are to consider the Ethics Code in their

572

Journal of Clinical Psychology: In Session, May 2008

Journal of Clinical Psychology: In Session

DOI: 10.1002/jclp

ethics decision making, but also should consider relevant laws and regulations as

well as ‘‘.

y

other materials and guidelines that have been adopted or endorsed by

scientific and professional psychological organizations and the dictates of their own

conscience, as well as consult with others in the field’’ (p. 1062).

As one of several sources of guidance, the Ethics Code does not replace the

psychotherapist’s judgment but should be used in concert with it. A number of

models of ethical decision making are available that can guide the psychotherapist

when faced by challenges with no readily clear course of appropriate action. Clause

and Cottone (2000) provided an excellent review of available decision-making

models. Further, psychotherapists may access the Markkula Center for Applied

Ethics’ Web site at http://www.scu.edu/ethics/practicing/decision/ for a helpful set of

ethical decision-making resources.

Challenges for Ethical Practice

APA’s Ethics Committee (2004, 2005, 2006) regularly compiles the types and

frequency of complaints received against psychologists. In the recent past, the most

common complaints, in order of decreasing frequency, entail

*

boundary problems and multiple relationships, both sexual and nonsexual

*

practicing outside one’s areas of competence

*

insurance and fee issues

*

confidentiality

*

false, fraudulent, or misleading public statements

*

child custody evaluations

*

inappropriate follow-up and termination

*

inappropriate response to a crisis.

These categories are not necessarily mutually exclusive. For example, when

conducting a child custody evaluation, a clinician may practice outside of areas of

competence while engaging in an inappropriate multiple relationship. Other

combinations of unethical behaviors among these categories may easily be seen.

Regardless, these most challenging areas of clinical practice closely mirror the

articles in this issue. The seven ensuing articles offer thoughtful reviews, case

examples, and practical guidance on the ethics of psychotherapy.

Overview of Articles

In the first article, ‘‘Informed Consent to Psychotherapy: Protecting the Dignity and

Respecting the Autonomy of Patients,’’ Celia Fisher and Matthew Oransky address

the critical role of informed consent in the psychotherapy process. They emphasize

the role of a thoughtful and comprehensive informed consent process as a means of

promoting clients’ best interests and in laying a foundation for the psychotherapy

relationship. Informed consent minimizes risks to clients and prevents many

potential ethics challenges. Their numerous case examples and practical suggestions

will help psychotherapists to develop informed consent procedures that should help

avert many of these challenges.

Jeffrey Younggren and Eric Harris then address confidentiality and privilege,

along with their exceptions in their article, ‘‘Can You Keep a Secret? Confidentiality

in Psychotherapy.’’ These authors explain the centrality of confidentiality for the

success of every psychotherapy relationship, explain how it differs from the legal

concept of privilege, and highlight the multiple threats to confidentiality that exist.

573

Ethical Practice of Psychotherapy

Journal of Clinical Psychology: In Session

DOI: 10.1002/jclp

Further, they utilize case law and provide practice recommendation so that each

client’s confidentiality may be optimally preserved.

Gerald Koocher, in his article entitled ‘‘Ethical Challenges in Mental Health

Services to Children and Families,’’ expands on consent and confidentiality as they

specifically apply to clinical work with minors and their families. Koocher applies the

4-C model—competence, consent, confidentiality, and congruence of interests—

when children and their parents participate in or set goals for psychotherapy. His

article addresses the unique challenges that confront psychotherapists who must

balance competing interests of children and their parents. Koocher provides

thoughtful analyses of these most frequent dilemmas and offers practical

recommendations to help prevent ethical lapses.

Samuel Knapp and Leon VandeCreek then address the ‘‘business’’ of psychother-

apy in their article, ‘‘The Ethics of Advertising, Billing, and Finances in

Psychotherapy.’’ They tackle the sticky topics of advertising, billing, and finances,

which may adversely impact the psychotherapy process and relationship if not

properly addressed. They do so through realistic case examples and by applying

virtues to assist psychotherapists in achieving the highest ideals in business practices.

In her article, ‘‘Competence and Scope of Practice: Ethics and Professional

Development,’’ Erica Wise addresses the complexities and challenges of establishing

clinical competence. Through case examples, she emphasizes a comprehensive and

proactive approach to competence that utilizes self-reflection and self-care along

with ongoing professional development.

Next, Kenneth Pope and Patricia Keith-Spiegel provide a thoughtful approach

for managing boundary concerns and nonsexual multiple relationships in

psychotherapy in their article, ‘‘A Practical Approach to Boundaries in

Psychotherapy: Making Decisions, Bypassing Blunders, and Mending Fences.’’

Their realism is sensitive to clients’ treatment needs, individual differences, and the

potential of negative client reactions. Importantly, they provide psychotherapists

with a detailed review of frequently occurring cognitive errors that may lead to

harmful results.

In the final article, ‘‘Psychotherapy Termination: Clinical and Ethical Responsi-

bilities,’’ Melba Vasquez, Rosie Bingham, and Jeffrey Barnett address the final phase

of psychotherapy: termination. They highlight differences between termination and

abandonment, discuss the many ways that a psychotherapy relationship may end

(both planned and unplanned), and recommend practical steps to help ensure a

successful outcome to the psychotherapy process.

In the end, our hope is that this compilation will provide psychotherapists with a

solid foundation for ethical practice. These articles provide practical strategies for

addressing the most common ethical challenges. Learning how to prevent these

challenges when possible, and how to respond to them thoughtfully and effectively

when they arise, will serve the best interests of all psychotherapists, and even more

importantly, the best interests of our clients.

References

American Psychological Association. (2002). Ethical principles of psychologists and code of

conduct. American Psychologist, 57, 1060–1073.

American Psychological Association, Ethics Committee. (2004). Report of the Ethics

Committee, 2003. American Psychologist, 59, 434–441.

574

Journal of Clinical Psychology: In Session, May 2008

Journal of Clinical Psychology: In Session

DOI: 10.1002/jclp