Ethics Rounds

Psychologists who work in campus counseling centers face a daunting array of challenges. There is universal consensus that students bring to campus more and greater pathology than ever before. Violence at campuses across the country has placed enormous pressure on schools to ensure the academic community's safety. Administrators see psychologists as central in the effort to prevent campus violence. Yet far from deferring to clinicians' expertise and judgment, these same administrators--who may have little or no mental health training--increasingly demand to know which students are receiving mental health services, and in some cases even push to become involved in aspects of clinical care. Responding to these pressures takes considerable clinical skill, political acumen, organizational understanding and ethical reflection.

The Ethics Office receives many calls from psychologists in all areas of education, research and practice. Given the circumstances above, the noticeable increase in calls the office receives from psychologists working in campus counseling centers is not surprising. There seems no reason to believe the situation will change in the foreseeable future. A challenge for the Ethics Office is to reflect with these psychologists on how the values in the Ethics Code can help frame clinically competent, organizationally savvy, ethically appropriate responses to the many and often conflicting pressures they face.

A tension apparent in calls the office receives involves whether and the extent to which a counseling center should reach out to individual students who may be in distress. Recently we were asked whether Ethical Standard 5.06 serves as an impediment to contacting students who had not themselves approached the counseling center:

5.06 In-Person Solicitation

Psychologists do not engage, directly or through agents, in uninvited in-person solicitation of business from actual or potential therapy clients/patients or other persons who because of their particular circumstances are vulnerable to undue influence. However, this prohibition does not preclude (1) attempting to implement appropriate collateral contacts for the purpose of benefiting an already engaged therapy client/patient or (2) providing disaster or community outreach services.

Very soon after receiving this question, another psychologist from an entirely different part of the country contacted the office and suggested that reaching out to students and offering services in an unsolicited manner may infringe upon the students' right to privacy and self-determination. The psychologists posing these questions were, for entirely understandable and legitimate reasons, focusing on two separate aspects of our Ethics Code.

Principle B in the Ethics Code helps ease the apparent tension between these two calls:

Principle B: Fidelity and Responsibility

Psychologists establish relationships of trust with those with whom they work. They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct, clarify their professional roles and obligations, accept appropriate responsibility for their behavior, and seek to manage conflicts of interest that could lead to exploitation or harm. Psychologists consult with, refer to, or cooperate with other professionals and institutions to the extent needed to serve the best interests of those with whom they work.

Note how Principle B speaks directly to these psychologists' questions and related issues. First, Principle B begins with "trust." Trust exists on both the individual and institutional levels. For a counseling center to function effectively, there must be trust both between the counseling center and school administration, as well as between the clinicians and the recipients of services. When trust breaks down on either level, providing competent and clinically useful services becomes extraordinarily difficult. This is one reason why counseling centers need to be very attentive when asked by a school administration to adopt nontraditional roles such as providing mandated treatment. Trust also becomes a significant issue whenever information is disclosed, for example to a school administrator, without a client's knowledge or consent. Even a single disclosure can have effects that reach throughout the community.

Second, Principle B speaks about responsibilities to the specific communities in which psychologists work. How psychologists in campus counseling centers carry out their responsibilities to the school community will depend on many factors, such as the school's unique culture and the counseling center's philosophy and policies. Some centers will focus on training individuals in the academic community to encourage individuals in distress to visit the center or inquire about services. Other centers may be more open to acting on information they receive from third parties and reaching out before hearing from the student in question. Note that because Ethical Standard 5.06 prohibits "solicitation of business" and explicitly allows "community outreach," the standard would not prevent a nonprofit, campus counseling center from reaching out to a member of the school community in order to offer services or invite a visit. At the same time, such outreach must be clinically informed. Many centers will be exceedingly cautious for clinical reasons about making unsolicited contacts, especially when other avenues for reaching students in distress and encouraging them to seek counseling center services may be available.

Third, Principle B urges psychologists to clarify their roles and obligations and cooperate with "other professionals and institutions" (emphasis added). Principle B underscores how campus counseling centers exist in specific and unique settings where a nuanced and contextualized view of informed consent is necessary, as is a willingness to cooperate with other professionals. Two ethical standards are directly relevant to cooperation and informed consent in an institutional setting:

3.09 Cooperation With Other Professionals

When indicated and professionally appropriate, psychologists cooperate with other professionals in order to serve their clients/patients effectively and appropriately.

3.11 Psychological Services Delivered To or Through Organizations

(a) Psychologists delivering services to or through organizations provide information beforehand to clients and when appropriate those directly affected by the services about (1) the nature and objectives of the services, (2) the intended recipients, (3) which of the individuals are clients, (4) the relationship the psychologist will have with each person and the organization, (5) the probable uses of services provided and information obtained, (6) who will have access to the information, and (7) limits of confidentiality. As soon as feasible, they provide information about the results and conclusions of such services to appropriate persons.

Ethical Standards 3.09 and 3.11, read in conjunction with Principle B, highlight how campus counseling centers operate within complex systems that have multiple and competing interests and demands. Cooperation, of course, is a two-way street and calls to the Ethics Office suggest that demands, for example regarding specific clients, are not always made to counseling centers in a collegial or cooperative manner.

The less cooperation from other aspects of the system, the harder psychologists will have to work from their end. Such a situation, while by no means ideal, does offer an opportunity to view the entire academic community--students, faculty, parents, administrators, and staff--as an organic whole and to interpret particular difficult interactions as symptoms of systemic challenges. Guidance offered by the Ethics Code is that the more the community understands what counseling centers have to offer and how counseling centers work most effectively and ethically, the more likely it is that the school environment will facilitate a counseling center offering its maximum benefit to the entire academic community.

As a community of professionals, we should recognize and appreciate the clinical, organizational and ethical challenges that face our colleagues in campus counseling centers. Psychologists in these settings will continue to come under fierce pressures from many directions. In addition to the considerable skills these psychologists bring to bear in addressing the multiple and conflicting demands on their time and loyalties, let us hope they will also feel the respect, support and admiration of us, their colleagues at APA.

Stephen Behnke, JD, PhD, is director of APA's Ethics Office. Send questions, comments or suggestions regarding this column to Ethics Rounds.