Welcome to ‘CE Corner'
"CE Corner" is a quarterly continuing education article offered by the APA Office of CE in Psychology. This feature will provide you with updates on critical developments in psychology, drawn from peer-reviewed literature and written by leading psychology experts. "CE Corner" appears in the February 2012 issue of the Monitor.
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CE credits: 1
Exam items: 10
As a result of having participated in this continuing education program, participants will be able to:
Explain four factors that can affect both ethical vulnerabilities and ethical resilience.
Identify at least three ways in which psychologists’ vulnerabilities can lead to ethical disaster.
Explain at least three ways in which psychologists can develop ethical resilience.
Psychologists want to contribute to human welfare — and the vast majority of them do. But despite their best intentions, they may find themselves in situations where they unwittingly slip into unethical behaviors.
Most psychologists try to prevent such lapses by, for example, learning the APA Ethics Code and attending risk management workshops to better understand ethical risks. Yet research has shown that such efforts are not enough to keep psychologists from ethical blunders.
How then can psychologists prevent such missteps? We suggest that psychologists at all developmental stages — from student to seasoned professional — are wise to examine and better understand their personal feelings and values and how they can lead to ethical problems. Doing so not only reduces the risk of psychologists drifting into ethical trouble, but also helps move the quality of professional practice from merely adequate to optimal.
The problem and efforts at solutions
Psychology training programs accredited by APA are required to provide ethics education to their students. This helps students and colleagues understand where the “floor” in ethical behavior lies and how the standard of care is commonly interpreted. That usually includes learning the APA Ethics Code, as well as state rules and regulations, relevant state and federal statutes and court decisions, and mastering a particular ethical decisionmaking model.
Unfortunately, research suggests that cognitive strategies alone are not sufficient. Although many psychologists and trainees can accurately describe their ethical responsibilities, they report that they might, in certain situations, act otherwise.
Bernard et al. (1987) came to that conclusion in a study that looked at psychologists’ responses to a hypothetical scenario: A psychologist learns that a male colleague is sexually involved with a client, despite a previous confrontation about such behavior. The researchers found that 37 percent of the study’s clinical psychologists said they would not report the colleague’s violation, even though they knew that they should. Similarly, Pope, Tabachnick and Keith–Spiegel (1987) found that 80 percent of their psychologist-respondents thought that “working when too distressed to be effective” is unethical, yet 53 percent reported doing so. Such research suggests that knowledge per se represents only a portion of what is required for sound ethical practice.
A broader view
Research has also found that psychologists’ ethical responses are shaped by multiple factors. They include the awareness that ethical issues are present, social and cultural influences, habits, emotions, intuitions, identity, virtues and character, multiple or competing motivations, prior decisions, and the executive and organizational skills needed to implement decisions. These factors have the potential to overpower one’s knowledge of ethics codes and rational decision-making models.
For instance, we now know that rational models of cognition often fail to capture the reality of human choice and behavior; people’s motives are not always known and their judgments are often biased (e.g., Kahneman, 2003; Kahneman & Tversky, 1979). Research has also shown that whether clinicians reported they would do what they believed they should do varied by situation and by their closeness to the person exhibiting ethically questionable behavior (Wilkins et al. 1990). Psychologists have also found that in at least some circumstances, emotions and social and cultural factors influence moral judgments and behaviors more than moral reasoning (Haidt, 2001, 2007).
Because of these human variables, we believe that building resilience and confronting vulnerabilities in psychologists’ lives is a form of primary prevention. When applied to professional behavior, such actions include addressing the emotions and personal values of individual psychologists well before problematic ethical behavior arises. By drawing on the science of prevention (Coie et al., 1993), we can bolster psychologists’ protective factors and minimize risks of ethical missteps.
Four factors affecting resilience and vulnerability
Psychologists and students who want to enhance their resilience and minimize their vulnerabilities may benefit from carefully reflecting on where they stand in relation to four dimensions: desire, opportunities, values and education (DOVE). Each of these dimensions can foster ethical behavior and personal resilience. At the same time, each may represent vulnerabilities that can lead to ethical breaches. We do not claim that these four represent an exhaustive list. Rather, we propose them as a beginning of the discussion. The four are:
1. Desire to help. Why do people choose to be psychologists? One common answer is that psychologists want to help others. However, desire to help can also create vulnerability. As Behnke (2008) observed, “There’s no one thing that has gotten more psychologists in [ethical] trouble than the desire to be helpful.”
A typical example is the well-intentioned boundary violation. Under normal circumstances, a good person who wants to be helpful may lend small amounts of money to a friend or accept an invitation to a social function. Psychology students are trained, as a general rule, not to cross such boundaries in professional circumstances because doing so may reduce treatment effectiveness, harm clients, or lead to being manipulated. Learning the skills to properly channel our desire to help others is not easy, especially when emotions, deep value differences, or interpersonal conflicts are involved.
2. A powerful opportunity. Psychologists have the opportunity to contribute to knowledge, provide clinical services, teach or advance social policy. Thus, they have the power to foster change in their clients, and at least in some small measure, make the world a better place (e.g., Pope & Vasquez, 2007).
Opportunity can provide strength and build resilience. If a paper is well received, a client improves, a student does well or a policy is adopted, the psychologist is reinforced by success and may then take on even greater challenges.
Psychologists generally appreciate their opportunity and guard it carefully. But opportunity also can entail vulnerability because of the power psychologists have over those who are entrusted to their care. Unfortunately, power can be abused and trust violated and psychologists are vulnerable to abusing their powerful opportunities.
We propose that a central underlying mechanism of vulnerability to abusing one’s opportunity is self-deception (e.g., Saradjian & Nobus, 2003) or self-serving bias (Shepperd, Malone, & Sweeny, 2008). When opportunities are exploited and power and trust abused, it may not be because offenders failed to understand intellectually that they had done something wrong. Rather, misbehavior may more often be a function of personal feelings and intuitions that obscure good judgment. These processes interfere with sound decision-making because they are not primarily intellectual but emotional (Kahneman, 2003). Given the opportunity to help, and the sincere desire to do so, we may wish to help a student for whom we feel sympathy by giving a grade he or she did not deserve and fail to see the exception as harmful to academic honesty and fairness. Doing so may also negatively affect the student and others if the higher grade leads them to assume that the student possesses knowledge or skills that he or she lacks. When such professional boundaries are crossed, it is because we have the opportunity to do so.
Remembering that harm can come from an abuse of opportunity may be difficult at times, but it is vital because psychologists can harm clients, themselves, their profession and society.
3. Values. We contend that psychologists generally share certain core values that in part also define them as individuals (Handelsman, Gottlieb, & Knapp, 2005). For example, most psychologists believe that it is important to contribute to society. Other commonly held values include the quest for knowledge, the advancement of science and striving for social justice. These professional values are tied to personal values that arise from our individual experience, reflections, and value traditions; these values can be a source of great resilience.
Values usually lead people in positive directions and help accomplish worthwhile goals. Psychologists rely on these values during times of difficulty, assuming they will contribute to prudent judgment. They also promote consistency in work and behavior and enhance one’s sense of personal identity. For example, a teacher may refuse to change a student’s grade because it would undermine the academic enterprise. A researcher may resist the lure of falsifying data because he or she knows it will harm the openness and trust on which science depends. A psychologist may avoid “upcoding” a client’s diagnosis (reporting a more severe diagnosis to ensure reimbursement) to maintain the integrity of the diagnostic classification system and avoid dishonesty.
How can such values represent vulnerabilities? Situations may arise in which psychologists lose sight of the fact that professional values are not always dependable and should not be applied equally in all situations. Consider the following example. Dr. Y, a clinical child psychologist, was invited to one of her client’s bar mitzvah. She explained to the client and his parents why it would be inadvisable for her to attend based on her professional value that it was important to maintain fairly rigid boundaries for treatment to be successful. The parents and client understood her concerns clearly and asked her to come nonetheless, arguing that she would not be invited to the reception and that hundreds of people were invited to the ceremony, thus increasing the probability of her anonymity and minimizing the chances of boundary violations or breaches of confidentiality. Furthermore, her client told her that acting as a witness to this rite of passage was very important to him. In adhering to her previous position, Dr. Y failed to underscore her empathy for the situation and to find alternative ways to strengthen her therapeutic alliance with the clients. In part, as a result of her decision, the client and his family were hurt and ultimately terminated treatment.
Psychologists may also confuse personal values with therapeutic ones (Strupp, 1980) or inappropriately convert a client’s values to their own (Tjeltveit, 1986). Psychologists who think private schools are much better than public schools and hold the personal value that nothing is more important than a good education may think that parents who care about their children would not send their children to public schools. Using their influence with clients, they may implicitly assert that clients who exhibit the highest levels of mental health and are the best parents will make sure their children attend private schools. However, sending children to private schools may impoverish families, may not represent their values, and may not be the only way for the family to make progress in addressing the problems that brought them to psychotherapy.
4. Education. Psychologists are educated people and most value education highly. At a personal level, when loved ones are ill or have problems, psychologists use their education and knowledge to help. As educated citizens, psychologists contribute to the community and, in return, draw strength from their participation. But, if education is viewed in strictly cognitive terms and valued only as an intellectual activity, it can leave little room for nurturing emotional intelligence.
Although one would hope that colleagues are taught to use, and continue to use, their internal processes to monitor the impact of their behavior on others, not all psychologists hold such a broader understanding of education. Accordingly, Pope and Vasquez (2007) discuss “emotional competence,” which “involves self-knowledge, self-acceptance, and self-monitoring.”
Therapists must recognize their emotional strengths and weaknesses, their needs and resources as well as their abilities and limitations for doing clinical work (see Pope et al., 2006). Another crucial form of education pertains to self-care (Baker, 2003; Barnett, Baker, Elman, & Schoener, 2007; Norcross & Guy, 2007). Properly understood, self-care refers not merely to avoiding impairment and ethical violations, but also to avoiding ethical mediocrity and moving toward excellence.
Yet not all trainees in professional preparation programs have the opportunity to acquire these skills. Too many professionals complete their training without the emotional education and awareness needed to avoid self-deception and to act in the prudent, considered manner that society expects and that represents professional ethical excellence.
A final way in which education can make people vulnerable is when psychologists fail to continue their learning process. New ways of understanding may be neglected, as psychologists continue to rely on what they once learned, even if it’s outdated.
Applying DOVE: A case example
As a child and adolescent, Evangelina Cruz, PhD, had experienced both victimization and discrimination. She developed a desire to help others at a young age and saw becoming a psychologist as the way to achieve her goal of helping others and making a difference. She worked hard in school. Despite economic obstacles, she was accepted at a prestigious university, and a professional preparation program of equal rank, with a strong emphasis on multiculturalism and feminism.
It was just what she had hoped for. Cruz was an outstanding student and won a coveted internship at a large urban mental health center that specialized in treating trauma victims and torture survivors. This position allowed her to develop expertise in treatment approaches for women with post-traumatic stress disorder (PTSD). Her scholarly writing and public advocacy won her early career awards and the respect of her colleagues. These experiences deepened her personal values and increased her desire to help the disempowered.
Shortly after entering independent practice, Cruz was consulted by Angie Immel, who presented with moderately severe symptoms of acute anxiety and depression she claimed were the result of sexual harassment by her boss, Alex Morse. She said Morse began pursuing her from the time she started working for him. When she rejected his initial overtures, she reported, his advances increased, and he began making inappropriate, highly sexualized remarks in private. Immel said that she tolerated this behavior and had not become symptomatic until Morse began to touch her; then she became afraid.
Immel said she complained to the human resources department, but nothing had been done because, according to her, Morse was best friends with and the golfing partner of the human resources director. Immel also made oblique references to filing an Equal Employment Opportunity Commission complaint and a lawsuit, but Cruz did not fully appreciate what Immel meant by these references. Cruz assumed she would not be personally involved in the legal process, and she and Immel never discussed it. She saw the legal issues as unrelated to her work and chose to maintain focus on the distress of her client. At the same time, she supported Immel’s efforts based on her own belief that Immel had been exploited.
Cruz treated Immel with cognitive-behavioral therapy, but Immel did not respond as well as Cruz expected. In part, Cruz’s efforts were frustrated because at every session Immel asked her to document the aversive incidents that occurred during the previous week. Cruz informed Immel that this recording of events was unnecessary, but Immel persisted, and Cruz deferred to her client’s wishes. Although the treatment was not going well, Cruz persevered.
One day, she received a telephone call from Blanca Knox, Immel’s attorney, who informed her that she would be calling Cruz to testify as an expert witness in a sexual harassment case against Morse and his company. Cruz first resisted Knox’s request because she knew the data she had were limited and that she could not directly address the legal question regarding what caused Immel’s condition. But Knox was persistent, telling her that her testimony was vital to the case and that, without it, Immel would surely lose. Eventually, in her desire to advocate for her client, Cruz testified that Immel suffered from PTSD that was the direct result of Morse’s behavior.
Shortly after the trial, at which Morse and his company were not held liable, Cruz received notice that a complaint had been filed against her with the state board of psychology for offering testimony that was beyond the boundaries of her competence. Cruz found herself confused, frightened, overwhelmed and completely unappreciated and misunderstood. She became outraged and came to view the complaint as another example of oppression of the disadvantaged.
Analysis: As a psychologist, Cruz brought many strengths to her work. She had a strong desire to help others based on her values and personal experience, and the opportunity to do so through her education and training. Her background motivated her, and her accomplishments reinforced her; she was on course for a successful and rewarding career. By analyzing the DOVE factors, we can see how the resilience produced by those strengths became vulnerabilities when she began treating Immel. The first vulnerability for her was that her knowledge of the legal system was lacking. Her ignorance may have been due to deficiencies in her training, but it may also have been due in part to her value of helping the disadvantaged.
This value may have contributed to her too quickly viewing Immel as a victim, rather than taking the time to consider alternative hypotheses. Unfortunately, it became clear that Immel’s accusations were untrue, in part or in whole, and were motivated by a desire for retribution for other perceived wrongdoings and/or at securing a financial settlement.
A third factor that may have contributed to Cruz’s situation was her desire to help. Such feelings may have led her to trust her client and not question her motives. Her desire may have become a more serious vulnerability when Immel did not improve and in fact made what appeared to be unreasonable demands on her.
Finally, when Knox called her, Cruz found that she had the opportunity to help Immel in an unanticipated way that could bring her client great benefit. Unfortunately, many dimensions of Cruz’s resilience became vulnerabilities. They caused her to lose control of the treatment process, and became obstacles to the necessary self-examination that could have helped her avoid such an unpleasant outcome.
In our view, the profession has focused too much on logical and quasi-legal reasoning to analyze the development of transgressions and too little on personal resilience and the ability to address vulnerabilities that form the antecedents of sound preventive ethical practice. The four conceptual dimensions we introduced here represent only a portion of the multiple factors that can either foster optimal clinical practice or lead us down a road that is paved with good intentions but ends in ethical disaster. We hope they raise questions that will help to prevent ethical lapses and lead to optimal practice. To that end, we offer the following recommendations:
Ongoing awareness. Students should be made aware of the fluid nature of ethical vulnerabilities and resilience, the importance of prevention, and the role of the DOVE factors during their course work and practicum training; they should be encouraged to address them on a regular basis with peers, supervisors and consultants. It is best that students become accustomed to doing so on a regular basis as a part of their professional responsibilities. However, they cannot be expected to do this on their own. Such behavior should routinely be taught and modeled by faculty and trainers.
Psychologists are people. Emotions and situational factors exert the same powerful influence on the behavior of psychologists as they do on people in general. Professionals striving for ethical excellence accordingly need to pay particular attention to their emotional states and to social factors that may influence them. Ongoing awareness of these factors and the development and maintenance of strategies to cope effectively with emotions and situational factors are thus crucial.
The quest for excellence. Faculty and supervisors will ideally develop and employ policies that encourage students, not simply to meet the minimum standards of care, but to go beyond them and strive for their highest ethical goals (Handelsman et al., 2002, 2009). A psychologist may use standard therapeutic approaches and obey all applicable ethical standards, but fail to see the possibility of, and implement, an innovative psychotherapeutic approach that represents an advance over usual practice. Although achieving excellence is by no means easy, especially given the varied ethical perspectives that exist (Tjeltveit, 1999, 2006), careful ethical reflection can foster better working relationships with students, colleagues and clients, all of whom can assist us in identifying issues and challenge what may be departures from sound practice (e.g., Gottlieb, 1997; Handelsman, 2001; Koocher & Keith–Spiegel, 2008; Norcross, 2000; Pope & Vasquez, 2007). Such increased self-awareness may prevent problems from developing and thus reduce the risk of ethical infractions.
Balance and self-care. Reducing vulnerabilities and enhancing resilience requires a proper balance of care for clients and for oneself. Students, educators and other psychologists thus need to attend to relevant research and engage in behaviors associated with self-care, including physical exercise, selfreflection, spirituality (for some people), friendship, awareness of one’s own values, quality leisure time, control over work environment, and the enhancement of emotional competence (Baker, 2003; Norcross, 2000; Norcross & Guy, 2007; Pope & Vasquez, 2007; P.L. Smith & Moss, 2009; Weiss, 2004). Engaging in good self-care that involves those components is challenging, but both achievable and crucial.
Personal values and ethics. Little is taught about personal values in ethics education, much less how they may create resilience or vulnerabilities for us. In part, this may be due to our profession’s value of objectivity, the need to cover required material in the curriculum and realistic time constraints. Such conflicts are understandable, but when we consider the potential for self-deception that can be created by our desire, opportunity, values and education, further examination of the full range of the ethical dimensions of psychotherapy is vital.
Self-assessment. Psychologists, scholars and trainers should assess themselves throughout their professional careers as a component of general risk management. It may be especially important to reevaluate one’s vulnerabilities and resilience more frequently and intensively during times of stress, such as divorce, illness or major loss. Doing so with a trusted colleague makes the self-assessment process all the more valuable.
Early intervention. When vulnerabilities increase too much, some form of intervention may be helpful, or even essential. Psychologists need to be open to turning to psychotherapy, structured supervision or consultation with colleagues, whether formal or informal. What is crucial is that psychologists work with someone who can help them honestly face themselves and their vulnerabilities and can help them reduce vulnerabilities and rebuild resilience.
Prevention. More generally, when vulnerabilities are identified, psychologists need to take whatever prompt corrective action is necessary to reduce risks for themselves and their clients. Strengths need to be nurtured as well so that they can be drawn on when facing difficult clinical, personal or ethical challenges.
This article is based on “Avoiding the Road to Ethical Disaster: Overcoming Vulnerabilities and Developing Resilience,” from the APA journal Psychotherapy Theory, Research, Practice, Training (Vol. 41, No. 1).
Alan C. Tjeltveit, PhD, is a professor of psychology at Muhlenberg College. Michael C. Gottlieb, PhD, practices forensic and family psychology in Dallas, Texas, and is a clinical professor at the University of Texas Southwestern Medical Center, where he teaches professional ethics.