Ethically Speaking

Each day, the APA Ethics Office receives many calls from members asking for consultations on an ethics issues. I emphasize "ethics" because inevitably other kinds of issues arise in a situation challenging enough for an APA member to take time out of a busy schedule and call the Ethics Office. These include legal, clinical and risk-management questions which then become part of the consultation.

The first step in responding to a request for consultation is therefore to differentiate what kinds of issues the situation raises. A "four-bin" approach can help this process of differentiation. The four bins are: legal, clinical, ethical and risk management. Although the bins are closely related, they are not the same. Clarity regarding what kind of question belongs in which bin can be very helpful in resolving a dilemma, at least enough to allow a psychologist to move forward. The consultation begins, therefore, with identifying what questions arise in each of the bins.

In the legal bin are questions that relate to federal laws (including regulations) and the laws and regulations of the particular jurisdiction, whether it is a state, province or territory. In the clinical bin are questions that relate to the best treatment or assessment interests of the individual with whom the psychologist is working. In the ethical bin are questions that relate to the APA Ethics Code and the right thing to do. In the risk management bin are questions that relate to how a particular course of action increases or decreases the psychologist's exposure to liability. A good analogy for the bins is the four wheels on a car. Each of the wheels must be in good working order for the car to proceed successfully.

Proceeding successfully will depend on the wheels being well coordinated with one another. Thus, following the process of differentiating the four bins — legal, clinical, ethical and risk management — is a process of integrating the bins to form a coherent response to the dilemma. It is important to emphasize that the process of integration depends on a clear and careful differentiation. When questions are not clearly differentiated from one another, it can be difficult to identify what kinds of questions need to be answered to resolve the dilemma.

It is interesting to note how often workshops for psychologists make little distinction among legal, clinical, ethical and risk management issues, as if they are interchangeable. A good resolution to the dilemma often rests upon clearly identifying what different kinds of questions are involved. These distinctions are enormously important, in part because the issues call for different kinds of expertise. Legal questions may require an attorney with expertise in a jurisdiction's mental health laws. Clinical questions may require expertise from a psychologist in a particular practice or assessment area. Ethical questions may be answered by the APA Ethics Office, and risk management questions are usually best answered by the psychologist's insurance carrier. For this reason, calls to the APA Ethics Office often involve referring the psychologist to other sources of expertise. Although both the director and deputy director of the APA Ethics Office are attorneys as well as psychologists, no attorney could be familiar with the mental health laws and regulations of every jurisdiction where APA members practice, any more than a psychologist could be familiar with — much less have expertise in — every clinical disorder.

Differentiation and integration are central to the four-bin approach. A comprehensive analysis will entail examining each bin to determine what questions are in the bin, how questions in a particular bin relate to questions in the other three bins, whether the situation requires that a certain bin receive priority over the other bins, how possible tensions among the bins may be resolved, and where the appropriate expertise can be found to answer questions outside the consultant's expertise.

An example illustrates the four-bin approach. A client tells a psychologist about abuse that occurred in the distant past when the client was a minor. Wondering whether this information requires a child abuse report, the psychologist contacts the Ethics Office. The consultation begins in the legal bin to determine whether the information triggers a legal duty to report in the jurisdiction; the Ethics Office may refer the psychologist to a mental health law expert to help answer this question. If the answer is yes, Ethical Standard 4.05, disclosures, allows the disclosure because there is a legal mandate to file a report. From the legal and ethical bins, the consultation moves to the clinical bin: the psychologist will consider the most clinically appropriate manner of making the report, for example, whether it is clinically advisable to involve the client in the reporting process even up to having the client make the report. If the legal, ethical and clinical bins have been thoughtfully addressed (and assuming that the informed consent process at the beginning of treatment was handled appropriately), there will be little to consider in the risk management bin. The psychologist's exposure to liability will be minimal.

This issue's "CE Corner", "Best practices for an online world" by Daniel Lannin and Norman Scott, PhD, provides another example that illustrates how the four-bin analysis may be helpful in thinking through dilemmas. Lannin and Scott examine psychologists' online activities. Were a psychologist to contact the Ethics Office for a consultation regarding whether a particular use of the Internet was appropriate, the questions Lannin and Scott pose could be framed in terms of the four bins. Their proposed first step, "First, psychologists must consider the risks and rewards that their online activity might have on their clients," represents the clinical bin. By giving this question priority of place, Lannin and Scott set the stage for a clinically driven ethics. Their next step, "the principle of integrity inspires psychologists to be upfront and honest in therapy about the potential role confusion that could occur with online interactions with clients" moves the consultation to the ethical bin by highlighting the centrality of informed consent. Lannin and Scott include the risk management bin in their analysis, "To limit the liability risk of using social media, practitioners may need to take certain precautions" such as contacting their liability insurance representatives. Finally, Lannin and Scott assign a role to the legal bin by identifying both federal and state law as important considerations in determining what information may appropriately be disclosed on the Internet. By explicitly identifying all four bins in their article, Lannin and Scott provide a comprehensive approach for psychologists who wish to have an online presence.

It is rare — although it does happen — that a consultation will raise questions in only one of the four bins. Far more often, two or more bins have questions for a psychologist to consider. A disciplined process of going through each bin, first to differentiate the different kinds of questions the consultation raises and then to integrate the bins with one another, represents a thoughtful and comprehensive four-bin analysis.

Dr. Steven Behnke, JD, PhD, MDiv, is the director of APA's Ethics Office.
‘Ethics Rounds' now available as CE
Previously published "Ethics Rounds" columns have been converted into CE programs. For details visit CE.

‘Ethics Rounds' now available as CE

Previously published "Ethics Rounds" columns have been converted into CE programs. For details visit CE.