Ethically Speaking

In my February and April columns, I offered a "four-bin" approach to consultation. This approach differentiates legal, clinical, ethical and risk management questions and then integrates the bins into a response that allows a psychologist to move forward. In this column, I elaborate on the implications of the four-bin approach for how psychologists talk about ethics.

The Ethical Principles of Psychologists and Code of Conduct (2002, amended 2010), APA's Ethics Code, draws an inextricable link between the ethical and clinical bins. Ethical standard 3.05, Multiple Relationships, illustrates this close relationship:

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.

Ethical standard 3.05 points psychologists initially in the direction of a clinical judgment: The psychologist must assess whether a multiple relationship interferes with the psychologist's objectivity, competence or effectiveness, or otherwise risks exploitation or harm. Assessing whether there is a reasonable expectation of impairment in the psychologist's work as a psychologist entails thoughtful consideration, and perhaps a consultation, regarding the client's clinical challenges, strengths and vulnerabilities. This assessment may likewise entail examining the nature, intensity and duration of the service and the likely impact the multiple relationship would have on the psychologist's ability to remain in a professional role vis-à-vis the client — the countertransference implications. When the psychologist determines that the likelihood of harm is greater than the likelihood of benefit, the psychologist refrains from entering into the multiple relationship for ethical reasons. In this sense, we have adopted and embrace a clinically driven ethics.

Preserving the distinction between clinical discourse and ethical discourse is important despite the inextricable connection between the two. When a thoughtful boundary between these discourses is not respected, each discourse becomes much more difficult. The problem is especially acute when discussing clients who face challenges on Axis II.

A fruitful and interesting venue to explore these issues is at ethics workshops where psychologists are asked to consider a complex clinical vignette and offer various options for the treating psychologist to pursue. The discussion may explore the clinical risks and benefits of each course of action. Once this discussion has plumbed the pros and cons of each option from a clinical perspective, the question is posed: what percentage of workshop attendees would favor each particular treatment choice?

Two things inevitably emerge at this point in the discussion. First, psychologists may view more than one option as clinically appropriate and may differ as to what they would do in the clinical moment under discussion. Second, the group will identify options that all agree would not be clinically appropriate and that they would advise a colleague to avoid. These observations lead to important conclusions: Faced with a clinical dilemma, reasonable and competent psychologists may differ on what is the clinically appropriate course of action. Also, reasonable and competent psychologists can reject interventions as not in the realm of reasonable disagreement among competent psychologists. These conclusions have important implications for how we talk about ethics.

We need to take care using the word "ethics" in situations where competent and reasonable psychologists may differ over clinical decision-making. Care and attention are important because the mere mention of "ethics" invokes a different kind of discourse. The statement, "I disagree with you clinically," is not the same as, "I believe you may have behaved unethically." When the two are equated, the word "ethics," especially when used by psychologists in positions of greater authority, may serve as an exercise in power to quash what is in reality a clinical disagreement. The psychologist (or trainee) on the receiving end of such a statement is now in the position of defending his or her ethics, which is quite different — and much more fraught — than debating the most appropriate clinical decision. Invoking ethics can be a show stopper, because it abruptly shifts the terms of the discourse.

A worthwhile exercise in clinical case presentations is to pause whenever the word "ethics" is used and consider how and why ethics has been introduced into the discussion at a particular moment. Ideally, ethics is invoked as an invitation to explore how our core values are being expressed through a psychologist's work. Often, however, ethics is used in a more complex way, to express differences of opinion about clinical technique or theory, or to raise questions about a psychologist's competence. Although there are times when it is entirely appropriate to raise questions regarding the ethics of a treatment, it is also important to be mindful of how a clinical discussion differs from a discussion about ethics, and the possible effects of injecting ethics into a clinical discussion without having considered carefully how ethics fits in. Many psychologists have been present at case presentations or conferences where accusations of "This psychologist was unethical," are surrogates for "I would not have done it this way," or "I disagree with that psychologist's approach."

After discussing the clinical implications of a vignette at a workshop, I often ask the group to delineate areas where they believe reasonable and competent psychologists may differ, and where we would expect all, or nearly all, psychologists to concur. The more the group moves from an area of reasonable difference to concurrence, the closer we are to a discussion of ethics, either because the group believes that all competent psychologists would support a particular course of action, or because the group believes all competent psychologists would reject a particular course. The area between the two tails is where invoking ethics is particularly thorny because that is the area where reasonable differences of opinion occur.

The risk management bin has a role as well because ethics is sometimes confused with exposure to liability. Although ethics and risk management are related, they are not the same. In the four-bin approach, differentiation precedes integration. A psychologist may decide, for ethical reasons, to embark upon an intervention that will increase his or her exposure to liability. Doing the right thing and getting into trouble are correlated but not perfectly so, and thoughtful psychologists will preserve this important distinction.

The four-bin approach has implications for how we talk about ethics. The words we choose affect how easily and well we communicate. "Ethics" is a particularly powerful example because of the connotations this word holds for morality and character. The four-bin approach counsels psychologists to look carefully in each bin, and to think about which bin we are gazing into at a particular moment and why.