Issues and Insights
A Model of Ethicol Decision Making
From o Multicultural Perspective
Marsha Wiggins Frame and Carmen Braun Williams
Because shifts in the world's ethnic and racial demographics mean
that the majority of the world's population is non-Whtte (M. D'Andreo
8c R Arredondo, 1997). it is imperative that counselors develop a means
for working ethically with a diverse clienteie. in this articie, the authors argue that the current Code of Ethics and Standards of Practice of the American Counseling Association (1995) does not
adequately address the demands of working with non-White, nonWestern clients. Using a universalist phiiosophy, an ethic of care (C.
Gilligan, 1982; R.M.Kidder, 1995; J. G. Ponterotto & J. M. Casas, 1991),
the context ot power (M. Hiil, K, Glaser, & J. Harden, 1995), and the
process of acculturation, the authors offer a model for ethical decision making from a multicultural perspective.
T
ke ethical practice of counseling and psychotherapy requires that practitioners have knowledge about and sensitivity to clients' cultural background and social context. Counselors are bound by professional and
ethical obligations to "respect the dignity and promote the welfare of clients"
(American Counseling Association [ACA], 1995, Section A.I.a.) and to practice competently. However, in order to uphold these standards in a multicultural
world, counselors may well be caught in difficult double binds. For example,
on one hand, the ACA (1995) Code of Ethics and Standards of Practice discour-
ages dual relationships such as engaging in social activities with clients (Section
A.6.a.), but on the other hand, the same activities may be precisely the vehicles
for promoting client welfare. Such a paradox creates a significant ethical dilemma for mental health practitioners of all disciplines.
The purpose of this article is to suggest that the current ACA ethics code
does not adequately address the demands of working with non-White, nonWestern clients. By using a case involving a dual relationship, we showcase
a practitioner's dilemma when caught between one interpretation of the ethics code and the implicit demands of a multicultural context. It is also the purpose of this article to offer a model of multicultural decision making based on
a universalist philosophy, an ethic of care (Gilligan, 1982; Kidder, 1995;
Marsha Wiggins Frame, Departme}it of Counseling Psychology and Counselor Education, University of Colorado at Denver and Health Sciences Center. Carmen Braun Williams, Diversity Initiative, Office of the Vice President for Academic Affairs and Research, University of Colorado System.
Correspondence concerning this article should be addressed to Marsha Wiggins Frame, Campus Box
106, PO Box U3364, UCDHSC, Denver, CO 80217-3364 (e-mail: marsha.frame@cudenver.edu).
Counseling and Values " April 2005 " Volume 49
]66
Ponterotto & Casas, 1991), the context of power (Hill, Glaser, & Harden, 1995),
and the process of acculturation. Following is a case study that illuminates
the double bind practitioners may find themselves in as they are forced to choose
betu'een standards-based ethical practice and the welfare of the client of color.
Case Illustration
Maria Elena Gutierrez, a 19-year-old Mexican American woman, was referred
to counseling by her college academic adviser because of her ambivalence about
continuing in college. In the first session, Maria Elena was withdrawn; made
little eye contact with Barbara, the European American counselor; and spoke in
hushed tones. When Barbara inquired about her family background, Maria Elena
reported she was a second-generation Latina and that her family emigrated from
Mexico when she was 7 years old. She told the counselor that she has two younger
brothers, Juan, 15, and Pedro, 12, and a younger sister, Lucia, 8. Although Maria
Elena attended two more sessions of counseling, she did not actively participate, and Barbara was unsure of how to proceed. Finally, Barbara asked, "What
can I do to make counseling more helpful to you?" Maria Elena responded.
You could come to my home for a meal and meet my family. In fact, why don't you
come on Sunday? It is my little sister's First Communion and there will be a big family celebration after Mass. All of our relatives v^'ill be there . . . Maybe if my father met
you, he wouldn't object so much to my coming to counseling. He thinks you are putting
bad thoughts in my head.
In response to this case, some counselors in a peer supervision group began
discussing various approaches to dealing with the ethical dilemma of avoiding a dual relationship while at the same time being sensitive to the cultural
demands of working with Maria Elena. They discovered that group members
held some divergent ethical perspectives based on differing philosophical
assumptions that buttress ethical theory.
A Voriety of Ethical Perspectives
One approach to ethics is known as utilitarianism. Individuals who hold
this perspective believe that a behavioral code is morally right if the consequences of adopting it result in the greatest good for the greatest number of
people (Hinman, 2001b). The emphasis here is on consequences, not intentions. Ethical relativism is the view that moral standards are grounded only
in social custom (Fiesed, 2001). Those who subscribe to this position acknowledge the fact of moral diversity and believe that people should not pass judgment on practices in other cultures when they do not understand them. Indeed,
proponents of this view claim that each culture is a right unto itself {Hinman,
2001a). Absolutist, or rule-based ethics, is based in the philosophy of
Immanuel Kant. In opposition to utilitarianism, absolutists hold that the
morality of an act must not be judged by its consequences but by its motivation. Thus, the underlying premise of absolutist-based ethics is that an
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individual's actions can only be judged as ethical if he or she is basing those
actions on a principle that he or she would accept as universal and applicable to all (Kierstead & Wagner, 1993). Universalism is a stance that honors diversity, but lifts up universal moral principles that are common to most
cultures. The caring (Kidder, 1995) and reciprocal empathy (Ivey, 1987) perspective involves being able to enter another's world cognizant of one's own
cultural background and of one's impact on another individual based on
power and privilege. It includes knowledge of another's culture and presupposes a relationship in which difference is honored and values are not
imposed on the other individual. Following is an example of how each of
these positions was reflected in the peer supervision group.
Utilitarianism
Mark, a 35-year-old-European American counselor, believed that Barbara should
do whatever would result in the greatest good for the greatest number of people.
He argued that making Maria Elena's father happy might not be in the best
interest of everyone involved, including the other counselors and clients in the
center. Mark's approach to ethics is known as utilitarianism or "ends-based
thinking" (Kidder, 1995, p. 24). This philosophical approach is also called
"consequentialism," because at its heart is the principle of looking at projected
outcomes as a means of determining ethical behavior (Kierstead & Wagner, 1993;
Kultgen, 1988). Monica, a 42-year-old African American counselor disagreed
with Mark, saying that she did not believe that Maria Elena should be deprived
of a more familiar relationship with her coimselor so that some "greater good"
might be served. She reminded the group that it is usually the dominant culture
that determines, based on its values, what the greatest good is.
Ethical Relativism
Eruique, a 32-year-old Mexican American counselor, suggested that Barbara
should focus primarily on Maria Elena's culture and the behavioral expectations that go along with it. He claimed that Maria Elena would best be
served if Barbara visited her client's home for the Sunday meal as a means
of honoring her tradition and cementing the therapeutic relationship. He
believed that the issue of a dual relationship was not so problematic when
working with a client from a non-White ethnic background. Enrique took a
position of ethical relativism, in which each reference group is allowed its
own criteria for ethical behavior (Bayles, 1981). Thus, two beliefs or sets of
norms that contradict each other can both be true. Moreover, ethical behavior is judged only on the basis of the group's or culture's standards, not those
of other groups or cultures (Pedersen, 1995). This ethical perspective results
in allowing each culture or group to generate its own ethical standards. For
example, ethical standards consistent with cultural norms may be generated for working with Latinos and another set of culturally congruent standards developed for working with African Americans. These standards could
Counseling and Values • April 2005 •Volume 49
167
differ from one another despite being appropriate for a particular ethnic group.
Mark said he thought Juan's idea was a possibility, but that it did not fully
address the fact that both the counselors and the clients live in a multicultural,
not a monocultural, world.
Absolutist, or Rule-Based, Thinking
Sarah, a 57-year-old European American counselor and supervisor, told Barbara
that she thought keeping to the ethical standard of avoiding dual relationships
(ACA, 1995, A.6.a.) was what was required in this case. "You can't just make
exceptions whenever you want to because you think a particular client has special needs. That's why we have ethical standards—to keep counselors from behavLng inappropriately." Sarah's perspective was one of rule-based, or absolutist,
thinking. Referred to by Kant as the "categorical imperative" {as cited hi Kidder,
1995), in this approach to be ethical is to act in such a way that one's behavior
becomes a universal standard that others ought to follow. The absolutist applies
the same rules across cultures with "the same fixed and unchanging perspective" (Pedersen, 1995, p. 35). Again, Monica raised her concem that by simply
accepting the ethical standards at face value, cultural differences would be ignored. She said she was worried that such an approach would mean that White,
Westem persons would continue to determine the criteria by which all behavior
is evaluated. Monica said that with all respect to her supervisor and her profession's
ethics, she felt that not to struggle with cultural differences would be especially
damaging in a pluralist society. She said she thought being so rule bound was
dangerous because the approach used a shigle standard of ethical judgment.
Universalism
Marie, a 45-year-old European American counselor, said she thought "there
must be a way to deal with this dilemma from a 'both/and' approach to ethics." She said that she thought it was important to affirm cultural differences
while emphasizing commonalities that link cultures. She claimed that there
were some universal moral principles that could guide Barbara, but that her
actions might be different in different circumstances because of divergent
cultural values. Pedersen (1995) explained that universalists "combine the
search for culture-specific manifestations of difference with a search for fundamental similarities that link each cultural context with every other context"
(p. 36). Ponterotto and Casas (1991), drawing on Pedersen's notion of universalism, outlined four such universal principles that influence ethical theory
and practice. The first is altruism, which helps counselors focus on both psychosocial problems and psychocultural strengths of various cultural groups.
Altruism also concentrates on real-world problems. Second, responsibility
includes the coconstruction of problems and solutions, as well as reciprocal
involvement across cultural groups. Justice requires refraining from exploitation and ensuring faimess in counseling relationships. Caring calls for "helping
culturally different clients regardless of the consequences" {Pedersen, 1995,
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p. 37). Marie concluded that using these principles could enable Barbara to
have dinner with Maria Elena's family to build rapport and to meet her client's
needs, and that by doing so Barbara would not be jeopardizing Maria Elena's
welfare nor exploiting her.
Caring and Reciprocal Empathy
Rachel, a 29-year-old Jewish American counselor (who had done significant processing of her own ethnic, cultural, and religious background and the impact of
her perspective on others), engaged Barbara in a dialogue about Barbara's perception of herself as a European American woman and her impact on Maria Elena,
a Mexican American. She encouraged Barbara to begin exploring Maria Elena's
world as a Mexican American woman and what her interactions are like with a
European American woman who has a position of power and privilege. Rachel
asked Barbara, "How much have you considered the vast differences between
your world and Maria Elena's? What do you think are the implications of these
differences for your relationship with Maria Elena and her family?"
Rachel's view mirrors Gilligan's (1982) care-based, or relational, ethics. The
Stone Center relational model {Jordan, 1997) further reflects Rachel's emphasis on the impact of and need for sensitivity to cultural differences between
therapist and client. Specifically, the Stone Center model emphasizes the healing
power of cross-cultural therapeutic relationships in which therapists are able
to operate from a place of understanding about the psychological effects of
racism; to transcend hierarchical, racially based social arrangements; and to
connect In a profoundly caring manner with clients {Jordan, 1997). Essentially,
care-based ethics revolves around empathy for the client (Ivey, 1987). Ivey used
the word empathy to mean "not only awareness and understanding of the unique
individual... but also the broad array of cultural/historical factors that may
underlie individual experiencing" (Ivey, 1987, p. 199). Defined this way, empathy involves counselors' self-examination regarding the impact of their background and possible privilege on iheir understanding of and potential for
understanding clients who are ethnically or culturally different from themselves. Such empathy also includes counselors' knowledge of clients' cultural
context. It requires appreciation of different cultural norms and a refusal to
impose one's values on clients. Rachel said she thought her approach invited
counselors and clients to enter into each other's worlds and perspectives at a
deep and honest level.
A Model of Culturally Sensitive Ethical Decision Making
To help counselors such as Barbara make ethical choices that intentionally
include values and worldviews of a diverse clientele and to counteract the
constraints inherent in the current ACA (1995) Code of Ethics and Standards of
Practice, we propose a model of ethical decision making from a multicultural perspective (see Table 1). Our model is grounded in universalist philosophy that
recogruzes cultural differences but emphasizes common principles such as alCounseling and Values • April 2005 "Volume 49
169
TABLE 1
Multicultural Ethical Decision-Making Model
Ethical Decision-Making Step
Identify and define an ethical
dilemma
Explore the context of power
Assess acculturation and racial
identity development
Seek consultation
Generate alternative solutions
Select a course of action
Evaluate the decision
Components of the Process:
Questions to Ask Oneseif
What is the right vs. right issue? What are the conflicting, incompatible courses of action? What is the crux
of the dilemma? Who is involved? What are the stakes?
What are my values? What are those of my client, my
supervisor, and others involved? What are the cultural
and historical factors that are at play? How do the
principles of altrusim, responsibility, justice, and caring apply? How could these principles issue in different behaviors based on cultural diversity? What insights
does my client have regarding the dilemma? How is
my client affected by the various aspects of the problem? How do I feel about the problem? What does my
intuition fell me to do?
Where am I located in the power structures of my culture and community? Where is my client located? How
could the use of power affect my decision? How could
a power differential between myself and my client affect the welfare of my client? How can we share lenses
to come to an ethical and just decision?
Where is my client in the process of acculturation? Where
am I? How do these levels of acculturation affect my
ethical thinking and acting? How far do I need to go to
meet my client's needs? What about my needs?
Who do I know that is a culturally competent counselor? What are the values, beliefs, meanings, cultural
traditions of my consultant? How do these shape my
consultant's perspective? What is my consultant's
position in the context of power?
How does each of the options available to me fare when
examined on the basis of the model's criteria above?
What does my intuition tell me to do? What are my fears
or misgivings about each option?
What role has my client played in the decision-making
process? What contributions has my client made?
What are my motives in selecting this course of action? What is my rationale? What is the critique ot my
decision? Have I documented my plan of action?
How does this choice fit with the ethical code? How were
my client's cultural values and experiences taken into
consideration? How were my own values atfirmed or
challenged? How was power used in the action? How
would others appraise the action? What did I learn from
the struggle to resolve this ethical dilemma?
truism, responsibility, justice, and caring {Ponterotto & Casas, 1991) that link
cultures. The model also draws on Ivey's (1987) notion of empathy that invites
reciprocal cultural understanding between client and counselor, such that each
grasps the historical/cultural factors that contribute to the other's subjective experience. From feminist models of ethical decision making (Hill et al., 1995), we
borrow the concepts of one's position in the culture vis-a-vis power, as well as
"person of the therapist" factors (Hill et al, 1995, p. 24) such as feeling and intu-
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ition. Added to the mix is an assessment of both the client's and counselor's
woridview and level of acculturation from traditional ethnic to fully acculturated (Paniagua, 1994; Santiago-Rivera, 1995; Trevino, 1996; see Figure 1).
Identifying and Defining Ethical Dilemmas
The first step in applying the model of ethical decision making is to recognize
and identify an ethical dilemma (see Figure 1). Kidder (1995) correctly pointed
out that ethical dilemmas lie not so much in making choices hetween right
and wrong as they do in choosing between right and right. Indeed, Kitchener
(1984) defined an ethical dilemma as "a problem for which no course of action seems satisfactory... the dilemma exists because there are good, but contradictory ethical reasons to take conflicting and incompatible courses of
action" (p. 43). A model of ethical decision making from a multicultural perspective is essential precisely because of the necessity of responding to "right
versus right" dilemmas.
In this step, it is critical to examine the factors that constitute the problem.
More specifically, this step involves (a) clearly understanding the crux of
the dilemma; (b) determining who is involved in the dilemma and what the
stakes are; (c) clarifying the values of client, counselor, supervisor, and others involved in the dilemma; (d) considering the cultural and historical factors that are at play in the dilemma; (e) reviewing the existing ethical code
for directives; (f) applying the principles of altruism, responsibility, justice,
and caring; (g) involving the client in reciprocal empathy and inviting his
or her insights; and (h) reflecting on one's own feelings and intuition and
COUNSELING PROCESS
Ethical Perspectives
and Decisions
Assessment of Worldview
and Identity
Traditional
ethnic ^
cullure ^m
culture
Traditional
ethnic ^
culture ^m
culture
FIGURE 1
The Ethical Decision-Making Process From a Multicultural Perspective
Counseling and Values • April 2005 "Volume 49
171
their role in the dilemma. After these aspects of the problem have been considered seriously, the context of power is considered.
In the case of Maria Elena, this process would involve Barbara's recognition that a conflict exists between the prevailing interpretation of the ethical
code and Maria Elena's request for her to attend her sister's First Communion. It requires that Barbara examine the norms and behavior patterns of Maria
Elena's culture and determine if they are consistent with her family's need to
cormect with Barbara before trusting her to work with Maria Elena's emotional
issues. Barbara may choose to engage Maria Elena in a conversation about
the meaning of the invitation and the dilemma that she (Barbara) is facing.
Moreover, this step involves Barbara's sense of intuition about her intent related to attending the Eirst Communion: It is important that Barbara acknowledge that she is neither exploiting Maria Elena's hospitality nor violating her
boundaries, but rather attending the First Communion is to honor her client
in the client's cultural and family context.
Acknowledging the Context of Power and the
Reality of White Privilege
Hill et al. (1995) argued that both the therapist's position and the client's position
in culture, relative to the power that each has, affect how the ethical code is applied
and thus are central to ethical decision making (see Figure 1). For example, what
constitutes harm may be seen quite differently through the eyes of a poor Latina
woman than through the eyes of an upper-middle-class White man. What is needed
is a sharing of lenses when applying ethical principles to specific dilemmas.
The social context of power not only affects ethical decision making but also
shapes the nature of the therapeutic relationship and course of therapy. For
example. Helms and Cook (1999) asserted that "the person with the most
powerful social role (e.g., the supervisor) serves as a definer of the interaction" (p. 288). Their racial identity interaction model examines implications
of differences in power and racial identity for the therapy process. The impact
of therapists' racial socialization on case conceptualization, their predisposition to explore or avoid racial and cultural issues, and their understanding
of what constitutes culturally competent practice are critical ethical issues
requiring systematic attention (Helms & Cook, 1999).
Related to the context of power is the issue of White privilege. Writers (Daniels
& D'Andrea, 1996; Ivey, Ivey, D'Andrea, & Daniels, 1997) in the field of
multicultural counseling have suggested that one of the reasons counselors
have failed to incorporate culturally diverse views and practices is that many
counselors and counselor educators are han:ipered by their own Eurocentric
and monocultural positions. They underestimate the reality of White privilege
and power that have characterized the counseling profession and that have
resulted in unintentional racism (Daniels & D'Andrea, 1996; Ivey et al., 1997;
Ridley, 1995). Even the term multicultural is often used to mean only cultures
other than those in the mainstream (Ibrahim, 1996). Thus, ethnocentricism
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has contributed to counselors' impaired vision when it con:ies to n:\ultiple
perspectives, especially vis-a-vis the ethical standards of the profession. What
is needed are new models of ethical decision making that honor the ethnic,
racial, and social context of all clients.
Assessing Acculturation and Racial Identity Development
The next step in the ethical decision-making process is to assess the level of the
client's acculturation and racial identity development (see Figure 1). Several assessment instruments have been developed to determine levels of racial identity
development and acculturation for African Americans (Helms, 1990), Latinos
(Cuellar, Harris, & Jasso, 1980), Asian Americans {Suinn, Rickard-Figueroa, Lew,
& Vigil, 1987), and American Indians (Hoffman, Dana, & Bolton, 1985). However, because the time necessary to administer these instruments may preclude
their use, counselors may choose instead to conduct a brief assessment of three
key acculturation variables: generation, preferred language, and social interaction with members of one's own racial/ethnic group compared with interactions
with members of other groups (Paniagua, 1994). Levels of acculturation are clues
about the degree to which the values and assumptions inherent in the ethical
codes match the client's cultural values, but they may not give a comprehensive
picture of the client's interactions and coping mechanisms vis-a-vis the dominant culture. In general, the more acculturated the client and the counselor, the
less likely their cultural values will diverge from those of the dominant culture.
Working with more traditional clients who are immersed in their indigenous culture
will require counselors to move beyond rule-based thir\king and to seek creative
solutions that honor cultural diversity and avoid exploitation.
Seeking Consultation
In order to minimize bias and increase self-awareness, seeking consultation with
culturally competent colleagues and supervisors is critical (see Figure 1). Recommendatior\s of culturally competent professionals may be obtained by contacting
national and state ethnic minority counseling and psychological organizatior\s,
state licensing boards, and local clirucal agencies that provide mental health services to culturally diverse clients. Part of the consultation process involves engaging the consultant in a self-analysis of cultural and personal values, beliefs,
experiences, and meanings that contribute to his or her perspective on the dilemirw.
The consultant's position in the context of power also needs to be considered.
Considering Multiple Possibilities
A major barrier to incorporating a variety of worldviews into ethical counseling practice has been not only the Western slant of the Code of Ethics and Standards of Practice (ACA, 1995) but also the tendency of practitioners to interpret
these guidelines in unidimensional (rule-based) ways. The assumption is that
Counseling and Values • April 2005 •Volume 49
173
concepts such as freedom and responsibility result in particular behaviors
that can be judged as ethical or unethical. This objective view of the ethical
code constricts the range of behaviors that can be considered appropriate and
results in the imposition of the dominant culture's interpretation on the Code
of Ethics and Standards of Practice.
In response to the "one right way" approach, the postmodern paradigm can
be applied to the ethics of counseling practice. This application means acknowledging the subjective nature of one's assumptions about the world and
focusing on "the interpretive nature of hun:ian behavior, meanings, and identities" (Anderson, 1994, p. 146). A postmodern approach means abandoning
assumptions of objectivity, empirical knowledge, and universal truth. Thus,
the one (dominant. Western) perspective must give way to the many
(multicultural) perspectives (see Figure 1).
Generating Alternative Solutions
When counselors are able to adopt a stance that welcomes multiple perspectives
and when data from the previous steps have been gathered, the counselor then
develops a variety of possible solutions to the dilemma (see Figure 1). It is critical
to evaluate each possibility in light of the model's criteria of universal principles,
an ethic of caring and reciprocal empathy, context of power, and level of acculturation. For example, in Maria Elena's case, the counselor, in consultation with
colleagues and consultants, could list the various courses of action stemming
from different ethical frameworks. She could consider the extent to which each
course of action respects Maria's Elena's culture and closely examine each option for potential cultural biases or power inequities. Maria Elena's counselor
then reflects on her emotional reaction to the various options generated.
Selecting a Course of Action
The next step in ethical decision making is choosing a solution that is bom of a
partnership with the client, rigorous self-examination, and a well-delineated
rationale. Specifically, counselors should clearly define relevant ethnic-cultural
norms and behavior and identify ethical choices emanating from these norms.
Next, counselors should carefully review the ethics code to determine whether
culturally congruent solutions are, in fact, inconsistent with the code. Culturally responsive solutions are not always in conflict with ethics codes; rather,
misinterpretations of ethical principles may cause counselors to unnecessarily eliminate viable alternatives that uphold cultural values. If, however, the
solution seems to be inconsistent with ethics codes, counselors are advised to
discuss their options with a culturally competent consultant to determine
whether their actions, despite being in conflict with a specific section of the
code, uphold the overarching principle of client welfare. If the issue of client
welfare is unclear, the counselor should reevaluate his or her options. If client
welfare would be advanced, the counselor then implements the decision, documents the action, and supports it by addressing the criteria in the decision-making
model (see Figure 1).
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Evaluating the Action
After making an ethics decision, the counselor reviews the action and asks
important questions: How does the action fit with the existing ethics code?
Does it consider cultural values and experience of the client? How have one's
own values been affirmed or challenged? How was power used in the action?
How would others appraise the action? and What did I leam from the struggle
with an ethical dilemma? (See Figure 1.)
Application of the Model to the Case
In analyzing the case of Maria Elena, one is struck by the ethical dilemma:
Not attending the First Communion celebration in the client's home is right
from the perspective of the ACA (1995) Code of Ethics and Standards of Practice,
which urges counselors to avoid dual relationships that could "impair professional judgment or increase risk of harm to clients" (Section A.6.a.). Attending the First Communion celebration is right, too, in that it serves the welfare
of the client (ACA, 1995, Section A.I), who may terminate counseling if Barbara is not connected to Maria Elena's family in a personal way. There is just
as much risk of harming the client by failing to honor her culture and family
expectations as there is of potential exploitation by moving outside conventional professional boundaries.
Identifying and Defining the Dilemma
In attempting to define the problem, Barbara determined the crux of the dilemma was a conflict between two mandates in the ethical code: client welfare versus dual relationships. The individuals involved in the dilemma
included Maria Elena; Barbara; Maria Elena's immediate and extended family; the counselor's supervisor, Sarah; and the peer supervision group. What
was at stake in this situation was whether or not Maria Elena would continue in counseling and whether or not Barbara could maintain professionalism while venturing into the more personal, family arena.
The cultural and historical factors involved the Mexican culture's value placed
on family and the role of the father in protecting his children's (especially daughters') welfare (Falicov, 1996). There was also the family's fear that Maria Elena
would reject her cultural values and family beliefs if she was exposed to an
authority figure (Barbara) who might try to indoctrinate her with Westem ideas.
When applying the principles of altruism to the dilemma, Barbara uncovered both the psychosocial problem of the family's isolation from American institutions and services and the psychocultural strength of family and social
support available to the client through the Hispanic community and the Roman Catholic Church. Because altruism's focus is on real-world problems,
Barbara determined that helping Maria Elena might require venturing into a
family in an imfamiliar culture in order to tackle her client's fears of academic
success. Responsibility, when applied to this case, suggested that Barbara could
leam something from Maria Elena's family and culture and that they could leam
Counseling and Values • April 2005 •Volume 49
175
something from Barbara. Barbara reasoned that justice would be served if she
could find a way to offer Maria Elena the counseling she needed without either
making her dependent or exploiting her. Barbara was clear that she was motivated by caring and had a personal investment in Maria Elena's well-being and
in providing assistance to her regardless of the consequences.
In the spirit of reciprocal empathy, Barbara explained the dilemma to Maria
Elena and asked for her comments. Maria Elena said,
You won't hurt me by coming to my house and meeting my family. We expect to have
important people visit us in our homes. You could hurt me more by not coming, because my family will think you are rude and that you do not care about us.
After reflecting on all aspects of the problem she had uncovered, Barbara asked
herself, "What am I feeling? What does my intuition tell me is the right thing to
do?" When discussing the case with her supervisor, Sarah, Barbara said,
1 know you see this dilemma differently than I do, but my gut tells me I need to go to
Maria Elena's home—that they have honored me with the invitation. But if I go, I
need to determine a way to maintain my objectivity so I can do my best work with
Maria Elena, if she chooses to continue in counseling.
Acknowledging the Context of Power and the
Reality of White Privilege
Barbara reflected on the context of power in which her client found herself. As a
young person of color from a poor Hispanic family, Maria Elena was moving into
mainstream American culture by attending college and pursuing an academic
degree. Although she had grown up in the United States and was familiar with
its values and customs, nevertheless she had experienced devaluation because
of her gender, ethnicity, and social class. Barbara could see how Maria Elena and
her family might interpret her refusal to attend the First Communion as a racist
act and how they could believe she thought they were not worth her time. Barbara was also aware of how being White allowed her the privilege of identifying
with the dominant culture's values, including education and independence. She
realized she would need to be careful not to impose these ideas on her client.
Assessing Acculturation and Racial Identity Development
When reviewing Maria Elena's case with her, she and Barbara determined
that she was indeed bicultural—that she felt at home in both Mexican and
White culture and could move freely between the two. However, based on
Maria Elena's comments, it was clear to Barbara that Maria Elena's parents
were very traditional. Although they had hved in the United States for 12
years, they resisted American ways, spoke Spanish in their home, and seldom ventured beyond their Hispanic community. Maria Elena understood
the professional distance that the ACA (1995) Code of Ethics and Standards of
Practice imposed on Barbara's practice, but she was also aware that without
her father's blessing she would not feel free to continue the counseling.
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Seeking Consultation
Barbara decided to seek consultation with Miguel, a Hispanic colleague.
Miguel was quick to point out that both Barbara and Maria Elena were in
double binds. Barbara was torn between the conflicting demands of the ACA
(1995) Code of Ethics and Maria Elena was caught between her family's values and her need for help resolving her problem. Miguel suggested that the
danger in Barbara's attending the First Communion and any other subsequent family functions had less to do with exploitation than with the risk of
imposing her values on Maria Elena. He said.
Just because you believe in higher education doesn't mean it's the right thing for Maria
Elena. Her father will see her as successful when she has a husband and children. She
needs the freedom to decide without interference from you.
Generating Alternative Solutions
Barbara realized that it was important for her to be open to multiple perspectives on the dilemma, taking seriously the views of her colleagues. She
had come to the point of determining a variety of options for herself in this
ethical dilemma. She came up with f^our possibilities: (a) She could refuse
to attend the Eirst Communion celebration because to do so would be to
violate the prohibition against dual relationships; (b) she could offer to
meet the family on another occasion in a neutral location; (c) she could
attend the Eirst Communion and meet Maria Elena's family; or (d) she could
refer Maria Elena to another counselor, perhaps one of Hispanic background, thus avoiding the issue altogether.
Barbara decided that refusing to attend the First Communion would be
interpreted as rejection by Maria Elena's family and would result in losing
Maria Elena as a client. Such a decision could also result in Maria Elena's
not getting the help she was seeking. Barbara determined that her sense of
caring and reciprocal empathy would not permit her to take this path. Barbara also decided that referring Maria Elena to another counselor, even a
Mexican American one, would be evading the issue. Although this course
of action might give her temporary relief, it did not guarantee that Maria
Elena's interests would be served. Barbara considered the middle-of-the-road
option of meeting Maria Elena's family at another time and another place,
but she rejected this option on the grounds that it did not alleviate the problem for either part. Maria Elena's family still expected a significant person
to meet them in their hon:\e on their terms, and meeting in a restaurant or
other public place did not eliminate the possibility of a dual relationship.
Selecting a Course of Action
Barbara decided that the most ethical thing to do was to accept Maria Elena's
invitation to the First Communion. She decided she would explain her ratio-
Counseling and Values • April 2005 • Volume 49
177
nale to her supervisor, document her decision-making process, and continue
to process her decision with her peer consultation group regarding the case.
Evaluating the Action
Barbara reviewed her decision and determined that although it might be suspect
regarding dual relationships, she was on solid ground when it came to respecting the welfare of the client. She also concluded that attending the First Commtinion affirmed Maria Elena's family and cultural values and actually resulted in
giving her more authority as a helper in the eyes of Maria Elena's family. Barbara admitted that her own values had been challenged in the process, mostly
because she had seen herself as a person who "never breaks the rules." However,
she reported that she was able to identify other sets of values that took priority
over a unidimensional interpretation of the Code of Ethics (ACA, 1995). She said
she believed that Maria Elena's family were empowered by her decision and that
to have done otherwise would have devalued them and their culture.
Conclusion
At the beginning of the 21st century, there is a tremendous demographic transformation taking place in the United States. In the next 50 years, a majority
of the people living and working in the United States will be non-White and
of non-European background. We have suggested that the current ACA (1995)
Code of Ethics and Standards of Practice does not adequately address the demands of counseling non-White, non-Western clients. We have offered a model
of ethical decision making that incorporates several factors: (a) the philosophy of universalism, including the principles of altruism, responsibility,
justice, and caring (Ponterotto & Casas, 1991); (b) reciprocal empathy (Ivey,
1987); (c) the context of power (Hill et al., 1995); and (d) the process of acculturation (Paniagua, 1994; Santiago-Rivera, 1995). We have demonstrated by
means of a case illustration how the model can be applied; perhaps in the
model is the possibility to be both multicultural and ethical at the same time.
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Clinical Supervision of Psychotherapy: Essential Ethics Issues for
Supervisors and Supervisees
Jeffrey E. Barnett and Corey H. Molzon
Loyola University Maryland
Clinical supervision is an essential aspect of every mental health professional’s training. The importance
of ensuring that supervision is provided competently, ethically, and legally is explained. The elements
of the ethical practice of supervision are described and explained. Specific issues addressed include
informed consent and the supervision contract, supervisor and supervisee competence, attention to
issues of diversity and multicultural competence, boundaries and multiple relationships in the supervision relationship, documentation and record keeping by both supervisor and supervisee, evaluation and
feedback, self-care and the ongoing promotion of wellness, emergency coverage, and the ending of the
supervision relationship. Additionally, the role of clinical supervisor as mentor, professional role model,
and gatekeeper for the profession are discussed. Specific recommendations are provided for ethically
and effectively conducting the supervision relationship and for addressing commonly arising dilemmas
C 2014 Wiley Periodicals, Inc. J. Clin. Psychol.: In
that supervisors and supervisees may confront.
Session 70:1051–1061, 2014.
Keywords: supervision; ethics; informed consent; boundaries; competence
Clinical supervisors serve in a number of crucial roles in the clinical training and professional
development of future mental health professionals. They teach, mentor, share their experience
and wisdom, help guide supervisees’ professional development, and serve as gatekeepers of the
profession (Bernard & Goodyear, 2014). Their ultimate outcomes are to impart knowledge,
help enhance skills, and help prepare the supervisee for success at the next level of training
and practice. Because supervisees are providing direct clinical services to clients while often at
very early stages of their training, supervisors maintain a significant responsibility to provide
sufficient oversight and training to help ensure that clients receive the best services possible and
to help minimize risks of harm to them (Falender & Shafranske, 2004).
Numerous ethical issues, challenges, and dilemmas may arise that are relevant to both the
conduct of the supervisory relationship and the interactions between supervisees and their
clients. Clinical supervision that integrates a focus on these ethics issues will hopefully help
prevent many of the more commonly occurring challenges and dilemmas, and for those that
do arise, it is hoped that they will be thoughtfully addressed and resolved in a timely manner
consistent with the supervisee’s and/or client’s best interests (Barnett & Johnson, 2008; Vasquez,
1992). The major areas of ethics that pertain to clinical supervision and the provision of clinical
services by supervisees are discussed and specific recommendations for proactively and effectively
addressing them are provided. While no one article can address every possible challenge and
dilemma that may arise, we do hope to provide a framework for addressing relevant ethics issues
that are likely to occur.
Assessing the Supervisee’s Training Needs
Tailoring the supervision provided to each individual supervisee’s training needs is essential.
Prior to even having the supervisee see clients, supervisors should determine the supervisee’s
strengths and weaknesses, areas that necessitate additional training before seeing clients, and
areas where the need for more intensive supervision may be indicated (Barnett, 2011). Supervisors
Please address correspondence to: Jeffrey E. Barnett, Department of Psychology, Loyola University
Maryland, 4501 N. Charles Street, Baltimore, MD 20210. E-mail: jbarnett@loyola.edu
C 2014 Wiley Periodicals, Inc.
JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 70(11), 1051–1061 (2014)
Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22126
1052
Journal of Clinical Psychology: In Session, November 2014
should consider a review of previous coursework and clinical experiences and engage in a
discussion of the supervisee’s relevant knowledge and experiences, such as how to conduct an
interview, basic counseling skills, goals of treatment, assessment of treatment needs, and the like.
The supervisor then can provide remediation as needed, assign clients as would be appropriate,
and provide the type and intensity of clinical supervision indicated by the supervisee’s level of
training, knowledge, and skill (Barnett, 2011).
Some supervisees may be quite advanced in some areas of practice, yet may need additional
training or even remediation in others. Thus, no one approach to clinical supervision can ever
be appropriate for every supervisee and each supervisee’s training needs may change over time,
so modifications in how supervision is provided may need to be made (Barnett, 2011; Bernard
& Goodyear, 2014).
Competence
It is essential that each clinical supervisor possess two types of competence: competence in the
clinical areas to be supervised (e.g., child therapy, adult assessment, substance abuse treatment)
as well as in the practice of clinical supervision (Barnett, 2011; Barnett & Johnson, 2008). This
is consistent with Standard 2.01, Boundaries of Competence, of the American Psychological
Association (APA) Ethics Code (APA, 2010), which states that before providing any professional
services, psychologists ensure that they do so “with populations and in areas only within the
boundaries of their competence based on their education, training, supervised experience, consultation, study, or professional experience” (p. 4). It is advised that those interested in providing
clinical supervision to others first undergo formal training in clinical supervision that includes
both didactic instruction and clinical training that involves supervision of the application of
one’s supervision skills (Falender et al., 2004).
As with all other types of clinical competence, supervision competence falls along a continuum; one is neither fully competent nor totally incompetent. Similarly, one may be competent
in one aspect of one’s role and not in others, and one may be competent at one point in time
and not at others. It is thus important to take care in establishing and maintaining one’s various
competencies. Clinical supervisors should be active students of the art and science of clinical
supervision, continually working to enhance their competence in this important area of practice.
When unsure if one’s particular competencies are sufficient and if they meet required standards, it is recommended that colleagues with experience and expertise in that particular area of
professional practice be consulted.
Likewise, when a supervisee is treating a client whose clinical needs fall outside the supervisor’s
areas of competence, delegating supervision of that particular client to a colleague with the
needed competence is recommended. Clinical supervisors should predict the potential for issues
related to their competencies and discuss in the supervision contract appropriate courses of
action for supervisees to take if such an issue was to arise.
Informed Consent
Just as with psychotherapy, assessment, and all other professional services mental health clinicians provide, and consistent with Standard 3.10, Informed Consent, of the APA Ethics Code
(APA, 2010), it is essential that a thorough informed consent process be engaged in at the
outset of the supervisory relationship (Bernard & Goodyear, 2014; Falender, 2011; Thomas,
2007, 2010). This can take the form of a supervisory contract or agreement that is signed by
both parties (for sample supervision contracts, see Bernard & Goodyear, 2014; Falender, 2011;
Thomas, 2007, 2010).
At a minimum, this agreement should include the following topics: expectations, responsibilities, and obligations of both supervisor and supervisee; any fees and financial arrangements
relevant to the supervisory relationship; scheduling and emergency contact information; documentation and record keeping requirements; the use of any audio and video recording; evaluation and feedback to include the expectations and requirements for successful completion of
the training experience; expectations for confidentiality and any reasonably anticipated limits to
Ethics Issues in Supervision
1053
confidentiality; legal requirements such as mandatory reporting requirements; expectations for
use of the supervisor and when the supervisee should contact him or her; and information about
how and when the supervisory relationship will be ended (Barnett, 2011; Bernard & Goodyear,
2014; Falender, 2011; Thomas, 2007, 2010).
As with any other informed consent agreement, it is important to ensure that consent by the
supervisee is given voluntarily, that the supervisee is competent to give his or her own consent
(e.g., is above the age of majority), that what the supervisee is agreeing to is understood by him
or her, and that the consent is not only reviewed and explained verbally but also documented in
writing (Barnett, Wise, Johnson-Greene, & Bucky, 2007). Additionally, it is important to keep
in mind that informed consent is not a singular event, but rather an ongoing process (Barnett
et al., 2007). As circumstances or situations change in the supervisory relationship (e.g., changes
in the supervisee’s responsibilities) the informed consent agreement should be updated.
A Developmental Approach to Clinical Supervision
Clinical supervision may be provided through varying means and intensities dependent on the
supervisee’s training needs (Barnett, 2011). As the supervisee progresses through stages of professional growth and development, his or her training needs and need for a particular type of
supervision will change (Falender & Shafranske, 2004; Stoltenberg & McNeill, 2009). Thus, the
clinical supervisor will likely take a rather active role in the beginning of the supervisory relationship, and then gradually reduce his or her involvement to allow the supervisee to take on greater
autonomy and responsibility. For example, as the supervisee demonstrates the ability to competently handle increasing amounts of autonomous functioning, supervision can progress through
the following continuum, noting that not every supervisee’s training needs will necessitate the
need for each of these types of supervision:
1. The supervisee observing the clinical supervisor providing a particular clinical service (e.g.,
having the trainee observe the supervisor conduct an intake interview or observe the supervisor administer a test).
2. The supervisor and supervisee engaging in a role-play of a particular clinical service during
individual supervision.
3. If possible, the supervisor and supervisee providing the clinical service jointly (e.g., co-leading
a group or conducting an intake interview together).
4. The supervisor observing the supervisee providing the clinical service and sharing feedback
and suggestions in real time (e.g., using I-Supe to communicate directly during a session).
5. The supervisee video recording the provision of clinical services and providing the supervisor
with the videos and with clinical documentation to review prior to the supervision session. The
supervisor then integrating the review of the videos and documentation into their supervision
sessions.
6. The supervisee audio recording the provision of clinical services and providing the supervisor
with the recordings and with clinical documentation to review prior to the supervision
session. The supervisor then integrating review of the recordings and documentation into
their supervision sessions.
7. The supervisee audio and/or video recording selected cases for intensive review in clinical
supervision, and for the remainder of cases providing the supervisor with documentation of
the professional services provided.
It is also important to keep in mind that numerous other approaches to clinical supervision
exist and many clinical supervision strategies may prove useful. Factors such as the supervisor’s
theoretical orientation and a range of other factors may influence how clinical supervision is
provided (Falender & Shafranske, 2004). Additionally, the strategies listed above do not represent
a linear progression. It is possible that an advanced supervisee may receive a referral for a client
whose treatment needs fall outside the supervisee’s usual areas of clinical competence. In these
situations, the supervisor and supervisee may jointly agree to move back to an earlier stage of this
developmental progression for the supervision of this particular case, as a means of promoting
both the development of clinical competence and the best interests of the client receiving the
1054
Journal of Clinical Psychology: In Session, November 2014
clinical services, while simultaneously functioning at a higher developmental level of supervision
for other clients’ treatment.
Creating a Safe Holding Environment
Although there typically is an evaluative component to the supervisory relationship, for the
supervisee to obtain maximum benefit from the clinical supervision, and thus for the clients
treated to receive the best care possible, the supervisee must perceive the supervisory relationship
to be sufficiently safe to be able to openly share thoughts, ideas, experiences, and feelings with
the supervisor (Association for Counselor Education and Supervision [ACES], 2011; Winnicott,
1965). In fact, without experiencing trust, security, and safety in the supervisory relationship,
supervisees may tend to censor what is shared with the supervisor for fear of negative feedback,
criticism, or a negative evaluation, which greatly puts at risk the quality of supervision and the
quality of the treatment provided to the supervisee’s current and even future clients (Ladany,
Hill, Corbett, & Nutt, 1996).
Although there is a need for feedback and recommendations for change and growth to foster
the learning process, it is hoped that this can be done in a manner that promotes openness to
the supervisory process. For this important learning to occur, it is vital that supervisees feel
safe enough to experiment, try new things outside their comfort zone, and be able to report
back to the supervisor on “failures,” not just successes, to achieve maximum benefit from the
supervision process (Moghe & Barnett, 2007; Worthen & McNeill, 1996). Similarly, clinical
supervisors should actively seek out, and be open to receiving, feedback from supervisees about
the supervisory relationship and process, and should actively demonstrate this openness during
informed consent and within the supervision sessions.
Evaluation and the Feedback Process
Although the establishment and maintenance of a trusting relationship and safe environment
are essential for clinical supervision to be successful, the supervisory relationship will typically
be an evaluative one, with the supervisor providing feedback and evaluation to the supervisee as
well as to his or her training program (Bernard & Goodyear, 2014). These requirements should
always be discussed during the informed consent process. The supervisee should understand
the criteria for evaluation, the expectations and standards to be met to successfully complete
the training experience, and how and when the evaluation process will be conducted (Thomas,
2007).
Both formal and informal evaluations and feedback should be provided to supervisees
(Bernard & Goodyear, 2014). Any formal evaluation rating form and criteria for success should
be reviewed with the supervisee at the outset of the supervisory relationship to ensure understanding of all expectations and standards (Falender & Shafranske, 2004). Additionally, a
schedule for formal evaluation should be agreed upon, and the supervisee should be informed of
all individuals who may receive the results of these formal evaluations and how they may be used
(Thomas, 2007). Additionally, informal feedback should be provided to the supervisee on an
ongoing basis. Timely, helpful, and constructive feedback to the supervisee on an ongoing basis
is an ethical imperative (ACES, 2011). Feedback and recommendations for improvement should
be provided to supervisees with sufficient time and support for them to have the opportunity to
engage in any needed remediation prior to receiving a final evaluation at the completion of the
training experience (Falender & Shafranske, 2004).
Clinical Supervisor as Gatekeeper to the Profession
Despite the positive roles of clinical supervisor described above, ultimately each clinical supervisor has the responsibility to ensure that those who are not suited for independent practice in the
mental health professions are not authorized to do so (Bernard & Goodyear, 2014). At times it
may be tempting to take a “wait and see” approach, but if a series of consecutive supervisors
take this approach, a supervisee with inadequate clinical skills or who does not possess the
Ethics Issues in Supervision
1055
needed personality attributes or disposition may be passed along like a “hot potato” (Johnson
et al., 2008), to the likely detriment of that individual’s future clients and to the detriment of the
profession.
Although at times it may be uncomfortable to implement this role, it is essential that clinical supervisors take this obligation seriously by providing opportunities for remediation to
supervisees who display problems with professional competence, and taking necessary action to
prevent continued progression toward independent practice in the profession if remediation is
not successful, consistent with requirements for evaluation and the provision of feedback to the
supervisee’s training program that are addressed and agreed upon in the supervision contract.
Standards for successful completion of the training experience should be clearly articulated to
the supervisee at the outset of the supervisory relationship and progress toward achieving them
(or lack thereof) should be reviewed periodically throughout the training experience (Bernard
& Goodyear, 2014; Falender & Shafranske, 2004; Thomas, 2007).
Clinical Supervisor as Professional Role Model
In addition to all the teaching that clinical supervisors provide, they also serve the important
function of professional role model (Barnett, 2011). More than what clinical supervisors say
to their supervisees, how they interact with the supervisee and how they act toward others
may have a greater effect on impressionable supervisees who are in the process of forming
and developing their professional identity (Vasquez, 1992). For example, a clinical supervisor
who speaks at length with the supervisee about the importance of respecting and maintaining
each client’s confidentiality, but who also leaves his or her clients’ records on their desk for
the supervisee to see the clients’ names and who casually discusses clients by name and shares
sensitive information about them in the hallway with a colleague, will likely affect the supervisee’s
view of what a mental health professional is and does by these actions. The same will be true
with regard to how the supervisor safeguards sensitive information the supervisee shares about
him or herself in supervision sessions.
Finally, how the clinical supervisor conducts him or herself in supervision sessions with the
supervisee will likely have a significant affect on how the supervisee functions as a professional as
well. If the supervisor is warm, empathic, and understanding (or cold, emotionally distant, and
unsupportive, for that matter) with the supervisee, the supervisee may internalize these qualities
and emulate them in relationships with clients, both now and in the future, as well as with their
future supervisees.
Clinical Supervisor as Mentor
In addition to serving as instructors and role models, clinical supervisors can serve in the
very important role of mentor. The role of mentor goes beyond that of clinical supervisor
in that the mentor takes a personal interest in the mentee’s overall professional growth and
development (Johnson, 2007). Mentors may focus discussions on career planning, balancing
work and family, establishing one’s career, addressing finances, getting involved in the profession,
becoming engaged in scholarship, and the like. In fact, the mentor may invite the mentee to join
him or her at professional meetings and conferences, introducing the mentee to the mentor’s
colleagues, assisting with professional networking activities, and working to help promote the
mentee’s career. Mentor and mentee may work jointly on research and writing projects or may
serve on professional organization committees together, with the mentor helping to integrate
the mentee into the profession.
An important aspect of the mentoring done by effective supervisors is to assist their mentees
to better understand and navigate the administrative structure and political dynamics of the
training setting. Experienced supervisors have much to share with neophyte clinicians on how
to work effectively in a particular training environment.
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Journal of Clinical Psychology: In Session, November 2014
A Focus on Diversity–Cultural Competence
Issues of diversity in all its forms should be given active attention in all aspects of the supervision
process as well as within the supervisory relationship. It is important for supervisors to address
issues of diversity between the supervisor and supervisee within supervision as well as to foster
the development of cultural competence for supervisees in their work with clients (Barnett,
2011; Barnett & Johnson, 2008; Vasquez, 1992). Effective clinical supervisors will model how to
thoughtfully and sensitively address issues of diversity in how they attend to differences between
the supervisor and supervisee (e.g., gender, gender identity, age, race, culture, ethnicity, language,
sexual orientation, socioeconomic status, disability; Vasquez, 1992). Thoughtful supervisors
will also push supervisees to consider and address how these factors may be affecting the
supervisees in their clinical work with clients. It is essential that cultural competence (really,
diversity competence) is considered an essential aspect of clinical competence and is integrated
into all aspects of the supervisee’s clinical work as well as into all aspects of clinical supervision
as is relevant (APA, 2010; Vasquez, 1992).
A Focus on Ethics and Legal Issues
A focus on ethics and legal issues should occur both by modeling them throughout the supervisory relationship and through didactic discussions (Barnett, 2011; Vasquez, 1992). As educators
and role models, clinical supervisors should endeavor to inculcate in their supervisees a focus
on ethical and legal practice (Barnett & Johnson, 2008). This focus should go beyond merely
meeting minimal standards of the profession to developing a lifelong focus on aspiring to achieve
the highest ethical ideals of our profession in all we do professionally. These aspirational ideals
(Beauchamp & Childress, 2008) form the basis of each mental health profession’s code of ethics
and include:
1. Beneficence—the obligation to help others and do good through all our professional decisions
and actions.
2. Nonmaleficence—the need to avoid exploitation and harm of others in our professional
activities and relationships.
3. Fidelity—our obligations to others that can be explicit such as are articulated in the informed
consent agreement, and implicit obligations of all mental health professionals such as to be
honest and caring.
4. Autonomy—to promote each client or supervisee’s independent functioning over time and
to not engage in actions that will promote their dependence on us.
5. Justice—the fair and equitable treatment of all and providing all individuals with equal
opportunities for and access to needed care.
6. Self-care—the need to take adequate care of ourselves on an ongoing basis to help prevent
burnout and resultant problems with professional competence while promoting psychological
wellness (needed to be able to effectively implement the first five ethical ideals).
It is additionally important that supervisees develop a sophisticated approach to addressing
ethical challenges and dilemmas that involves the application of a process of ethical decision
making rather than looking for “the right answer.” Clinical supervisors can model this approach
throughout supervision by guiding the supervisee though a series of questions based on the
ethical ideals listed above that will promote a thoughtful approach to ethical decision making.
Examples include: Will engaging in this behavior be in my client’s best interest? Will acting in
this way be consistent with my obligations to this individual? Will this action possibly result in
harm to this other individual? A number of models of ethical decision making are available and
can be shared with supervisees for their use (see Cottone & Claus, 2000, for a review of many
available decision-making models).
Ethics Issues in Supervision
1057
A Focus on Self-Care and Psychological Wellness
Practicing in the mental health profession, whether as a clinical supervisor or as a supervisee,
brings with it numerous challenges and stresses. Issues such as clients who may relapse or
not improve, meeting administrative requirements, dealing with decreased funding and lower
reimbursement rates, having clients engage in dangerous and threatening behaviors, and a host
of others make this a very challenging profession. For supervisors, the stress of being responsible
for all services provided by supervisees, and at times needing to provide negative feedback, can
be quite stressful and challenging. For supervisees, the challenges of meeting with clients without
a supervisor present, being evaluated, and having one’s clinical work regularly scrutinized can
each be distressing.
Additionally, all mental health professionals must address and deal with the many challenges
in their personal lives, which can include relationship, financial, health, and other difficulties.
Taken together these stressors can result in distress (i.e., the subjective emotional response to the
stressors in our lives), which if not adequately addressed can develop into burnout and problems
with professional competence (Baker, 2003).
Ethical supervisors will promote their own psychological wellness by actively practicing selfcare strategies, and working to keep a balance between various professional obligations and
between their professional and personal lives. Doing so will not only help ensure their ongoing
competence but also model these ethical practices for supervisees. Similarly, ethical supervisors should regularly address issues of psychological wellness, self-care, distress, burnout, and
problems with professional competence in supervision to help ensure supervisees are proactively addressing these issues, both at present and to develop career-long habits and behaviors
(Bernard & Goodyear, 2014). Further, should any challenges or problems be present that may
adversely affect the supervisee’s professional competence, addressing them prior to a negative
effect developing is desirable.
Documentation and Record Keeping
Clinical documentation is required in each mental health profession’s code of ethics, laws and
regulations, practice guidelines, and institutional policies (e.g., APA, 2007, 2010). Timely, thorough, and effective documentation of the services provided by mental health practitioners can
serve a number of important purposes (Falender & Shafranske, 2004). These include:
1. To help the busy clinician remember important information about the client’s treatment from
session to session, promoting the provision of high quality mental health services.
2. To provide information to members of a treatment team to assist each of them in coordinating
the services provided in light of each other’s treatment efforts and the results seen.
3. To help assure continuity of care should a client leave treatment at one point in time and then
return for additional treatment at a later date, whether with this clinician or with another.
4. As a risk management strategy to create a tangible record of all services provided, any use
of colleagues for consultation, the clinician’s decision-making process, the client’s role in
treatment, and outcomes achieved.
5. Because each mental health profession’s code of ethics requires it.
6. Because laws, regulations, and institutional policies require it.
While all clinical supervisors will be familiar with the requirement to document all direct
clinical services (assessment, treatment, telephone calls in between sessions, etc.), some may not
be aware of the value and importance of both the supervisor and supervisee documenting each
supervision session. This documentation can (a) help reduce the chance of misunderstandings
occurring, (b) help increase accountability on the part of the supervisee, (c) be an excellent
aide for both parties when reviewing it to track progress both of the supervisee’s clients and
the supervisee’s professional development, and (d) serve an important risk management role in
providing a tangible record of what has transpired in supervision and the supervisor’s reasonable
good faith efforts to provide high-quality clinical supervision (Falender & Shafranske, 2004).
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Journal of Clinical Psychology: In Session, November 2014
Boundaries and Multiple Relationships
Boundaries are the ground rules of all professional relationships (Smith & Fitzpatrick, 1995).
They include touch, self-disclosure, gifts, time, interpersonal space, and location. Each boundary
can be avoided, crossed, or violated. Boundary crossings may be clinically appropriate and even
necessary at times, and boundary violations by definition are harmful and unethical (Gutheil
& Gabbard, 1993). Attention to boundary issues, both as elements of the supervision of the
supervisee’s treatment of clients and within the supervisory relationship, is equally important.
In addition to raising supervisees’ awareness of boundary issues in their work with clients,
supervisors should be ethical role models for supervisees regarding the appropriate management
of boundaries (Barnett & Johnson, 2008). Thus, for example, supervisors may appropriately
utilize self-disclosure in supervision to enhance the value of the learning experience for the
supervisee. As with all boundaries, crossings are defined by their clinical relevance, conformity
with prevailing professional standards, being welcomed by the recipient, and being motivated by
a desire to meet the other individual’s clinical or supervisory needs, not by one’s own personal
needs or motivations.
Additionally, decisions about boundaries should be made with sensitivity to individual differences to include diversity differences as a behavior may be viewed as an appropriate and even
necessary boundary crossing by some individuals and as an unwelcomed and inappropriate
boundary violation by others (Smith & Fitzpatrick, 1995).
Multiple relationships are present when a mental health professional is engaged in a secondary
relationship with an individual with whom one has a professional relationship. Thus, a clinical
supervisor might have a personal, social, business, financial, or other similar type of multiple
relationship with a supervisee or a supervisee might have such relationships with a client. As
it is explained in Standard 3.05, Multiple Relationships, of the APA Ethics Code (APA, 2010),
all multiple relationships are not patently forbidden, but those that hold the potential for
exploitation of or harm to the supervisee or client should be avoided. Also, if being in a multiple
relationship with a supervisee or client would likely impair one’s objectivity and judgment, it
should be avoided (APA, 2010).
Although some multiple relationships are unavoidable, such as in rural settings and certain
other “closed” communities (Campbell & Gordon, 2003), all multiple relationships that are
exploitative such as sexually intimate relationships, should always be avoided (APA, 2010). They
are always unethical and demonstrate a clear abuse of the imbalance of power in the professional
relationship.
It is also important to note that multiple relationships may be beneficial to the supervisee
(Thomas, 2010). For example, a supervisor who has evaluative authority and who maintains responsibility for monitoring his or her supervisee’s clinical activity may be simultaneously working
with the supervisee on a research project or presenting at a conference with the supervisee. Thus,
multiple relationships between clinical supervisors and supervisees can be beneficial so long as
they appropriately foster the supervisee’s professional development and are not exploitative in
nature (Thomas, 2010).
One multiple relationship dilemma often present in the supervision relationship involves the
boundary between providing supervision and providing psychotherapy. Although most supervisors would know that one should not serve in both of these roles simultaneously, there always
exists the possibility that a supervisor may slowly over time shift from the role of supervisor into
the role of psychotherapist. The risk of this boundary transgression occurring may be greatest
when supervision is provided from a psychodynamic orientation, which will often involve an
examination of the supervisee’s countertransference reactions to his or her clients, although it
may occur whenever supervisors and supervisees address the supervisee’s underlying emotional
responses, issues, and conflicts.
This exploration of the supervisee’s emotional responses and reactions to the client may
involve a focus on the supervisee’s unresolved issues and emotional conflicts, and can easily
develop into providing psychotherapy to supervisees if care is not taken. In these situations,
supervisors should remain aware of the potential to enter into a psychotherapist role. When this
Ethics Issues in Supervision
1059
appears imminent and when addressing these issues is in the supervisee’s best interests, a referral
to another competent professional for psychotherapy is recommended.
Emergency Coverage and Avoiding Abandonment
Clinical supervision is a significant responsibility and a sizeable commitment on the part of the
supervisor. Merely being attentive and available during regularly scheduled supervision sessions
is insufficient. Each supervisor has an obligation to make emergency coverage arrangements
and ensure that supervisees know under what circumstances to contact the supervisor and how
to do so (ACES, 2011; Bernard & Goodyear, 2014). Such issues should be openly discussed as
part of the informed consent process and updated over time as is needed (Bernard & Goodyear,
2014; Falender & Shafranske, 2004; Thomas, 2007).
Supervisees should never be practicing independently and without adequate support and
oversight from their supervisor (Barnett, 2011). The clinical supervisor’s availability will affect
the training experience of the supervisee and may have a direct effect on the quality of services provided to the supervisee’s clients, and it may also have a significant modeling effect on
supervisees as they are developing their professional identity.
Should a clinical supervisor be away from the office or otherwise unavailable due to illness,
vacation, attending a professional conference, or the like, it is essential that this be discussed
in advance (if possible) and alternative supervision arrangements should be made so that the
supervisee does not experience any lapse in clinical supervision coverage. Because some potential
interruptions in the supervisor’s availability may be unanticipated and unplanned for, such as
an accident or illness, it is best that emergency or back up coverage arrangements be made in
advance and discussed as part of the initial informed consent process (ACES, 2011; Bernard &
Goodyear, 2014).
Termination and Ending the Professional Relationship(s)
The supervisory relationship, just like the supervisee’s treatment relationships with clients, at
some point in time will come to an end. At times these endings are planned for and anticipated; at
other times they may be forced on us or come as a surprise. Regardless, the issue of the ending of
the professional relationship is one that should be discussed openly throughout the relationship
beginning during the informed consent process (Barnett, 2011; Bernard & Goodyear, 2014;
Falender & Shafranske, 2004; Thomas, 2007). A clinical supervisor may be planning for a leave
of absence or may be transferring to another employment setting. A supervisee may be working
at a particular agency for one semester or one academic year and then moving on to another
training site. Supervisors should address these issues with their supervisees to help ensure the
best possible training experience, but also because of the effect of modeling of professional
behavior.
Additionally, the supervisee should be actively and openly addressing these issues with each
client, as described above (Bernard & Goodyear, 2014). If a supervisee will need additional
supervision after the clinical supervisor leaves a practice setting and if a client is in need of continued treatment after the supervisee’s time at that setting ends, these issues should be discussed
well in advance of these endings and advanced arrangements for a new clinical supervisor or
psychotherapist should be made so that no significant lapse in professional services provided
occurs.
Conclusions
Clinical supervisors play a vital and essential role in the training and professional development
of students and junior colleagues. But how supervision is conducted can significantly affect
the quality of the learning process for the supervisee and can greatly affect outcomes such as
the quality of clinical services provided by supervisees to their clients. Attention to the ethical
issues reviewed in this article is essential for supervisees and their clients to achieve maximum
benefit. Although this article can only serve as an introduction to the topic, and attention to
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Journal of Clinical Psychology: In Session, November 2014
relevant ethics codes, laws, regulations, and institutional policies are essential as well, it is hoped
that readers will use the information and recommendations shared in this article to begin a
lifelong process of a focus on ethics in all aspects of their roles as both clinical supervisors and
supervisees.
Selected References & Recommended Reading
American Psychological Association. (2007). Record keeping guidelines. American Psychologist, 62, 993–
1004. doi:10.1037/0003-066X.62.9.993
American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from http://www.apa.org/ethics
Association for Counselor Education and Supervision. (2011). Best practices in clinical supervision. Retrieved from http://www.acesonline.net/resources/
Baker, E. K. (2003). Caring for ourselves: A therapist’s guide to personal and professional well-being.
Washington, DC: American Psychological Association.
Barnett, J. E. (2011). Ethical issues in clinical supervision. The Clinical Psychologist, 64, 14–20.
Barnett, J. E., & Johnson, W. B. (2008). Ethics desk reference for psychologists. Washington, DC: American
Psychological Association.
Barnett, J. E., Wise, E. H., Johnson-Greene, D. J., & Bucky, S. F. (2007). Informed consent: Too much of a
good thing or not enough? Professional Psychology: Research and Practice, 38, 179–186.
Bernard, J. M., & Goodyear, R. K. (2014). Fundamentals of clinical supervision (5th ed.). Upper Saddle
River, NJ: Pearson Education.
Campbell, C. D., & Gordon, M. C. (2003). Acknowledging the inevitable: Understanding multiple relationships in rural practice. Professional Psychology: Research and Practice, 34, 430–434. doi:10.1037/07357028.34.4.430
Cottone, R., & Claus, R. (2000). Ethical decision-making models: A review of the literature. Journal of
Counseling & Development, 78(3), 275–283.
Falender, C. A. (2011). Getting the most out of clinical supervision: A guide for practicum students and
interns. Washington, DC: American Psychological Association.
Falender, C. A., Erickson Cornish, J. A., Goodyear, R., Hatcher, R., Kaslow, N. J., Leventhal, G., . . . Grus,
C. (2004). Defining competencies in psychology supervision: A consensus statement. Journal of Clinical
Psychology, 60, 771–785.
Falender, C. A., & Shafranske, E. P. (2004). Clinical supervision: A competency-based approach. Washington, DC: American Psychological Association.
Gutheil, T. G., & Gabbard, G. O. (1993). The concept of boundaries in clinical practice: Theoretical and
risk-management dimensions. The American Journal of Psychiatry, 150, 188–196.
Johnson, W. B. (2007). Transformational supervision: When supervisors mentor. Professional Psychology:
Research and Practice, 38, 259–267.
Johnson, W. B., Elman, N. S., Forrest, L., Robiner, W. N., Rodolfa, E., & Schaffer, J. B. (2008). Addressing
professional competence problems in trainees: Some ethical considerations. Professional Psychology:
Research and Practice, 39, 589–599. doi:10.1037/a0014264
Ladany, N., Hill, C. E., Corbett, M. M., & Nutt, E. A. (1996). Nature, extent, and importance of what
psychotherapy trainees do not disclose to their supervisors. Journal of Counseling Psychology, 43, 10–24.
doi:10.1037/0022-0167.43.1.10
Moghe, S. C., & Barnett, J. E. (2006). What makes for effective supervision anyway? The Maryland Psychologist, 52(2), 19, 23.
Smith, D., & Fitzpatrick, M. (1995). Patient-therapist boundary issues: An integrative review of theory and
research. Professional Psychology: Research and Practice, 26, 499–506. doi:10.1037/0735-7028.26.5.499
Stoltenberg, C. D., & McNeill, B. (2009). IDM supervision: An integrative developmental model for supervising counselors and therapists (3rd ed.). New York, NY: Routledge.
Thomas, J. T. (2007). Informed consent through contracting for supervision: Minimizing risks, enhancing
benefits. Professional Psychology: Research and Practice, 38, 221–231. doi:10.1037/0735-7028.38.3.221
Thomas, J. T. (2010). The ethics of supervision and consultation: Practical guidelines for mental health
professionals. Washington, DC: American Psychological Association.
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Vasquez, M. J. T. (1992). Psychologist as clinical supervisor: Promoting ethical practice. Professional Psychology: Research and Practice, 23, 196–202. doi:10.1037/0735-7028.23.3.19
Winnicott, D. W. (1965). The maturational processes and the facilitating environment. London: Hogarth
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Worthen, V., & McNeill, B. W. (1996). A phenomenological investigation of ‘good’ supervision events.
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Journal of Psychology and Christianity
Copyright 2010 Christian Association for Psychological Studies
2010, Vol. 29, No. 3, 263-267
ISSN 0733-4273
PRACTICE AND PROFESSIONAL ISSUES
Ethics statements are not all equally enforceable. The CAPS Statement, for example, is a
guidelines statement, and is not and has never
been an enforceable code. The sincere concern
on the part of the CAPS leaders who framed it
was that members would aspire to the highest
standards of professional conduct and perform
their duties in ways in keeping with their commitments as followers of Christ. Agreement with the
guidelines is a condition of membership, but the
association is not an adjudicatory body with the
resources to investigate and judge complaints
against members.
In its latest revision, the APA identifies its own
code as having both an enforceable and a nonenforceable section. The general principles (Principles A-E) are aspirational ideals and are not
considered enforceable. However, the ethical
standards (Sections 1-10) are.
It should be added that, as important as it is to
understand one’s own code of ethics, it is also
essential that modern professionals be familiar
with the laws of their states pertaining to mental
health issues, with the rules of practice as set
forth by their state boards, and with pertinent federal law. These regulations may supersede or add
specificity to professional ethics codes. For example, state laws often set forth therapists’ duties to
protect or to warn when a patient makes threats
against another person. Federal laws such as the
Health Insurance Portability and Accountability
Act (HIPAA) set forth standards for things like the
privacy of mental health records and the types of
information that should and should not be in
those records.
Psychologists also need to stay abreast of the
various treatment and practice guidelines published by the APA. The most recent of these is the
Record Keeping Guidelines statement of 2007
(APA, 2007).
Ethics Codes: Monitoring the Major Changes
Randolph K. Sanders
Private Practice
New Braunfels, TX
Several professional associations have revised
their ethics codes in the past decade (American
Association for Marriage and Family Therapy,
2001; American Counseling Association, 2005;
American Psychiatric Association, 2006; American
Psychological Association, 2002). The Christian
Association for Psychological Studies (CAPS) also
revised its ethical guidelines statement in 2005.
Associations revise codes for a number of reasons. The most obvious is to codify the association’s values with regard to new, emerging, or
recently recognized practices and issues within
the field. Codes are also modified in attempt to
make them more consistent with federal or state
laws affecting the mental health professions.
While seeking uniformity between codes and
legal statutes is a good thing in principle, it is
often much harder than it first appears, since
laws affecting mental health are not always consistent from one state to another.
Codes are sometimes revised in response to the
ways they are used (and misused) in legal actions
against therapists (Schoener, n.d.). This may actually lead to a shortening of a code when a revision committee wishes to tighten and sharpen
language so that there is less room for misunderstanding. This occurred in the latest revision of
the APA code which is actually 20% shorter than
its predecessor. Similarly, provisions in codes
may be rewritten to make them more intelligible
to the professionals who practice under them.
The major codes have undergone substantial
revision in recent years. The article which follows
will update professionals on some of the more
salient changes to the ethics codes, and the rationales behind them. Items thought to be of particular interest to Christian therapists will be given
special attention. Special focus will be placed on
the American Psychological Association Code
(2002), the CAPS Statement of Ethical Guidelines
(2005), and the American Counseling Association
Code (2005).
Multicultural and Diversity Issues
An increasing concern of most ethics codes and
for the professions in general has to do with multicultural and diversity issues. An appreciation for
these issues is woven throughout most current
codes. The CAPS Statement’s section on competence encourages members to make sure they are
sensitive to and have the proper training when
working with special (diverse) populations. The
Correspondence regarding this article should be sent
to Randolph K. Sanders, Ph.D., 1136 Spring Hill Rd.,
New Braunfels, TX 78130-7215; capsintl@yahoo.com
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PRACTICE AND PROFESSIONAL ISSUES
latest ACA code urges counselors to “actively
attempt to understand the diverse cultural backgrounds of the clients they serve” and how their
own “cultural identities” affect them in the counseling process (ACA, 2005: Introduction). Principle
E of the APA Code continues to emphasize
respect for people’s rights and dignity regardless
of cultural or individual differences (APA, 2002),
and the APA has also adopted a set of guidelines
separate from the ethics code that focuses on
multicultural issues (APA, 2003).
Multiple Relationships
Arguably, one of the most significant recent
changes in ethics codes has to do with an evolving, and in general, more permissive approach
toward certain types of non-sexual multiple relationships (NSMR’s). Traditionally, ethics codes
tended to take a restrictive approach toward
NSMR’s, finding them acceptable only under rather
limited circumstances, such as rural settings where
practitioners frequently see clients outside of therapy and where referral resources are severely limited. However, in response to an increasing body
of literature arguing cogently that some NSMR’s
are not harmful and that others can actually be
helpful to therapeutic outcomes (Lazarus & Zur,
2002), the new APA code clearly indicates that not
all NSMR’s must be avoided, and defines the types
of NSMR’s that should be avoided. The code indicates that psychologists should refrain
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/her
functions as a psychologist, otherwise
risks exploitation or harm to the person with whom the professional relationship exists. (APA, 2002: 3.05)
The code further specifies that
multiple relationships that would
not reasonably be expected to
cause impairment or risk exploitation or harm are not unethical.
(APA, 2002: 3.05)
The current American Counseling Association
(ACA) code also takes a more permissive
approach toward NSMR’s, but with a different
twist. The ACA code clearly indicates that some
NSMR’s are “potentially beneficial,” but that counselors must carefully document (ahead of time if
possible) their rationale for the multiple relation-
ship. If “unintentional harm” occurs as a result of
entering into the multiple relationship, the counselor must also show how he/she attempted to
remedy the situation (ACA, 2005: A.5.d). The
code also deals with situations where the professional changes roles in the midst of counseling, as
say, when the counselor suggests a change from
individual counseling to family counseling. In
these situations, the counselor is to obtain
informed consent from the counselee for the
change, explaining possible consequences, and
allowing the counselee to refuse the services
(ACA, 2005: A.5.e).
As noted in the APA code, some NSMR’s, such
as providing therapy to one’s student, clearly
remain inappropriate. But the greater openness to
potentially beneficial NSMR’s comes as welcome
news to many therapists such as those who function in church-based settings where the likelihood
of contact with clients outside of therapy is often
quite high (McMinn & Meek, 1997; Sanders,
Swenson, & Schneller, in preparation).
Unfortunately, the codes still leave therapists in
the difficult position of trying to determine in
advance whether an NSMR will be helpful, harmful or innocuous. Aside from avoiding NSMR’s
altogether, the prudent therapist will have to do
his/her best to build skills in recognizing present
or potential NSMR’s, and will have to use his/her
best judgment along with consultation with other
professionals to determine whether to proceed or
to refer. In either case, documentation of the decision-making rationale is important.
Psychological Testing: What is “Raw Data?”
The 1992 APA Code prohibited psychologists
from releasing raw test data to persons not qualified to use that information (APA, 1992: 2.02b).
Questions immediately arose among psychologists
in many jurisdictions about what constituted “raw
data” and how to respond to authorized requests
for psychological testing records not only from
clients and other professionals, but also from attorneys and the courts (Fisher, 2003). The 2002 code
takes a more liberal stance toward the release of
records of testing. In the new code, psychologists
must provide test data to the client or other persons identified in a client release, or as required by
law or court (APA, 2002: 9.04a,b). Test data “refers
to raw and scaled scores, client/patient responses
to test questions or stimuli, and psychologists’
notes and recordings concerning client/patient
statements and behavior during the examination
(APA, 2002: 9.04a). There remains a provision that
PRACTICE AND PROFESSIONAL ISSUES
psychologists may refrain from releasing data to
protect a client or others from “substantial harm”
or to prevent misuse or misrepresentation of data,
but adds that the psychologist’s decision to do this
may be further constrained by relevant laws.
According to Celia Fisher, the chair of APA Ethics
Code Task Force for 2002, the decision to liberalize what could be released as test data was in
response to HIPAA and other new legal standards
that are moving in the direction of providing
greater rights to individuals to access their health
records (Fisher, 2003). Unfortunately, not only
have the APA and federal law addressed this issue,
but many states have also addressed it in various
ways, such that there remains confusion over how
and what test information should be released. Perhaps the wisest advice is to encourage psychologists to look to their state and federal laws
regarding the release of test data in addition to the
ethics code and when in doubt, consult a knowledgeable mental health attorney.
Informed Consent for Untested Treatments
In an effort to better protect the rights of clients,
the 2002 APA code provides a mandate for therapists to obtain explicit informed consent whenever they recommend that a client undergo a
treatment “for which generally recogniz...
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