Ask the Ethicist Blog

Ask the Ethicist is a feature on the website of the APA Division of Psychotherapy that provides a forum for asking questions involving ethics and professional practice issues. All psychotherapists face ethically challenging dilemmas and situations in their professional work, whether it be in providing psychotherapy, in conducting research, in supervision or consultation, or in other professional roles. Ask the Ethicist offers Division 29 members the opportunity to ask their questions about ethical challenges and dilemmas they face. Dr. Barnett will provide timely suggestions for responding to these challenges and dilemmas.

Jeffrey Barnett

Jeffrey Barnett

Jeffrey Barnett, Psy.D., ABPP is a Professor in the Department of Psychology at Loyola Univeristy Maryland and a licensed psychologist in practice in Arnold, Maryland. He is a Diplomate in Clinical Psychology and in Clinical Child and Adolescent Psychology of the American Board of Professional Psychology and a Distinguished Practitioner of Psychology in the National Academies of Practice. He is a recent past chair of the Ethics Committee of the American Psychological Association and has previously been chair of the Maryland Psychological Association Ethics Committee. Dr. Barnett has published numerous articles, chapters, and books on ethics and professional issues in Psychology and has given numerous presentations and continuing education ethics workshops for psychologists and other mental health professionals. His most recently published books include Ethics Desk Reference for Psychologists (APA Books, 2008, with Brad Johnson), Ethics Desk Reference for Counselors ( ACA Books, 2009, with Brad Johnson), and Financial Success in Mental Health Practice (APA Books, 2008 with Steve Walfish).

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Comments

  1. Linda Chastain says:

    Dear Dr. Barnett,

    I work at a county mental health center and have a concern about one of our psychiatric nurse practitioners’ ethical behavior. She has been given an okay to provide psychotherapy to those clients who receive medication management only. However, we have determined recently that she has been “stealing” clients from staff therapists already treating them I have been able to find something about “clients served by others” in the ACA ethics code but have been unable to find the issue directly addressed in other disciplines’ codes. In addition, it is very difficult to address this problem with the Director of the agency since the nurse practitioner is his wife. Can you steer me to other codes of ethics that address this issue or articles on the subject? I feel I need to have something in writing to show the Director that what she is doing is unethical.

    Sincerely,

    Linda Chastain

  2. Gnostic says:

    Dear Dr. Jeffrey Barnett,

    I was wondering if it is ethical/ legal for a professional psychologist to work both as a professional psychologist (doing their job in a professional way based on the psychological ethical vlaues and guidelines) but in their spare time to work as a volunteer instructor in a spiritual/meditation group giving tools and techniques of self improvement that are not really proven scientifically.

    I would really appreciate your response

    Kind Regards,

    LL

  3. Faith Prelli says:

    I have a question regarding professional ethics when working with mandated populations. Most of my clients are referred by probation/parole or Dept of Children and Families. During the course of their treatment, what is my responsibility/liability of disclosing past/current crimes to the referral source if a release is signed? The crimes do not meet criteria for mandated reporting laws within my state. I generally explain the limits to confidentiality with my clients frequently, stating my requirements to disclose to probation certain aspects of their treatment (attendance, tox screens, general participation statements, records’ eligibility for subpoena) and also the mandated reporting laws in my state. I also encourage them to ask prior to disclosure if they have any questions about limits to confidentiality. However, other clinicians at my site interpret the release of information for the referral source differently and this has become a recurring question. Thank you in advance for your response.

    • Jeffrey Barnett says:

      Faith Prelli asks:

      I have a question regarding professional ethics when working with mandated populations. Most of my clients are referred by probation/parole or Dept of Children and Families. During the course of their treatment, what is my responsibility/liability of disclosing past/current crimes to the referral source if a release is signed? The crimes do not meet criteria for mandated reporting laws within my state. I generally explain the limits to confidentiality with my clients frequently, stating my requirements to disclose to probation certain aspects of their treatment (attendance, tox screens, general participation statements, records’ eligibility for subpoena) and also the mandated reporting laws in my state. I also encourage them to ask prior to disclosure if they have any questions about limits to confidentiality. However, other clinicians at my site interpret the release of information for the referral source differently and this has become a recurring question. Thank you in advance for your response.

      Jeff Barnett responds:

      Excellent question, Faith. One of the first things to clarify is what your obligations are to the various parties involved. While the individual sitting across from you in the treatment room may seem like your ‘client’ in fact, the agency that referred the individual for treatment may actually be your client, that is the party to whom you owe certain obligations legally. When it comes to mandated treatment it is very likely that the agency is your client. That doesn’t mean that you don’t have any obligations to the individual who is receiving the treatment, just that that person’s rights are quite limited.

      It is important to clarify from the outset what your obligations and responsibilities are and to whom you owe what duties. This should be clarified through the informed consent process. The individual receiving treatment legally may have no right to confidentiality and the agency may have the right to access all treatment related information. Again, it is important to clarify this with an attorney for your agency prior to offering treatment and to then include all reasonably anticipated limits to or exceptions to confidentiality in the informed consent agreement.

      Technically, if an individual is mandated to treatment they are therefore not participating voluntarily, thus making true informed consent impossible (since its not voluntary). But, we still have the obligation to provide the individual with assent, providing them with all relevant information in a manner that allows them to understand it. We provide the same information as in informed consent, they just can’t give consent to treatment; the agency who is mandating the treatment actually is providing the consent.

      Again, as with all situations where clinical practice, ethics, and law intersect, it is best to consult with an attorney so you will know what the law requires of you. You can then proceed accordingly in keeping with our profession’s ethics code and standards of competent practice.

      When a client is not mandated to treatment and participates voluntarily, mandatory reporting requirements do not apply to past criminal acts to to illegal behaviors that do not put an identifiable victim or victims at risk for harm. But, in the mandated treatment situation you describe whatever requirements for reporting certain behaviors to them are included in their order for treatment (often by a judge) must be complied with (after consultation with an attorney). I hope this is helpful.

  4. Stephanie Chervenak says:

    Dear Dr. Barnett,

    I am curious about ethical considerations when treating individuals who are HIV positive. What are my responsibilities as a clinician if I know that my client (HIV positive) is engaging in risky/unsafe sexual practices with someone? In this case, the other person’s life is endangered.

    This issue always stumps me, thank you for your thoughts!
    Stephanie

    • Jeffrey Barnett says:

      Stephanie Chervenak Asks:
      I am curious about ethical considerations when treating individuals who are HIV positive. What are my responsibilities as a clinician if I know that my client (HIV positive) is engaging in risky/unsafe sexual practices with someone? In this case, the other person’s life is endangered.
      This issue always stumps me, thank you for your thoughts!

      Jeff Barnett Responds:
      Hi Stephanie. Great question. This is one that often is very confusing and challenging for psychotherapists. One of the major concerns involves the different but related roles of ethics, law, and clinical practice. I believe some of what is behind your question concerns the issue of “duty to warn and protect” that comes from the landmark Tarasoff decisions in 1974 and 1976 (Tarasoff v. Regents of the University of California.

      In 1974 in the initial ruling the court opined that “where a psychotherapist had reason, arising out of a professional relationship with a patient, to believe, or reasonably should have believed, that the patient was intending to harm a specific victim, that a duty existed to warn that victim” (Mills, 1984).

      In 1976 the court revised and updated its opinion, adding to the obligation to warn the intended victim with the need to take actions to protect the intended victim such as by contacting the police, and possibly by even using treatment to prevent the harm from occurring.
      The Tarasoff rulings set legal precedent. But, over the years as states have passed laws to address these issues, the precedent has been codified into law. Yet, various states’ laws are different in their requirements. Some states have duty to warn statutes, some have duty to protect statutes, some have duty to warn and protect statutes, and some include treatment in their statutes. For example, in Maryland , the law is the duty to warn, protect, or treat. That is, if treatment can prevent harm to another person from occurring , it should be used first. Confidentiality should only be breeched in these situations when treatment is ineffective or is not possible.

      But, it is important to note that the Tarasoff rulings and these various state laws are speaking of a specific threat made in treatment to do harm (typically interpreted as lethal harm) to an identifiable victim or group of victims. This brings up several important points. First, it must be a threat to do harm. This implies that the harm did not already occur. The goal of these laws is to prevent future harm. Second, it must be an identified victim, otherwise who would we warn and who would the police potentially take action against? Third, the harm that is threatened should be lethal. If a client said in session that later that day they are going to punch their spouse, this would not meet the standards needed for breaching confidentiality.

      But, if one’s state law allows for this the psychotherapist should always consider treatment as the first option. These laws do not require that the psychotherapist make a call to the intended victim and to the police the moment a client discloses such a threat. We are to conduct a thorough risk assessment, address these issues in the treatment plan, and work to address underlying issues, in an effort to prevent the harm from occurring, and thus, to prevent the need to breech confidentiality.

      With regard to the issue of a client with HIV or AIDS disclosing engaging in unprotected sex with other individuals this is of course a very serious concern that will hopefully be addressed in treatment. With regard to breaching confidentiality there are several issues of relevance and great importance. First, it is essential that we always include potential limits to confidentiality in our informed consent agreements with our clients. Then, the following factors are relevant: intent to do harm, likelihood of actual harm occurring, the inability to know the identity of future sexual partners, and the likely presence of consent to engage in these behaviors (Chenneville, 2000). When it comes to unprotected sexual behavior one might reasonably argue that your client’s partners are engaging in this behavior consensually. To date there has been so much education about sexually transmitted diseases, practicing safe sex, and the like, that this situation can be seen as substantively different than the typical Tarasoff-like situation. Of course, if your client stated in session that he was going to rape a specific individual in the future and to do so without a condom, that might more closely approximate the need for the Tarasoff-like actions described above. But, when considering lethal actions, unprotected sex by an HIV-Positive or AIDS-infected individual is does not possess the lethality of shooting, stabbing, etc. another person. The rate of transmission of HIV from unprotected sex is not even close to 100% and for those who are infected there now exist effective treatments.

      Thus, it is important to keep in mind the requirements of your state’s laws. This includes duty to warn, protect, and treat laws as well as those relevant to reporting HIV. Some states do not all the reporting of HIV or AIDS status by licensed psychotherapists (e.g. Wisconsin) while other states require the reporting of it (e.g. Washington). So, knowledge of the relevant laws in one’s jurisdiction is essential. It is also important to keep in mind that breeching confidentiality due to harm to others has strict limitations. The harm must be threats of harm in the future, not in the past or ongoing. Additionally, the harm typically must have potentially imminent lethality (again, check your state laws for their specific wording). Finally, if these issues can effectively be addressed in treatment, that is preventing the risk of future harm through treatment, that should carefully be considered unless your state’s law contraindicates this. When addressing these issues are addressed in treatment it is important to thoroughly document all discussions, recommendations, interventions and actions taken, your client’s responses, and all consultations. Further, it’s not just important to document what you did, but also all that you considered and the rationale behind your decisions.

      I hope this is helpful to you. I do not represent myself as an attorney or an expert on every jurisdiction’s laws, and I do not know all the details of your case. But, I do hope this provides some issues for consideration and discussion. Please feel free to share your comments and any additional thoughts. I also welcome other members sharing their thoughts and perspectives on this important and challenging issue.

      References
      Chenneville, T. (2000). HIV, confidentiality, and duty to protect: A decision-making model.
      Professional Psychology: Research and Practice, 31(6), 661-670.
      Mills, M. (1984). The so-called duty to warn: The psychotherapeutic duty to protect third parties from
      patients’ violent acts. Behavioral Sciences & The Law, 2(3), 237-257.

  5. Taline Andonian says:

    Dr. Barnett,
    As graduate students we receive training not only in academia but in a myriad of different clinical settings, which often lead to a wide range of experiences in terms of supervision. Because of the emphasis that is placed on clinical/practical training for clinical psychology programs in particular a graduate student’s competencies are strongly related to the quality and type of supervision that he or she receives during practica experiences. Given this, how important do you think it is for supervisors of graduate students to receive training in the area of supervision? Should there be specific competency requirements for psychologists or other mental health clinicians who plan to train graduate students?

  6. Faith Prelli says:

    I have a client (18yr female) who I have seen twice a week for 8 months who is currently in a relationship plagued with intimate partner violence. This has been dubbed “mutual combat” by several of my co-workers, but in exploration with her, it appears as though the severity of his violence, his physical strength, and his emotional control create a dynamic where she sometimes reacts with violence (i.e., pushing him so she can escape, scratching his arms when they are around her neck) She has asked to begin couples therapy with her partner, and he has agreed. I am familiar with some of the literature on couples therapy and intimate partner violence and have had some training in this area, but no one else at my location (a community mental health center) is trained in couples therapy and/or intimate partner violence. My agency is now discussing the possibility of me seeing them as a couple while continuing to see her. Are there guidelines or best practice recommendations about whether it would be appropriate for me to see them as a couple?

  7. Jennifer Weinstein says:

    Dear Dr. Barnett,
    Currently, there is a push for people to be on medication, and clients often come in stating that they want medication. This is especially true in multidisciplinary environments where psychiatrists and APRNs work alongside psychotherapists. However, some people do not have this mindset. For therapists who believe that medication only needs to be used as a last resort or in obvious serious situations, is it ethical to not refer everyone to a med provider, and instead of offering medication right off the bat, to wait and try and achieve success in therapy first, in the hopes that medication will not be needed?

  8. Linda Moore says:

    Dear Dr. Barnett,

    In Jeff Magnavita’s statement regarding his vision for the future of Div 29, he stresses the importance and use of technology in psychotherapy research and practice. As you are likely aware, more and more psychologists are using technology and audio-visual (AV) recording as part of their psychotherapy practice, supervision, presentations and research. At the same time, I have found it very difficult to find detailed and/or current technical and practical information or ethical guidelines for the use of these technologies.

    In addition to specific technical, equipment and practical questions that arise in the use and implementation of audio-visual recording of psychotherapy sessions, I have a number of ethical questions as well. The following are some of the initial questions that come to mind:

    1) What should be included in an appropriate informed consent for AV recoding of a therapy session? For use in written and/or live presentations? For research use? For supervision and/or peer consultation?
    2) What procedures should be followed to ensure HIPPA compliance if AV recordings are used in long distance supervision/consultation? I know some ths have sent tapes of sessions by mail. What type of mail service is adequate? Do the AV therapy recording need to be encrypted? If so, how? For example, what programs will do this on a PC for a DVD, what about video tapes etc.?
    3) What procedures are appropriate to attract and obtain participation of pts in research and/or training projects? For example, for institutional/formal and private/informal research projects or for use in the training of other professionals, can the researcher/therapist offer free or reduced rate treatment for a pts participation in projects that require the use of AV recording? I think something along this line is relatively common practice in much of medical research.

    I would appreciate your thoughts on these concerns and input on where to find any existing guidlines.

    Thanks for your time,
    Linda

  9. Chris Overtree says:

    Dear Dr. Barnett,

    I have a client referral who is requesting, via an anonymous email message, to be screened by me as a possible patient anonymously. Although he states he is not suicidal or homicidal, nor does he meet any of the criteria for possible involuntary hospitalization (by his own report), he remains extremely concerned about allowing this judgement to be made by someone (e.g. me) other than himself. He wants to talk about his concerns, learn more about treatment, and then “walk away” if that is what he decides. Do I have any ethical or professional considerations to make if I accept his terms?

  10. I have been treating a man with complex PTSD who started to see me after his transference feelings toward his previous psychotherapist became unmanagable. He sees me infrequently and has consulted with about 5 subsequent therapists who he reports trigger his trauma. He frequently emails me and occasionally sees me for a session but also sees other therapists. I have decided to allow him to do so even though I worry about his overall stability and therapist shopping. I sometimes feel as if I would like to tell him to discontinue treatment with me but feel that allowing him to utilize me this way provides some benefit. Is it OK to continue to allow him to see me infrequently and use email to maintain the attachment?