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An Ethical Decision-Making Process

By: Ofer Zur, Ph.D.
 

 

 

Ethical Decision-making

Ethical decision-making in psychotherapy has received much attention. Many texts have focused on the principles of ethics in psychology (e.g., Beauchamp & Childress, 1983; Herlihy & Corey, 2015; Kitchener, 1984; Knapp & VandeCreek, 2012; Younggren & Gottlieb, 2017; Zur, 2007, 2017). As with the general principles of the APA (2017) Code of Ethics, they view the following five moral principles as the foundation of ethical decision-making:

Important guidance to consider when deciding if a planned multiple relationship is acceptable and is found in the aspirational ethical ideals of the profession as articulated in the General Principles of the APA Ethics Code (APA, 2017):

  1. Beneficence and Nonmaleficence: Providing help and assistance to clients while avoiding harm to them. Further, psychologists “are alert to and guard against personal, financial, social, organizational, or political factors that might lead to misuse of their influence” (p. 3).
  2. Fidelity and Responsibility: Fulfilling expected obligations to clients and only acting in ways that serve their best interests. This includes that psychologists “seek to manage conflicts of interest that could lead to exploitation or harm” (p. 3).
  3. Integrity: Acting ethically and honestly; not misleading, manipulating, or taking advantage of others; and endeavoring to “avoid unwise or unclear commitments” (p. 3).
  4. Justice: Treating each individual fairly and to ensure that each individual has “access to and benefit from the contributions of psychology and to equal quality in the processes, procedures, and services being conducted by psychologists (p. 3).
  5. Respect for People’s Rights and Dignity: Respecting and valuing all individuals regardless of individual differences and minimizing the effects of biases one may have. Additionally, “Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making” (p. 4).

Additional considerations in determining if a multiple relationship is acceptable or should be avoided include:

  • Availability of options and alternatives.
  • The potential for exploitation of, or harm to the client(s).
  • The relevance of the secondary relationship to the goals of treatment and the potential benefit to the client (Younggren & Gottlieb, 2004).

The ability to keep separate, or compartmentalize, the multiple roles and relationships so that the secondary relationship does not adversely impact the psychotherapy relationship (Austin, et. al., 2017; Barnett, 2015, 2016, 2017; Barnett & Yutrenzka, 1994; Boland-Prom & Anderson, 2013; Burgard, 2013; Corey & Herlihy, 2015; Dell, 2015; Dell, 2015; Halverson & Brownlee, 2010; Herlihy & Corey, 2015; Kaslow,Patterson & Gottlieb, 2011; Koocher & Keith-Spiegel, 2016; Zur, 2007, 2017).

  • Obligations to various individuals and organizations and any conflicts between their requirements and expectations.
  • The potential for impaired judgment or objectivity on one’s part in this decision-making process.

Several texts outline ethical decision-making for psychotherapists as being broad and inclusive and, as such, cover general ethical decision-making as well as concerns with therapeutic boundaries (e.g., Canter et. al., 1996; Corey et. al., 2003; Haas & Malouf, 1989; Herlihy & Corey, 2015; Koocher & Keith-Spiegel, 2016; Reamer, 2012; Welfel, 2002). Most of the ethical decision-making models identify several basic steps that comprise the ethical decision-making process. These steps include:

  • identifying the relevant ethical conflicts involved;
  • identifying the relevant section of the professional code of ethics;
  • development of alternative courses of action;
  • risk-benefit analysis of the likely short- and long-term consequences of each course of action on the individual(s) and/or group(s) involved or likely to be affected;
  • making an informed choice of course of action and applying the relevant ethical principles; evaluating the results of the course of action;
  • modifying the course of action as required or re-engaging in the decision-making process, if necessary.

Most of the models also emphasize the importance of involving the client in various junctions of the process.

Ethical Decision-making Regarding Boundary Crossings and Dual Relationships

A few texts focus on ethical decision-making and guidelines in regard to boundary crossings and dual relationships. Koocher and Keith-Spiegel (2017), Gutheil and Gabbard (1993), Corey et. al. (2015), Zur (2007), Smith and Fitzpatrick (1995), and Welfel (2002), among others, provided guidelines for handling boundary crossing in therapy. Some others have provided more specific guidelines, such as those for handling nonsexual touch (Hunter & Struve, 1998; Nordmarken & Zur, 2004; Smith et al, 1998), gifts (Knox et al., 2003; Smolar, 2003), bartering (Hill, 1999), or self-disclosure (Barnett, 1998; Peterson, 2002).

Several other authors have provided more specific models and guidelines for handling dual relationship situations. Kitchener (1988) bases her model on role theory and centers on the role conflicts created in multiple relationships. Her model lists three guidelines to differentiate between dual relationships that are likely to be problematic and those that are less likely to lead to conflicts.

  • The first guideline concerns incompatibility of role expectations, such as between the clinical and the social.
  • The second guideline states that as the obligations of different roles diverge, the potential for divided loyalties and loss of objectivity increases.
  • The third guideline states that as the power and prestige differential between client and therapist increases so does the potential for exploitation.

Based partly on the above model, Anderson and Kitchener (1998) propose an ethical decision-making model for posttherapy nonsexual dual relationships. They identify eight different dual relationships in which psychologists may engage. These relationships vary from incidental and unavoidable to intentional relationships formed after the therapeutic contact. Their model presents a series of questions around the following four general concerns in making a decision to enter a posttherapy relationship:

  • the initial therapeutic contract and termination considerations;
  • the dynamics and strength of the therapeutic bond, the power differential, and the potential of the new relationship to be counter-clinical;
  • the social role and expectations;
  • the therapist’s motivation for seeking or having a multiple relationship.

Gottlieb’s (1993) model uses three dimensions to assess the potential for harm from dual relationships:

  • power differential;
  • duration of treatment;
  • termination and potential future clinical engagements.

Gottlieb suggests that the psychologist assess the nature and intensity of the current relationship and evaluate the role incompatibility of the multiple relationships and possible role conflict. Ebert (1997) provides a comprehensive model for ethical decision-making for dual relationships that is based on conflict of interest. He argues that the construct of multiple relationships is not very useful because dual relationships can be unavoidable and helpful. Hence, it is not the dual relationship per se, but its potential to harm through conflict of interest that can lead to ethical violations. Lazarus and Zur (2002) and Zur (2007, 2017) provided a simpler decision-making model, which is based on clients’ specific needs, the setting, and, above all, whether the dual relationship is likely to be harmful, helpful or inconsequential. Finally, Younggren & Gottlieb (2017) suggest the following five questions for therapists who attempt to manage risk associated with multiple relationships:

  1. Is entering into a relationship in addition to the professional one necessary or should I avoid it?
  2. Can the dual relationship potentially cause harm to the patient?
  3. If harm seems unlikely or avoidable, would the additional relationship prove beneficial?
  4. Is there a risk that the dual relationship could disrupt the therapeutic relationship?
  5. Can I evaluate this matter objectively?

In addition to the above specific models for ethical decision-making regarding dual relationships, several other articles incorporate a decision-making process into their discussion of dual relationships (e.g., Barnett, 1999; Gutheil & Gabbard, 1993; Herlihy & Corey, 2015; Koocher & Keith-Spiegel, 2016; Sterling, 1992). These texts all acknowledge that dual relationships are not always avoidable, focus on the code of ethics, and stress the importance of context issues, such as the type and length of therapy and setting or communal considerations. Additionally, they all underscore the importance of awareness of potential conflict of interest.

Critical Thinking

Besides general ethical decision-making and specific ethical decision-making as it relates to dual relationships, a third area that is often under-emphasized in the decision-making process is the critical thinking process. Critical thinking has been identified as the ability and willingness to assess claims and make objective judgments on the basis of well-supported arguments and data. It involves the ability to look for flaws in assessments and oppose claims that have no supporting evidence (Reamer, 2012; Younggren & Gottlieb, 2017; Zur, 2005b, 2007, 2017). Critical thinking is based on the willingness, not only to ask difficult, unpopular questions, but also to be on the lookout for questions that have not been answered by textbooks and experts.

The critical thinking process usually follows a clear set of principles: to begin, it is necessary to define the problem or formulate the questions without resorting to over-simplification or over-generalization. The evidence and actual facts must be carefully examined together with an in-depth look at the unstated or possibly hidden motivations behind certain statements or positions. It is important to establish who may benefit from a certain decision and if there are other important stakeholders in addition to those directly involved. Impartial analysis of the assumptions and biases of all involved should be undertaken while assiduously avoiding emotional, intuitive, or faulty reasoning. Competing interpretations, even those that seem far-fetched or improbable, must be explored and considered. It will then be possible to formulate hypotheses that offer sound explanations of characteristics, behavior, and events.

On Risk-Benefit Analysis of Action and Inaction

Therapists should ask themselves certain questions before making a decision to share personal information with clients, send a greeting card, accept an embrace, or engage in dual relationships. The same is true before deciding if it is ethical to make a home visit or accept a gift. In the spirit of critical thinking, therapists must consider which are the right questions to ask.

These questions may be: “Should I cross this boundary (i.e., give/accept this gift)?” “Is it ethical to cross this boundary?” “What is the risk-benefit analysis for carrying out or not carrying out the proposed action?” Questions such as the first two, that focus on whether to cross or not or if a certain action is ethical or not, are likely to generate a narrower analysis than the last question which focuses on the risk-benefit of doing or not doing something. The question, “Should I accept this gift?” is likely to be met with a response such as, “Yes, accepting this gift is likely to enhance the client’s sense of self and strengthen the relationship between me and my client, who is struggling with low self-esteem and her relationship with rejecting parents.” Or, “No, accepting this gift is likely to support her belief that she can be loved only if she gives gifts.” Responding to the question, “Is it ethical to accept the gift?” may be answered by “Yes, it is ethical to accept the gift as there is nothing in the codes of ethics that states that it is unethical.”

Responding to the risk-benefit questions invites a broader analysis, which includes both potential harm and potential benefit for following or not following the course of action. For example: the risk of accepting a gift from this particular client involves affirming her belief that she is not lovable, interferes with the transference analysis, and may give her the impression that the therapist is greedy. On the other hand, accepting the gift is likely to enhance the therapeutic alliance and allow the client to experience the therapist’s expression of gratitude. The risk of not accepting the gift is the client experiencing shame, rejection, and an irrevocable rupture of the therapeutic alliance. It is important to know the cultural background of the client and whether refusing a gift is likely to be perceived as an insult or even a mortal offense. Rejection of the gift may result in the client dropping out of therapy. The potential benefit of not accepting the gift is that it may enable the client to become conscious of and verbally articulate her desire to be accepted and loved rather than “acting it out” by giving a gift.

Risk-benefit analysis of actions or inactions clearly brings to the forefront the context of therapy (i.e., clients’ factors, setting, and therapists’ factors) and the fact that there is no such thing as a medical intervention (and perhaps not any human action) that is not associated with risk. Decision-making processes that are solely based on “do not harm” without including the balancing mandate to act in the client’s best interest are inherently defective and are likely to yield flawed conclusions. The ethical imperative is to act competently and in the best interest of clients and not to exploit them. With rare exceptions, such as sexual relationships, a rational recommendation cannot be made about the ethical status of an action without knowing both its potential risks and the potential benefits.

Risk management has been one of the major concerns when making decisions regarding boundaries. As a result, the question, “Should I accept this gift?” is often answered negatively because of the risks posed by possible confrontation with boards and ethics committees or because it may be perceived negatively in court. However, if the question is articulated more broadly and includes risk-benefit analysis for action and inaction, risk management considerations are only one component that should be weighed against many other factors, primarily those involving the best interests of the client. Therefore, risk-benefit analyses do not simply reject boundary crossing because it involves risk; instead they invite therapists to ask the question “Are these risks justified?” or “Do these risks outweigh the benefits or not?” Therapists must take into consideration that they can actually do harm in the attempt to avoid harm (Fay, 2002). Of course, therapists must be committed to preventing and deterring intentional harm and negligent harm. Risk-benefit analysis also eliminates taking unnecessary risks. Therapists cannot make the unilateral decision to “do no harm.” Such an attempt may eliminate some of the most promising therapeutic modalities.

A Decision-Making Process

Following is a seven-step decision-making process that utilizes the codes of ethics to include critical thinking and to emphasize flexibility and clinical effectiveness. As it takes a broad approach to the decision-making process, it does not focus on specific concerns with power, power differential, length and intensity of the therapeutic relationship or transference. Instead, these concerns are incorporated into the specific model and are attended to when necessary and applicable.

Based partly on the above-mentioned ethical decision-making models and incorporating moral and critical-thinking principles, among others, the following is the progression for ethical decision-making for boundaries in psychotherapy.

The first step is identifying the issue. This can vary from the suitability of accepting a gift to consulting with a certain client at the therapist’s home office to the propriety of establishing a bartering relationship to the suitability of accepting a fellow congregation member as a client.

The second step is identifying the relevant moral, ethical, clinical, legal, professional, and other issues and conflicts involved. These may include concern with the client’s welfare, the client’s family and community, or possibly the hospital or military institution where the client is located. Issues of nonmaleficence, beneficence, fidelity, respect, responsibility, justice, and integrity are all of great consequence to this step. The codes of ethics are especially pertinent to this stage but the inquiry may include additional moral, philosophical, spiritual, and community values as well as other germane considerations. At this point, some conflicting issues may arise. Making a home visit or attending a wedding may be clinically advised but may compromise the client’s privacy and confidentiality, may pose physical danger to the clinician, may be viewed as risky by risk management experts, and may be disallowed by the clinic or the institution where therapy takes place. If a client offers the therapist a gift, the clinical, moral, cultural, spiritual, economical, and relational aspects of the gift may be relevant as they may be in conflict with one another. Entering into dual relationships with a client may be appropriate for the client from a clinical point of view but may affect other members in the community negatively.

This stage is aimed at mapping, as broadly as possible, the ethical, professional, and other relevant complexities, not resolving them. Prematurely narrowing the scope of the questioning and inquiry risks ruling out potentially valid options and may lead to an unsubstantiated, unethical, or harmful decision. When trying to identify the ethical issues involved, one may realize that the concerns are not always ethical but some are purely clinical or legal. Dare to wonder. Question each element, allowing the imagination a free rein but testing each thought critically against all the values that are the best part of the profession of psychotherapy.

The third step is to develop a series of alternative courses of action. Like the second step, this step invites the therapist to think broadly and consider as many options as possible. Prematurely reducing the options may distort the process and create an undesirable course of action. For example, prematurely ruling out touch, expensive gifts, or going on a nature hike with a client may inappropriately limit the clinical options. Inappropriately ruling out home visits or bartering will deprive innumerable ill or aging homebound or cash-poor people from receiving psychotherapy services. Prematurely ruling out all dual relationships will leave millions of people in rural areas without access to psychotherapy. It is imperative that risk management considerations not interfere with the development of alternative courses of action. Even though many scholars have warned us that most boundaries should be avoided because they pose risks for therapists, these options should nevertheless be considered during this phase.

The fourth step is conducting an analysis of the likely short-term, ongoing, and long-term risks and benefits of each course of action or inaction for anyone involved or likely to be affected. Besides the individual client(s), this may include the client’s family, loved ones, employees, place of employment, therapist, colleagues, community, or society. Such evaluations of pros and cons of certain actions and the avoidance of these actions can be highly complicated and difficult. The pros and the cons must take into consideration clinical, ethical, and legal aspects, as well as the standard of care. This leads to a consideration of the context of therapy, which includes clients’ factors (i.e., presenting problem, gender, culture, history, etc.), setting (i.e., private practice, military base, home office, mobile clinic on the reservation, etc.), and therapists’ factors (i.e., gender, culture, primary therapeutic orientation, etc.). Obviously, this step can present contradictory options and even opposing courses of actions.

The fifth step involves first separately weighing the risks against the benefits within each option and then comparing them and choosing a course of action. Obviously, the chosen course of action will rarely be ideal or perfect; it is only what seems best under the carefully examined circumstances.

Therapists must remember that applying such a thorough process (and documenting it) aligns them with the standard of care. Therapists are not judged by the outcome of their actions, as there is no guarantee that there will be no harm. They are judged by the integrity of their methodologies and decision-making processes. For example, the fact that a client committed suicide is not, by itself, an indication that the therapist operated below the standard of care. Therapists are evaluated and judged by the rationale for the interventions and process that is embedded in the decision-making process. In the case of a client who committed suicide, they will be evaluated by their methods of assessing risk and danger and the decision-making process followed in respect to averting harm.

The sixth step involves implementing the course of action chosen through the risk-benefit analysis. This involves articulating a treatment plan, which generally includes short-term, and, when necessary, intermediate and long term goals; employing interventions aimed at achieving these goals; outlining a theoretical-clinical rationale and/or empirical support for the proposed interventions; and establishing ways to evaluate the effectiveness of the interventions. As with any clinical and other interventions, this step must be carried out with thoughtfulness, flexibility and sensitivity.

The seventh step involves developing ways to assess the success or effectiveness of the plan and responding to the results of the assessment by either continuing, if it has proven successful, or modifying or discontinuing, if it has failed to accomplish some or all of its objectives. In the latter case, the therapist should re-engage in the decision-making procedure and develop an alternate course of action and a modified or new treatment plan.

References

 
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