ETHICS: CASE STUDIES I

Presented by

CONTINUING PSYCHOLOGY EDUCATION INC.

6 CONTINUING EDUCATION HOURS

“What makes an action right is the principle that guides it.”

T. Remley and B. Herlihy (2007)

Course Objective Learning Objectives

The purpose of this course is to provide an Upon completion, the participant will be able to:
understanding of the concept of ethics as 1. Explain the meaning and purpose of ethical
related to therapists. Major topics include: behavior.
competence, therapist impairment and burnout, 2. Understand the ethics of therapist competence.
client termination, informed consent, client 3. Recognize therapist impairment and burnout.
right to refuse treatment, and legal/ethics case 4. Discuss ethical standards pertaining to
studies. client termination.
5. Comprehend the historical development of
Accreditation informed consent.
Continuing Psychology Education Inc. is approved 6. Expound upon information to be included in
by the Illinois Department of Financial and informed consent material.
Professional Regulation as a continuing education 7. Interpret various Codes of Ethics.
sponsor for LCSWs and LSWs 8. Apply ethical standards to case studies.
(License # 159-000806), and for LCPCs and LPCs
(License # 197-000108). This course is approved by Faculty
the Illinois Department of Financial and Professional Neil Eddington, Ph.D.
Regulation for 6 hours of continuing education for Richard Shuman, MFT
LCSWs, LSWs, LCPCs and LPCs.

Mission Statement
Continuing Psychology Education Inc. provides the
highest quality continuing education designed to
fulfill the professional needs and interests of mental
health professionals. Resources are offered to
improve professional competency, maintain
knowledge of the latest advancements, and meet
continuing education requirements mandated by
the profession. Copyright  2010 Continuing Psychology Education Inc.

1 Continuing Psychology Education Inc. P.O. Box 2517 Springfield, IL 62708 FAX: (858) 272-5809 Phone: 1 800 281-5068
www.texcpe.com
ETHICS: CASE STUDIES I

INTRODUCTION Herlihy and Corey (1996) advise therapists to be wary of

unethical or questionable behavior such as extending the
The Codes of Ethics of the professional mental health number of therapy sessions to fulfill their own emotional or
organizations, including the National Association of Social financial needs; being unaware of countertransference
Workers (NASW, 1999), American Association for Marriage reactions to a client thereby heightening resistance and
and Family Therapy (AAMFT, 2001), American Counseling slowing growth; impressing values on clients incongruent
Association (ACA, 2005), and American Psychological with their cultural background; utilizing techniques or
Association (APA, 2002), serve to educate members about strategies comfortable for therapist but not necessarily
sound ethical conduct, professional accountability, and functional for client; and practicing with apathy and little
improved practice through mandatory and aspirational ethics. enthusiasm. Golden (1992) observed that many ambiguities
Mandatory ethics describes compliance with the “musts” and may abound during therapy, thus “When we find ourselves
“must nots” of the ethical standards and are enforceable navigating in waters that are not clearly charted by our
whereas aspirational ethics involves the highest standards of profession’s ethical codes, we must be guided by an internal
conduct to which one can aspire, implies one understands the ethical compass.”
moral fiber behind the code, suggests doing more than the This course uses cases that have been adapted from actual
minimum requirement and they are not enforceable. NASW incidents to illustrate realistic and common ethical issues
(1999) promotes the following aspirational ethics, termed facing practitioners; the names have been omitted to protect
“Ethical Principles” as ideals to which social workers may the privacy of those involved except when cases are already
aspire: public information through books, newspapers, or media.
• Service – Helps people in need and addresses social Codes of ethics, which represent moral principles created by
problems the various mental health organizations to provide guidance
• Social Justice – Challenges social injustice for right conduct and are binding on their members, and key
• Dignity and Worth of the Person – Respects the literature, are utilized to assist practitioners in making sound
inherent dignity and worth of the person ethical decisions promoting the welfare and best interests of
• Importance of Human Relationships – Recognizes the their clients and to avoid ethical conflicts.
central importance of human relationships
• Integrity – Acts in a trustworthy manner COMPETENCE
• Competence – Practices within established areas of
competence and evolves professional expertise Clients disclose their most personal secrets and struggles
Professionals assume a fiduciary obligation with their during therapy thus placing themselves in a vulnerable
clients, implying a “special duty to care for the welfare of position requiring therapist competence. “When clients put
one’s clients or patients” (Haas & Malouf, 1995, p. 2), their trust in us as professionals, one of their most
therefore, the professional’s standard relative to moral fundamental expectations is that we will be competent”
principles is much higher than the ordinary citizen’s. Meara, (Pope & Vasquez, 1991, p. 51). Competent professionals
Schmidt and Day (1996) believe that a virtuous professional uphold two essential ethical principles: beneficence, which is
upholding a fiduciary relationship would: a) be motivated to attempting to do only good for the client, and
do what is good, b) have vision and discernment, c) realize nonmaleficence, which is never doing harm. Welfel (2006)
the function of emotion in judging proper conduct, d) possess believes that competence includes a combination of
a high degree of self-understanding and awareness, and e) knowledge, skill, and diligence. Effective practice requires
comprehend the mores of his or her community and the intellectual and emotional competence (Pope & Brown,
legitimacy of client diversity (pp. 28-29). Contrarily, 1996). The intellectual component consists of attaining a
Koocher and Keith-Spiegel (2008) list characteristics of knowledge base, assessing and planning effective treatment
practitioners who demonstrate questionable, unethical or for a client or issue, and understanding one’s therapeutic
unprofessional behavior: limitations (i.e., a child specialist may lack skills required for
1. Are unaware or misinformed of the ethical standards older adults). Emotional competence relates to managing
2. Offer treatment outside the scope of their practice clinical information, personal biases, and self-care (Pope,
3. Display insensitivity to the needs of others or to situational Sonne, & Greene, 2006; Welfel, 2006). The concept of
dynamics competence has been difficult to define, though many efforts
4. Exploit clients by putting their own needs first have manifested through the development of ethics codes,
5. Act irresponsibly due to stress, laziness, non-awareness, standards of practice and practice guidelines, third-party-
or inattention payer quality assurance programs, state licensing and
6. React with vengeance against clients for perceived harm certification boards (Packard, Simon, & Vaughn, 2006), and
7. Experience burn-out or other emotional impairment specialized credentialing authorities. Nonetheless, uniform
8. Reveal interpersonal boundary issues agreement within the mental health field on the definition of
9. Are self-serving competence is lacking (Claiborn, 1982; Kaslow, 2004).
10. Generally, are ethical but occasionally blunder resulting Additionally, incompetence is often difficult to prove given
from oversight or distraction
2 Continuing Psychology Education Inc.
Copyright  2010 Continuing Psychology Education Inc.
ETHICS: CASE STUDIES I

the legal requirements of due process and supportive upcoming divorce. Client’s attorney asked therapist to testify
evidence. that client should receive child custody of her 7 year-old.
Peterson and Bry (1980) studied competence by examining Therapist lacked previous forensic experience or training but
appraisals of 126 Ph.D. students by 102 faculty and from the witness stand he offered opinions about the
supervisors. The dominant characteristic for “outstanding” adjustment of client and her child. Client’s husband filed an
trainees was “high intelligence” and “lack of knowledge” for ethical complaint against therapist on the grounds that he
incompetent trainees. Supervisors rated students the lacked training in child work and he never interviewed the
following year and determined the following four factors as child, thus he was negligent in offering an opinion.
central to competence: professional responsibility, Furthermore, this therapist did not attain information from
interpersonal warmth, intelligence, and experience. another therapist who was seeing the child, nor from the
The minimum competence standards for therapists are child’s father.
based on academic training and supervised experience Case 1-3: Practitioner completed graduate training in the
culminating in professional licensure. The counselor’s 1970s, before clinical neuropsychology evolved as a
license does not specify the type of clients, issues, or specialty with more advanced assessment tools. She has not
interventions he or she may address, instead, the practitioner studied neuroanatomy and her practice is mainly in
is ethically obligated to restrict practice to areas of psychotherapy. She accepted an attorney’s referral to assess
qualification based on training and experience. Attorneys a client who sustained a closed head injury and resulting
and physicians are not competent to practice in every aspect language, memory, and perceptual sequellae and she used her
of law and medicine, likewise, psychotherapists are not 1970s techniques.
competent to treat all people for all issues (Brenner, 2006; Analysis: In each case, therapist did not identify the limit or
Halderman, 2006; Maxie, Arnold, & Stephenson, 2006). The scope of his or her practice and training which led to crossing
ethical codes of the mental health organizations cite the ethical boundaries. The first case reveals a counselor lacking
following regarding competence: in minimum competence levels, training and experience. Her
Social workers should provide services and represent themselves as efficacy would only come into question if a formal complaint
competent only within the boundaries of their education, training, license,
was filed, nonetheless, therapists have an ethical
certification, consultation received, supervised experience, or other relevant
professional experience (NASW, 1999, 1.04.a.). responsibility to practice in specialty areas that are new to
Marriage and family therapists… maintain competence in marriage and them only after obtaining suitable education, training and
family therapy through education, training, or supervised experience supervised experience, and precautions must be taken to
(AAMFT, 2001, 3.1).
Counselors practice only within the boundaries of their competence, based
ensure competent work during the learning process. In the
on their education, training, supervised experience, state and national second case, practitioner was not cognizant of forensic
professional credentials, and appropriate professional experience practice or expert witness requirements that could have
(ACA, 2005, C.2.a.). created negative outcomes for all involved. He violated
Psychologists provide services, teach, and conduct research with populations
and in areas only within the boundaries of their competence, based on their
APA’s ethic code (APA 02: 9.01.a) which states,
education, training, supervised experience, consultation, study, or “Psychologists base the opinions contained in their
professional experience (APA, 2002, 2.01.a.). recommendations, reports, and diagnostic or evaluative
Competence also has legal implications because society statements, including forensic testimony, on information and
expects practitioners to be competent and it upholds these techniques sufficient to substantiate their findings” and ethics
high standards through licensing boards and the court system. code (APA 02: 9.01.b) that professes, “… Psychologists
Counselor incompetence is the second most often reported provide opinions of the psychological characteristics of
area of ethical complaint (dual relationships is first) as individuals only after they have conducted an examination of
indicated by Neukrug, Millikin, & Walden (2001). Given the individuals adequate to support their statements or
client harm, a therapist is open to lawsuit for malpractice and conclusions.” The therapist in the third instance had not kept
can be legally responsible in a court of law; many such current with newer neuropsychologial assessment techniques
lawsuits focus on competence. Therapists are encouraged to and appeared unaware of expert witness ethical
be cognizant of guidelines or standards applicable to their responsibilities. In such situations, practitioners are advised
areas of specialization as a best practice for demonstrating to seek formal education, training, consultation or
professional competence and lowering liability risks (Bennett supervision with an expert in that specialty. Considering that
et al., 2007). competence is difficult to define and assess, self-monitoring
Koocher & Keith-Spiegel (2008) present the following five is an effective method to ensure quality therapeutic service as
cases: reflected in these ethics codes:
Case 1-1: Therapist had practiced individual psychoanalysis Psychologists planning to provide services, teach, or conduct research
involving populations, areas, techniques, or technologies new to them
for ten years. After completion of a four-hour continuing undertake relevant education, training, supervised experience, consultation,
education workshop on family therapy, she offered family or study (APA, 2002, 2.01.c.).
therapy sessions to some clients while reading books in this Counselors continually monitor their effectiveness as professionals and take
field in her spare time. steps to improve when necessary. Counselors in private practice take
reasonable steps to seek peer supervision as needed to evaluate their efficacy
Case 1-2: Counselor treated a woman for six months with as counselors (ACA, 2005, C.2.d.).
various adjustment issues following a separation and

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ETHICS: CASE STUDIES I

While developing new skills in specialty areas, marriage and family about Mrs. Romero and her current husband without previous
therapists take steps to ensue the competence of their work and to protect
clients from possible harm. Marriage and family therapists practice in
evaluation. He also chose to ignore Mr. Austin’s history of
specialty areas new to them only after appropriate education, training, or alcoholism. Whether he lacked forensic experience, was lazy
supervised experience (AAMFT, 2001, 3.7). in collecting information, or was biased against certain
Social workers should provide services in substantive areas or use groups, the displayed incompetence produced dismal
intervention techniques or approaches that are new to them only after
engaging in appropriate study, training, consultation, and supervision from
consequences for Mrs. Romero and her family (Kitchener,
people who are competent in those interventions or techniques (NASW, 2000).
1999, 1.04.b.). Successful graduation from an accredited graduate program
does not necessitate or guarantee competence (Kitzow,
Case 1-4: Therapist performed a cognitive evaluation of an 2002). Determining competence with respect to various
adult utilizing the Wechsler Adult Intelligence Scale-Revised types of clients and issues is a decision requiring ethical and
(WAIS-R), four years after the revised WAIS-III was professional integrity often made by the individual
published. He responded, “They’re about the same, and the professional. The ethics codes indicate the following
new kit is too expensive.” concerning developing new skills:
Case 1-5: Counselor continued treating his child clients with (AAMFT, 2001, 3.7 – already cited).
When generally recognized standards do not exist with respect to an
long-term psychotherapy for secondary reactive enuresis
emerging area of practice, social workers should exercise careful judgment
despite significant evidence that certain behavioral treatments and take responsible steps (including appropriate education, research,
are very effective in a brief time. When confronted with this training, consultation, and supervision) to ensure the competence of their
information, he seemed surprised and then researched the work and to protect clients from harm (NASW, 1999, 1.04.c.).
Counselors practice in specialty areas new to them only after appropriate
professional literature.
education, training, and supervised experience. While developing skills in
Analysis: Both therapists are offering below-standard new specialty areas, counselors take steps to ensure the competence of their
treatment resulting from failure to keep abreast with work and to protect others from possible harm (ACA, 2005, C.2.b.).
advancements in the field. The first therapist rationalized his (APA, 2002, 2.01.c – already cited.).
performance, combining ignorance and arrogance. The
second practitioner was completely unaware but at least Case 1-7: A 35 year-old woman with a diagnosis of
interested in updating his knowledge base; even if the new psychomotor epilepsy and multiple personality disorder filed
technique poses professional or theoretical concerns from a complaint with the APA Ethics Committee against her
this counselor’s view, he has the ethical responsibility to psychologist of four years for practicing outside her areas of
inform clients of this alternative while offering competence. Client claimed that she discovered that her
recommendations. Ethically, practitioners must maintain psychologist did not have prior training or supervised
current skills and vigilance of progress within their areas of experience in her multiplicity of issues; client’s condition
practice. worsened during treatment leading to hospitalization.
Psychologist informed the Ethics Committee that she began
Case 1-6: Mr. Austin hired Dr. Dale in a child custody case treatment as an employee of a community mental health
in the hope of taking custody of his two sons, aged 9 and 11, center and was under supervision of two clinic consultants: a
from his ex-wife, Mrs. Romero, who held custody. Dr. Dale neurologist who controlled client’s medication and a
evaluated Mr. Austin, his current wife and the two children. psychiatrist experienced in multiple personality disorders.
In court, Dr. Dale testified that Mr. Austin and his wife Psychologist started a private practice during the third year of
would be better parents and should have custody of the therapy with client and was advised by psychiatrist to allow
children and Mrs. Romero should have limited visitation client to remain with the clinic while the clinic administrator,
rights. He said the boys preferred their father over their who was not a psychologist, recommended psychologist to
mother. Dr. Dale never evaluated Mrs. Romero or her work with client in private practice to avoid disruption of
current husband, rather, all such information was gained treatment. Psychologist continued therapy with client in
secondhand. The psychologist for Mrs. Romero highlighted private practice and kept the same psychiatrist for
that she had custody of the children before the current trial, consultation as needed. After six months of therapy
Mr. Austin infrequently saw the children, and he infrequently proceeding well, client began decompensating. Client called
paid his child support. Dr. Dale ignored hospital records sent psychologist late one night threatening suicide because she
to him by Mrs. Romero indicating the fact that Mr. Austin felt hopeless and she blamed psychologist for not being more
was an alcoholic and was probably still drinking. Mrs. helpful. Psychologist called the police who took client to the
Romero lost custody of the children at the trial. She then county psychiatric hospital emergency room where
received letters from her children stating that their father was psychologist met her and stayed with her until she was
drinking heavily and beating his second wife – the same admitted. Psychologist continued therapy with client at the
reasons why Mrs. Romero divorced Mr. Austin. Mrs. hospital until client refused to see psychologist. Client
Romero is Anglo but her current husband is Mexican ultimately returned to the community mental health center for
American; she wondered if that tainted Dr. Dale’s evaluation. therapy with a different practitioner.
Analysis: Dr. Dale appears to have violated the same two Psychologist informed the APA Ethics Committee that she
ethics codes as in Case 1-2, demonstrated by his conclusions acted professionally and responsibly as evidenced by her
consultations with the psychiatrist and that the clinic
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ETHICS: CASE STUDIES I

administrator recommended she take client into her private female sexuality. The complainant reported that C helped
practice. her husband with the loss of his father but his antiquated
Adjudication: The APA Ethics Committee found marriage views almost destroyed her marriage and she was
psychologist in violation of the principles of competence and concerned for the welfare of future marital clients. The
responsibility. She tried to operate beyond the limits of her Ethics Committee questioned Psychologist C about his initial
competence and used mistaken judgment in seeing the client training and continued exposure to the themes of marriage
in private practice as opposed to allowing client to continue and women. He expressed a lack of contemplating the
in the more structured environment of the clinic where issues, but the current situation led him to appreciate Mrs.
trained staff to deal with this issue was extant – as the A’s criticisms culminating in his reading current books on
psychiatrist had advised. Further, she did not take full the topics and planning to attend workshops.
responsibility for the consequences of her actions by Adjudication: The APA Ethics Committee found
transferring responsibility for her decisions to other parties – Psychologist C in technical violation of the need to undertake
who were not psychologists. Psychologist was censured with relevant education, training, and study yielding competence.
stipulation to take two advanced courses: organic In light of his response that he was striving to update his
disturbances and diagnosis and treatment of borderline knowledge of these issues, a majority voted to close the case
personality and multiple personality disorders. Psychologist with an educative letter and no further action (APA, 1987).
accepted the censure and stipulations (APA, 1987). In response to the awareness that society has historically
misunderstood, minimized or ignored women’s issues, the
Case 1-8: Psychologist A charged Psychologist B, a new APA (1975) launched a task force to study potential gender-
Ph.D. in social psychology, with performing duties beyond bias and gender-role stereotyping of women in
his level of competence. B received a license based on two psychotherapy. These four general areas of bias were
years experience performing research in a private mental recognized: a) often, therapists values were sexist and their
hospital, and he then opened a psychotherapy practice. The understanding of female biology and psychological process
private mental hospital’s administrator was a was lacking; b) generally, therapy promoted traditional
businesswoman, not licensed in psychology, and she gender roles; c) therapists commonly utilized out-dated
designated B as chief psychologist, a title that B used as a psychoanalytic concepts that devalued women; and d)
credential. B informed the APA Ethics Committee that his therapists occasionally treated women as sex objects.
state psychology license was generic, thereby, having no Ultimately, principles for competent practice for women
limits on practice, and his two-year work experience at the were endorsed by several APA divisions, including
mental hospital trained him to practice psychotherapy and act counseling, clinical, and psychotherapy stressing therapists’
as chief psychologist. He claimed psychologist A was awareness of their personal values and ways biases limit
simply professionally jealous. options of female clients. The resulting “Counseling and
Adjudication: The APA Ethics Committee declared Therapy of Women Preamble” (1979) states the following:
Psychologist B was practicing outside his area of competence Although competent counseling/therapy processes are essentially the same
for all counselor/therapist interactions, special subgroups require specialized
and was not accurately representing his education, training skills, abilities and knowledge. Women constitute a special subgroup.
and experience. He was censured with the stipulation that he Competent counseling/therapy requires recognition and appreciation that
cease and desist from practicing psychotherapy and from contemporary society is not sex fair. Many institutions, test standards and
utilizing the title of chief psychologist. Psychologist B did attitudes of mental health professionals limit the options of women clients.
Counselors/therapists should sensitize women clients to these real-world
not reply to the censure and stipulation, consequently, the limitations, confront them with both the external and their own internalized
Committee voted that he be dropped from Association limitations and explore with them their reactions to these constraints.
membership for violation of the above ethics standards and
for failure to cooperate (APA, 1987). Case 1-10: Therapist D was effective in offering workshops
on diagnosis and treatment planning for practitioners seeking
Case 1-9: Mrs. A filed a complaint against her husband’s third-party reimbursement from insurance companies.
therapist, Psychologist C, charging that he was disseminating Through a referral, she agreed to provide a series of in-
outdated ideas and values regarding women and marriage. service consultation sessions on the above topic with ten
Mrs. A’s husband was in therapy for a depressive reaction counselors at a community mental health agency. D did not
after the death of his father. After six months, the couple have formal training or supervision in agency consultation
experienced marital difficulties and the husband requested but she resolved that a little self-instruction would suffice. D
his wife attend several sessions. Mrs. A suspected that signed a 6-month contract with the agency director to offer
Psychologist C’s “old-fashioned” and patriarchal marital bi-weekly consultation with staff members to discuss cases
views were causing the marital strife. She informed the APA and increase likelihood that the agency was creating
Ethics Committee of C’s views on marriage as follows: the diagnosis and treatment plans resulting in third-party
woman is to be subservient and obedient, only “radical reimbursement. D and the director did not address how D
feminists” believe in the women’s movement, a woman’s would be evaluated or how she would report to the director.
career is a marital handicap, and she quoted C’s statements D instituted a written contract with the agency indicating that
toward sexual relations indicating insufficient knowledge of staff participation was voluntary and confidential; further,
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ETHICS: CASE STUDIES I

agency clients were informed of D’s involvement thereby Counselors discuss confidential information only in settings in which they
can reasonably ensure client privacy (ACA, 2005, B.3.c.).
addressing client confidentiality issues. All involved were
pleased with D’s performance but at the conclusion of the Although therapists possess broad training and experience,
contract, D was surprised when the director asked her to they have the ethical responsibility to seek education,
evaluate the quality of each staff member’s treatment plans. supervision, and consultation when entering into new
He said the agency was going to decrease its staff size and specialty areas. Therapist D was experienced in treatment
her opinion would be valuable in making staffing decisions. planning and insurance reimbursement but not in agency
Therapist complied with this request due to feeling obligated consultation. Her attempts to study consultation on her own
for his hiring her, the staff reduction was to inevitably occur proved ineffective regarding consultee confidentiality and
anyway, and she potentially might save the jobs of the most informed consent whereas having sought consultation may
competent staff clinicians. Several months thereafter, two have prepared her to address the agency director’s staff
former employees who participated in the consultation group evaluation request. She unintentionally violated her
filed a complaint with the ACA Ethics Committee, charging consultees’ rights and did not promote their welfare by
ethical misconduct for disclosing to the director individual divulging information that adversely affected their
staff members’ ratings of performance (Herlihy & Corey, employment. Codes of Ethics highlighting therapist
1996). responsibility to promote client welfare state the following:
Marriage and family therapists advance the welfare of families and
Analysis: Therapist complied with the ethical responsibility individuals. They respect the rights of those seeking their assistance, and
of having agency clients informed of her consultant role with make reasonable efforts to ensure that their services are used appropriately
staff members and her access to confidential client (AAMFT, 2001, Principle 1).
The primary responsibility of counselors is to respect the dignity and to
information. Codes of Ethics on informed consent reveal:
promote the welfare of clients (ACA, 2005, A.1.a.).
Clients have the freedom to choose whether to enter into or remain in a
Psychologists respect the dignity and worth of all people, and the rights of
counseling relationship and need adequate information about the counseling
individuals to privacy, confidentiality, and self-determination (APA, 2002,
process and the counselor. Counselors have an obligation to review in
Principle E).
writing and verbally with clients the rights and responsibilities of both the
Social workers’ primary responsibility is to promote the wellbeing of clients.
counselor and the client (ACA, 2005, A.2.a.).
In general, clients’ interests are primary (NASW, 1999, 1.01).
When psychologists conduct research or provide assessment, therapy,
counseling, or consulting services in person or via electronic transmission or
other forms of communication, they obtain the informed consent of the Case 1-11: Therapist E was newly licensed and motivated to
individual or individuals using language that is reasonably understandable to begin private practice. His marketing efforts were not
that person or persons… (APA, 2002, 3.10.a.).
attracting referral sources or clients but his pursuit of
Social workers should use clear and understandable language to inform
clients of the purpose of the services, risks related to the services, limits to becoming a network provider with XYZ Corp., a managed
services because of the requirements of a thirdparty payer, relevant costs, care company, led to referrals. E was not cognizant of the
reasonable alternatives, clients’ right to refuse or withdraw consent, and the impact of managed care upon private practice but he agreed
time frame covered by the consent (NASW, 1999, 1.03.a.).
to conform with XYZ Corp.’s approach to managed care. He
The content of informed consent may vary depending upon the client and
treatment plan; however, informed consent generally necessitates that the was referred a client presenting with depression but he
client: …b) has been adequately informed of significant information needed to refer client upon assessing that client was also
concerning treatment processes and procedures (AAMFT, 2001, 1.2.b.). anorexic and he lacked training and supervised experience in
Consultees are afforded similar rights, thus, informed consent this disorder. E called his case manager with XYZ Corp.
pertaining to goals of the consultation and potential who arranged a referral to another provider in the network.
disclosure of shared information is critical, especially when a Over time, Therapist E became somewhat uncomfortable
third party such as a supervisor is involved. with several of XYZ Corp.’s policies, including having to
Therapist D declared that disclosed information during communicate with numerous case managers (who only gave
consultation meetings was confidential for clients and their first name) rather than only one when requesting
consultees, further, the possibility of a consultee evaluation authorization for client sessions and needing to disclose
was not mentioned. Consultees were not given the choice to much information about the clients above and beyond the
participate or not with the understanding that their clinical diagnosis. He understood the additional request of
performance might be disclosed to and evaluated by the information was legal because clients signed XYZ Corp.’s
agency director. Therapist D violated the consultees’ privacy disclosure form but E wondered if it was ethical and just
rights by disclosing information not essential to the purpose what happened with this information such as clients’
of the consultation to the director. Privacy issues are childhood traumas, marital concerns, addictions and other
illustrated in the following codes: issues.
Social workers should respect clients’ right to privacy. Social workers
One of Therapist E’s clients exhausted her insurance
should not solicit private information from clients unless it is essential to
providing services or conducting social work evaluation or research. Once benefits before therapy was complete and the case manager
private information is shared, standards of confidentiality apply (NASW, advised E to space out the remaining three of the twenty
1999, 1.07.a.). allocated sessions over several months and to initiate a
Information may be shared only to the extent necessary to achieve the
purposes of the consultation (AAMFT, 2001, 2.6).
referral to a community mental health center. Therapist E
Psychologists include in written and oral reports and consultations, only informed the case manager that he disagreed with this plan
information germane to the purpose for which the communication is made because client needed continuity of care for an extended
(APA, 2002, 4.04.a.). time. The case manager was not convinced which led E to
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ETHICS: CASE STUDIES I

see the client pro bono (with resentment toward the managed continuing, he has an ethical responsibility to inform his
care company) and to wonder if XYZ Corp.’s case managers clients of the information to be shared with the company
were qualified to make psychotherapy decisions. because he cannot depend totally on the fact that clients have
Therapist E, shortly thereafter, was referred an 11 year-old signed the company’s disclosure form.
boy, under the boy’s father’s company insurance plan As Therapist E’s concerns about XYZ Corp.’s policies and
administered by XYZ Corp., for fighting at school. E procedures progress, he is advised to decide if he can
assessed that the boy’s misbehavior resulted from conflict continue being their provider and also adhere to these
between the parents so therapist recommended marital “conflicts between ethics and organizational demands”
counseling but this specific XYZ Corp. plan did not cover ethical standards:
marital counseling. Therapist E felt frustrated with managed If the demands of an organization with which psychologists are affiliated or
for whom they are working conflict with this Ethics Code, psychologists
care, commenced marital counseling with the parents of the
clarify the nature of the conflict, make known their commitment to the
boy, and billed the sessions under the boy’s name. E Ethics Code, and to the extent feasible, resolve the conflict in a way that
internally reasoned that improvement in the marital permits adherence to the Ethics Code (APA, 2002, 1.03).
relationship would benefit the boy (Herlihy & Corey, 1996). The acceptance of employment in an agency or institution implies that
counselors are in agreement with its general policies and principles.
Analysis: Upon determining client was anorexic, Therapist E
Counselors strive to reach agreement with employers as to acceptable
appropriately arranged for a referral to a qualified provider, standards of conduct that allow for changes in institutional policy conducive
thus not practicing beyond his boundaries of competence. to the growth and development of clients (ACA , 2005, D.1.g.).
Codes of Ethics relating to referral state: Marriage and family therapists remain accountable to the standards of the
Marriage and family therapists assist persons in obtaining other therapeutic profession when acting as members or employees of organizations. If the
services if the therapist is unable or unwilling, for appropriate reasons, to mandates of an organization with which a marriage and family therapist is
provide professional help (AAMFT, 2001, 1.10). affiliated, through employment, contract or otherwise, conflict with the
…psychologists have or obtain the training, experience, consultation, or AAMFT Code of Ethics, marriage and family therapists make known to the
supervision necessary to ensure the competence of their services, or they organization their commitment to the AAMFT Code of Ethics and attempt to
make appropriate referrals… (APA, 2002, 2.01.b). resolve the conflict in a way that allows the fullest adherence to the Code of
Social workers should refer clients to other professionals when the other Ethics (AAMFT, 2001, 6.1).
professionals’ specialized knowledge or expertise is needed to serve clients Social workers should not allow an employing organization’s policies,
fully or when social workers believe that they are not being effective or procedures, regulations, or administrative orders to interfere with their
making reasonable progress with clients and that additional service is ethical practice of social work. Social workers should take reasonable steps
required (NASW, 1999, 2.06.a.). to ensure that their employing organizations’ practices are consistent with
If counselors determine an inability to be of professional assistance to the NASW Code of Ethics (NASW, 1999, 3.09.d.).
clients, they avoid entering or continuing counseling relationships. With resentment, Therapist E continued therapy with the
Counselors are knowledgeable about culturally and clinically appropriate client whose benefits ended, hence, E upheld the following
referral resources and suggest these alternatives. If clients decline the
“termination of services” ethics code:
suggested referrals, counselors should discontinue the relationship (ACA,
Social workers should take reasonable steps to avoid abandoning clients who
2005, A.11.b.).
are still in need of services. Social workers should withdraw services
Therapist E developed confidentiality concerns for his precipitously only under unusual circumstances, giving careful consideration
clients due to XYZ Corp.’s anonymous and multiple case to all factors in the situation and taking care to minimize possible adverse
managers and their requirement for disclosure of much client effects. Social workers should assist in making appropriate arrangements for
continuation of services when necessary (NASW, 1999, 1.16.b.).
information. The limits of confidentiality are generally
discussed with clients during the intake session and ethical Nonetheless, therapist may need to self-assess his ability to
standards respond to this issue as follows: offer clinical objectivity and effectiveness despite resentment
Social workers should discuss with clients and other interested parties the toward the managed care company.
nature of confidentiality and limitations of clients’ right to confidentiality. Therapist E’s decision to see the parents of the 11 year-old
Social workers should review with clients circumstances where confidential boy and to bill the therapy under the boy’s name suggests
information may be requested and where disclosure of confidential
insurance fraud – a legal and ethical issue. His
information may be legally required. This discussion should occur as soon
as possible in the social worker-client relationship and as needed throughout rationalizations may represent the onset of an “ethical
the course of the relationship (NASW, 1999, 1.07.e.). slippery slope” meaning that he might continually disregard
Social workers should not disclose confidential information to thirdparty rules and condone dishonest practices in the future.
payers unless clients have authorized such disclosure (NASW, 1999,
Although Therapist E was qualified to establish a private
1.07.h.).
Psychologists discuss with persons… and organizations with whom they practice according to state licensure laws, his actions suggest
establish a scientific or professional relationship 1) the relevant limits of being uninformed and naïve pertaining to managed care
confidentiality and 2) the foreseeable uses of the information generated issues, thus questioning his level of competence to begin an
through their psychological activities (APA, 2002, 4.02.a.).
independent private practice. Practitioners are advised to
At initiation and throughout the counseling process, counselors inform
clients of the limitations of confidentiality and seek to identify foreseeable consult their association’s Code of Ethics and their state
situations in which confidentiality must be beached (ACA, 2005, B.1.d.). licensure laws when confronted with managed care issues. In
This therapist was responsible to know the type of client this case, E could have emphasized his rationale to XYZ
information that was required before agreeing to become an Corp.’s case manager that seeing the parents may offer the
XYZ Corp. provider, something he may have overlooked quickest and most effective way to treat the boy – instead, the
given his frustrations and financial needs. He will need to therapist violated these ethics codes:
address his concerns with XYZ Corp. and then decide Marriage and family therapists represent facts truthfully to clients, third-
party payors, and supervisees regarding services rendered (AAMFT, 2001,
whether to continue as their network provider. Upon
7.4).
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ETHICS: CASE STUDIES I

When psychologists agree to provide services to a person or entity at the 1997). A study of APA psychotherapy division members
request of a third party, psychologists attempt to clarify at the outset of the
discovered that 71.2% disclosed having worked when too
service the nature of the relationship with all individuals or organizations
involved. This clarification includes the role of the psychologist… an distressed to be effective and 5.9% performed therapy under
identification of who is the client, the probable uses of the services provided the influence of alcohol (Pope et al. 1987). A similar study
or the information obtained… (APA, 2002, 3.07). of academic psychologists found that 77.2% had taught while
Psychologists do not misrepresent their fees (APA, 2002, 6.04.c.).
In their reports to payors for services or sources of research funding,
feeling too distressed to be effective and 4.6% had taught
psychologists take reasonable steps to ensure the accurate reporting of the under the influence of alcohol (Tabachnick et al., 1991). The
nature of the service provided or research conducted, the fees, charges, or data suggest that psychologists are similar to other groups
payments, and where applicable, the identity of the provider, the findings, pertaining to sometimes being too emotionally upset to be
and the diagnosis (APA, 2002, 6.06).
Social workers should establish and maintain billing practices that accurately
effective in work or in other areas of life.
reflect the nature and extent of services provided…(NASW, 1999, 3.05). In contrast, psychologists exhibit significant amounts of
Social workers should ensure that their representations to clients, agencies, self-care behavior. Mahoney (1997) indicated that 80% of
and the public of professional qualifications, credentials, education, practicing psychologists read for pleasure, participate in a
competence, affiliations, services provided, or results to be achieved are
accurate (NASW, 1999, 4.06.c.).
hobby, take vacations, and attend movies, museums or
Counselors are accurate, honest, and objective in reporting their professional concerts for enjoyment while 75% physically exercise and
activities and judgments to appropriate third parties, including courts, health socialize with peers for support. This research concluded
insurance companies, those who are the recipients of evaluation reports, and that the average practitioner is healthy, happy, enjoys work,
others (ACA, 2005, C.6.b.).
and takes active measures to cope with personal problems
(including seeking personal therapy when appropriate).
THERAPIST IMPAIRMENT and BURNOUT Coster and Schwebel (1997) determined that 74% of
psychologists are well-functioning and Thoreson et al. (1989)
Therapist impairment is a deterioration of professional found that the majority of psychologists they surveyed were
abilities from a previous competent level (Kutz, 1986; healthy and satisfied with work and their interpersonal
Nathan, 1986; Schwebel, Skorina, Schoener, 1994) and relationships.
occurs when therapists personal problems overflow into their Coster and Schwebel (1997) and Mahoney (1997) reveal
professional activity and decreases therapeutic effectiveness. the following psychologist-recommended coping
Impairment is often caused by personal vulnerabilities such mechanisms to protect psychological well-being, avoid
as burnout, drug or alcohol abuse, depression, loneliness, impairment and promote client welfare:
etc., and it can lead to unethical behavior, defined as causing
• Maintain a strong interpersonal support system of family,
injury or harm to a consumer during performance of a
friends and companions which will help buffer work-
professional role (Stromberg & Dellinger, 1993). A lonely
related stressors.
and depressed therapist, for example, may lose sight of
• Interact with a peer group facilitating exchange of
professional boundaries and become sexually involved with a
objective feedback, stress-reduction, and problem-
client. Therapists are obligated to identify personal
solving. Learning that your peers are challenged in
emotional or physical concerns affecting professional
similar ways as yourself and listening to their solutions
effectiveness and to seek help for resolution. Concern for the
can be stress-reducing.
welfare of one’s clients is recommended over hesitancy to
accept help. Remley and Herlihey (2007) note the following • Spend time nurturing your personal well-being by living
common symptoms of impairment: a balanced lifestyle encouraging fun and physical activity
1. Deterioration in personal relationships, for example, along with work.
marital concerns and family dysfunction • Enjoy professional development activities that foster
2. Isolation and withdrawal from others remaining current with the field.
3. Sensing disillusionment with the profession • Monitor your personal weaknesses and impairment danger
4. Exhibiting emotional distance during therapy sessions signals such as dissatisfaction, withdrawal, depression,
5. Alcohol and/or drug abuse loss of energy, unjustified anger toward others,
6. Displaying changes in work style such as tardiness and alcohol/drug dependence, or impulses to act on sexual
absenteeism feelings. Pursue self-help behavior or therapy when
7. Becoming moody, depressed or anxious necessary.
8. Demonstrating procedural mistakes and poor • Remove yourself from professional work activities if
record keeping personal issues remain unresolved that could harm
Between 26% and 43% of practicing psychologists indicate consumers.
struggling sometimes with work effectiveness issues (Guy et Burnout is defined as a type of emotional exhaustion due to
al., 1989; Mahoney, 1997), including episodes of emotional extreme demands on energy, strength, and personal resources
exhaustion, distress over the size and severity of their in the workplace (Baker, 2003; Maslach, Schaufeli, & Leiter,
caseload, doubts about their therapeutic effectiveness, and 2001; Shiron, 2006). Therapist burnout yields symptoms of
disillusionment feelings (Mahoney, 1997). One study emotional exhaustion, depersonalization, and a sense of
revealed 26% of psychologists identified themselves as limited personal accomplishment and “may manifest itself in
having been impaired at a given time (Coster & Schwebel, a loss of empathy, respect, and positive feelings for their
8 Continuing Psychology Education Inc.
ETHICS: CASE STUDIES I

clients” (Skorupa & Agresti, p.281, 1993). Therapist may appointments without giving notice, and exhibited distance
become withdrawn, bad-tempered and uncooperative with from his clients. He was fired by the facility but performed
clients and colleagues (Mills & Huebner, 1998) which can well at his next therapeutic setting.
lead to poor decision-making and disrespect of one’s clients Case 1-13: Therapist G worked as a school psychologist in a
(Pope & Vasquez, 2005). Burnout is more likely for large urban public school system. She felt under-appreciated
therapists with less control over work activities, excessive and over-worked by clients and administrators coupled with
work hours, and many administrative tasks (Rupert & an inability to effectively manage her work situation
Morgan, 2005). Practitioners with smaller caseloads are less culminating in dislike of her position. G resigned from the
susceptible to burnout (Skorupa & Agresti, 1993). Age of job after securing another position elsewhere but she failed to
therapist is inversely related to burnout (Vredenburgh et al., give adequate notice and left several student evaluations
1999) presumably because younger counselors experience incomplete.
more stress as they are developing competence and Analysis: Both therapists experienced burnout resulting from
professional security. stress in their jobs, personal lives, various client issues dealt
The warning signs of burnout include the following: with daily, and other factors. Each was subjected to learned
inappropriate anger outbursts, feeling apathetic, continual helplessness and depression, in turn, their clients were
frustration, feeling depersonalized, depression, emotional and affected. Therapist F’s detachment and withdrawal was not
physical exhaustion, being hostile, experiencing malice or professional and Therapist G’s immediate departure probably
aversion toward clients, and reduced productivity or work negatively impacted several students and staff.
effectiveness. Predisposing factors that can lead to burnout The Codes of Ethics express the requirement of
include: ambiguous work roles such as unclear or changing acknowledgment and resolution of personal problems as
demands and expectations, work environment conflict and follows:
tension, incongruity between ideal and real job activities, Social workers should not allow their own personal problems, psychosocial
distress, legal problems, substance abuse, or mental health difficulties to
unrealistic pre-employment expectations, insufficient social interfere with their professional judgment and performance or to jeopardize
support at work, being a perfectionist with a feeling of being the best interests of people for whom they have a professional responsibility
externally controlled, experiencing death or divorce in the (NASW, 1999, 4.05.a.).
family, consistent helplessness, permeable emotional Social workers whose personal problems, psychosocial distress, legal
problems, substance abuse, or mental health difficulties interfere with their
boundaries, substance abuse, and maintaining excessively
professional judgment and performance should immediately seek
high self-expectations (Dupree & Day, 1995; Jenkins & consultation and take appropriate remedial action by seeking professional
Maslach, 1994; Koeske & Kelly, 1995; Koocher, 1980; Lee help, making adjustments in workload, terminating practice, or taking any
& Ashforth, 1996; Maslach, 1993; Maslach et al., 2001; other steps necessary to protect clients and others (NASW, 1999, 4.05.b.).
Counselors are alert to the signs of impairment from their own physical,
McKnight & Glass, 1995; Shiron, 2006).
mental, or emotional problems and refrain from offering or providing
Therapists can minimize burnout risk by receiving professional services when such impairment is likely to harm a client or
supervision and social support, especially for those working others. They seek assistance for problems that reach the level of
with difficult populations, feeling a strong purpose and professional impairment, and, if necessary, they limit, suspend, or terminate
their professional responsibilities until such time it is determined that they
mission in work activities, and seeking help if professional or may safely resume their work. Counselors assist colleagues or supervisors
personal stressors mount (Acker, 1999; Miller, 1998). in recognizing their own professional impairment and provide consultation
Joining an informal peer support group can foster ventilation and assistance when warranted with colleagues or supervisors showing signs
of pent-up stress and promote exposure to professional of impairment and intervene as appropriate to prevent imminent harm to
clients (ACA, 2005, C.2.g.).
support and problem-solving ideas. Additional self-care Psychologists refrain from initiating an activity when they know or should
strategies include taking a break or vacation from work, know that there is a substantial likelihood that their personal problems will
regular exercise, meditation, and engaging in hobbies. Work prevent them from performing their work-related activities in a competent
environment factors that protect therapists from burnout manner (APA, 2002, 2.06.a.).
When psychologists become aware of personal problems that may interfere
include: understanding your expected role, receiving positive with their performing work-related duties adequately, they take appropriate
feedback, work autonomy, opportunities to relieve stress at measures, such as obtaining professional consultation or assistance, and
work, social support at the worksite, experiencing personal determine whether they should limit, suspend, or terminate their work-
accomplishment, maintaining realistic criteria for client related duties (APA, 2002, 2.06.b.).
Marriage and family therapists seek appropriate professional assistance for
outcome, being cognizant of personal strengths and their personal problems or conflicts that may impair work performance or
weaknesses, and remaining under internal-control (Koocher clinical judgment (AAMFT, 2001, 3.3).
& Keith-Speigel, 2008). Marriage and family therapists are in violation of this Code and subject to
The following two cases are presented by Koocher and termination of membership or other appropriate action if they continue to
practice marriage and family therapy while no longer competent to do so
Keith-Spiegel (2008): because they are impaired by physical or mental causes or the abuse of
Case 1-12: Therapist F worked full-time at a cancer alcohol or other substances (AAMFT, 2001, 3.15.f.).
treatment facility for several years and due to concern for his
clients, made himself available “on call” beyond normal TERMINATION
hours. His performance lessened after the death of a liked
client and a personal marriage concern. F stopped returning Termination or referral of a client is generally based on
calls to clients and staff in a timely way, sometimes missed three conditions. First, when therapy has successfully
9 Continuing Psychology Education Inc.
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resolved client’s presenting issues and treatment is no longer Analysis: Therapist I practiced beyond the scope of his
required. Second, if client is not gaining any benefit from competency. Upon recognition that client needed a higher
therapy but is willing to continue given dependency upon the level of care, possibly inpatient treatment, therapist could
therapist. A referral is possible if therapist senses client have refused therapy until client sought appropriate
would benefit from a different practitioner. Third, upon assistance. If client’s behavior would have escalated to being
therapist belief that therapy continuation could be harmful to a danger to self or others, or suggested involuntary
client – a referral is also possible. Additionally, therapists hospitalization then therapist would be responsible to
discuss the issue of termination with clients thoroughly along consider an effective course of action.
with clarifying the reasons. The decision to terminate
therapy is based on the best interest of the client, hence, Case 1-16: A corporation hired Therapist J to assist in
therapists do not abandon their clients. Codes of Ethics on improvement of employee morale and lower product defects.
terminating therapy emphasize the following: Effectiveness data acquired by therapist himself validated
Psychologists terminate therapy when it becomes reasonably clear that the unsuccessful results, however, Therapist J disregarded the
client/patient no longer needs the service, is not likely to benefit, or is being
outcome information, informed the company that a longer
harmed by continued service (APA, 2002, 10.10.a.).
Psychologists may terminate therapy when threatened or otherwise trial was required, and persisted to offer the unproductive
endangered by the client/patient or another person with whom the services at a high fee for several more months until the
client/patient has a relationship (APA, 2002, 10.10.b.). corporation finally cancelled the contract (Koocher & Keith-
Except where precluded by the actions of clients/patients or third-party
payors, prior to termination psychologists provide pretermination counseling
Spiegel, 2008).
and suggest alternative service providers as appropriate (APA, 2002, Analysis: Therapist J willfully chose to overlook his data
10.10.c.). and continue providing ineffective services rather than re-
Counselors terminate a counseling relationship when it becomes reasonably evaluating treatment plans and constructing an alternative
apparent that the client no longer needs assistance, is not likely to benefit, or
is being harmed by continued counseling. Counselors may terminate
course of action. The ethical obligation to inform
counseling when in jeopardy of harm by the client, or another person with management of the absence of benefit was not timely
whom the client has a relationship, or when clients do not pay fees as agreed demonstrated.
upon. Counselors provide pretermination counseling and recommend other
service providers when necessary (ACA, 2005, A.11.c.).
Marriage and family therapists do not abandon or neglect clients in treatment
Corey et al. (2007) believe that even highly experienced
without making reasonable arrangements for the continuation of such therapists will occasionally question whether their personal
treatment (AAMFT, 2001, 1.11; 1.10 already mentioned). and professional competence is sufficient with some of their
Social workers should terminate services to clients and professional clients. Encountering difficulties with some clients does not
relationships with them when such services and relationships are no longer
required or no longer serve the clients’ needs or interests (NASW, 1999,
necessarily imply incompetence or the need to immediately
1.16.a.). refer, instead, it is wise to balance between expanding areas
Case 1-14: Client has been in therapy with Therapist H of competence and referring when appropriate. Professional
weekly for six years and has already resolved her presenting growth, extended competence, and avoidance of stagnation
issues. Her emotional status has not changed in may arise by accepting clients with new issues. While
approximately four years except she has developed a growing learning new skills and implementing new competencies,
attachment to therapist. H has not strongly recommended practitioners must ensure that clients are not harmed.
termination, rather, his attitude is “If the client thinks she Broadening boundaries of competence can occur through
needs to see me, then she does” (Koocher & Keith-Speigel, reading, professional development activities, consultation,
2008). co-counseling with experienced colleagues in a specialty
Analysis: Therapist H failed to ethically terminate treatment area, and receiving supervision. Whether administering
at the time client did not need continued services or therapy experienced or inexperienced therapeutic skills, therapists
was no longer beneficial. The possibility exists that would benefit by self-appraisal through peer consultation and
Therapist H facilitated client’s dependency, prolonged client evaluation.
needless therapy, thereby suggesting exploitation for
financial or emotional fulfillment. He is wise to periodically, INFORMED CONSENT
critically evaluate the therapy process with client and refer
client to a different therapist for consultation regarding need The process of informed consent is a legal and ethical
for further therapy. The best interest of client, not therapist, obligation to provide relevant information to clients
determines termination and referral. regarding expectations of therapy before onset of assessment
or treatment. Therapists should discuss goals, expectations,
Case 1-15: Therapist I treated client for escalating anger procedures, and potential risks (Becker-Blease & Freyd,
toward his employer but therapist observed client becoming 2006; Bennett et al., 2007; Everstein et al., 1980; Hare-
paranoid and deeply troubled. Therapist I recommended Mustin et al., 1979; Vogel & Wester, 2003) enabling clients
hospitalization to client several times but client rejected the to make intelligent choices such as whether to receive
thought. Therapist continued treating client, eventually therapy, with whom, and how the process will transpire. The
developing into the object of client’s paranoid anger essence of informed consent is designed to anticipate
(Koocher & Keith-Spiegel, 2008). questions of reasonable clients thus preventing future
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ETHICS: CASE STUDIES I

misunderstanding and frustration yielding a “culture of Leland Stanford Jr. Univ. Bd. of Trustees (1957).
safety” (Knapp & VandeCreek, 2006). Informing clients Appelbaum, Lidz & Meisel (1987, p. 41) conclude the Salgo
how therapy works demystifies the relationship and case stressed that physicians must provide patients the
empowers their active involvement. Clients, generally, must following: “disclosure of the nature of the ailment, the nature
rely upon and trust their practitioner to disclose information of the proposed treatment, the probability of success, and
necessary to make wise treatment decisions (Handelsman, possible alternative treatments.”
2001). Sullivan, Martin, and Handelsman (1993) note that In 1960, in the Kansas case of Nathanson v. Kline, the
“clients may be more favorably disposed to therapists who court endorsed the Judge Cordozo principle by stating,
take the time and effort to provide (informed consent) “Anglo-American law starts with the premise of thorough-
information” (p. 162). Further, Tryon and Winograd (2001) going self-determination. It follows that each man is
propose that therapist-client agreement on goals is positively considered to be master of his own body” (p. 1104). The
correlated with improved patient outcomes and satisfaction court expressed that the patient needs relevant information to
and they advise, “to maximize the possibility of achieving a make this determination, however, it was left to the doctors
positive treatment outcome, therapist and patient should be to determine what information was relevant: “The duty … to
involved throughout therapy in a process of shared decision- disclose … is limited to those disclosures which a reasonable
making, where goals are frequently discussed and agreed … practitioner would make under the same or similar
upon” (p. 387). Supportively, informed consent is a circumstances…. So long as the disclosure is sufficient to
recurrent process because the treatment plan may be altered assure an informed consent, the physician’s choice of
due to assessment results, client’s reactions and his or her plausible courses should not be called into question if it
changing needs. The client should be informed of treatment appears, all circumstances considered, that the physician was
plan changes and voluntarily agree with them. Marczyk and motivated only by the patient’s best therapeutic interests and
Wertheimer (2001) acknowledged the difficulty of mental he proceeded as competent medical men would have done in
health practitioners historically to offer comprehensive a similar situation” (1960, p. 1106). This case demonstrates
treatment choices because the discipline of the “community standard” rule whereby informed consent
counseling and psychology was “still very much a procedures must represent that which the general community
philosophy and not a science” (p. 33). They believe that of doctors customarily do.
mental health practitioners should be required to offer clients The case of Canterbury v. Spence (1972) resolved that
success rates of various mental health treatment based on physicians must disclose information pertaining to a
empirical research-based evidence similar to physicians proposed treatment that a reasonable person, such as the
treating patients with conditions as cancer. patient being treated, would require to render a decision to
The requirement for health professionals to secure informed accept or refuse treatment. The court conveyed, “The root
consent from their clientele prior to rendering services started premise is the concept, fundamental in American
in the field of medicine (Appelbaum, Lidz, & Meisel, 1987). jurisprudence, that ‘every human being of adult years and
Historically, in 1767, a court in England established that sound mind has a right to determine what shall be done with
physicians were responsible to acquire consent from their his own body.’ True consent to what happens to one’s self is
patients before touching them or offering treatment (Slater v. the informed exercise of a choice, and that entails an
Baker & Stapleton). This requirement was founded on the opportunity to evaluate knowledgeably the options available
basic tort principle of battery emphasizing that members of a and the risks attendant upon each. The average patient has
society are entitled to personal privacy, including not having little or no understanding of the medical arts, and ordinarily
their bodies touched without permission. Through history, has only his physician to whom he can look for
the health care professions maintained an authoritarian enlightenment with which to reach an intelligent decision.
position in terms of the patient’s needs as it was assumed that From these almost axiomatic considerations springs the need,
the physician knew the best course of action and the patient and in turn the requirement, of a reasonable divulgence by
lacked such knowledge – the principle of informed consent is physician to patient to make such a decision possible”
absent from the Hippocratic Oath. This authoritarian (Canterbury v. Spence, 1972, p. 780). The patient, not the
approach was challenged in a New York case, in 1914, when doctor, therefore, makes the final decision and the decision is
Judge Benjamin Cordozo (he later became a U.S. Supreme based upon relevant information supplied by the doctor: “It is
Court Justice) wrote, “every human being of adult years and the prerogative of the patient, not the physician, to determine
sound mind has a right to determine what shall be done with for himself the direction in which he believes his interests lie.
his own body” (Schloendorf v. Society of New York Hospital, To enable the patient to chart his course knowledgeably,
1914, p. 93). The principle that the patient and not the doctor reasonable familiarity with the therapeutic alternatives and
had the right to decide whether to undergo a specific their hazards becomes essential” (Cobbs v. Grant, 1972, p.
treatment approach was dormant for decades. The first case 514).
in the United States to uphold the requirement that patients This rationale illustrated the vital importance of trust and
must be educated or informed about their medical treatment dependence in the delivery of health care and differentiated
options and consequences before being able to give a valid such trust and dependence from the less profound and
consent to treatment that is legally binding was Salgo v. intimate general marketplace transactions often reflective of
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ETHICS: CASE STUDIES I

the caveat emptor policy: “A reasonable revelation in these informed consent to treatment: “The rule applies whether the
aspects is not only a necessity but, as we see it, is as much a procedure involves treatment or a diagnostic test…. If a
matter of the physician’s duty. It is a duty to warn of the patient indicates that he or she is going to decline a risk-free
dangers lurking in the proposed treatment, and that is surely a test or treatment, then the doctor has the additional duty of
facet of due care. It is, too, a duty to impart information advising of all the material risks of which a reasonable
which the patient has every right to expect. The patient’s person would want to be informed before deciding not to
reliance upon the physician is a trust of the kind which undergo the procedure. On the other hand, if the
traditionally has exacted obligations beyond those associated recommended test or treatment is itself risky, then the
with arms-length transactions. His dependence upon the physician should always explain the potential consequences
physician for information affecting his well-being, in terms of declining to follow the recommended course of action”
of contemplated treatment, is well-nigh abject” (Canterbury (Truman v. Thomas, 1980, p. 312).
v. Spence, 1972, p. 782). The court clarified that doctors need not inform patients of
The Canterbury v. Spence case rejected the notion that everything they learned during their training because patients
doctors, resulting from their “community standards,” could probably would not understand such complexities, instead,
regulate the type of information patients should receive. It patients only need relevant information presented in
was resolved that doctors could not determine the informed understandable and straightforward language so to make an
consent rights of the patient or those rights indirectly by informed decision: “The patient’s interest in information
creating “customary” standards concerning the type of does not extend to a lengthy polysyllabic discourse on all
information to be provided. Contrarily, patients were possible complications. A mini-course in medical science is
determined to have a right to make an informed decision and not required” (Cobbs v. Grant, 1972, p. 515).
the courts would guarantee patients were privy to relevant The courts changed the locus of control in decision-making
information to make the decision. The court noted, “We do to the patient and the duty of ensuring the decision for
not agree that the patient’s cause of action is dependent upon assessment or treatment being a result of clear and relevant
the existence and nonperformance of a relevant professional doctor disclosed information. The California Supreme Court
tradition…. Respect for the patient’s right of self- explained the derivation of informed consent as follows:
determination on particular therapy demands a standard set ”We employ several postulates. The first is that patients are
by law for physicians rather than one which physicians may generally persons unlearned in the medical sciences and
or may not impose upon themselves” (Canterbury v. Spence, therefore, except in rare cases, courts may safely assume the
1972, pp. 783—784). Furthermore, this case requires doctors knowledge of patient and physician are not in parity. The
to provide relevant information whether or not patients ask second is that a person of adult years and in sound mind has
the “right” questions in each area, hence, doctors could not the right, in the exercise of control over his own body, to
withhold information because a patient did not inquire. determine whether or not to submit to lawful medical
Doctors have a duty to render a sufficient full disclosure: treatment. The third is that the patient’s consent to treatment,
“We discard the thought that the patient should ask for to be effective, must be an informed consent. And the fourth
information before the physician is required to disclose. is that the patient, being unlearned in medical sciences, has
Caveat emptor is not the norm for the consumer of medical an abject dependence upon and trust in his physician for the
services. Duty to disclose is more than a call to speak merely information upon which he relies during the decisional
on the patient’s request, or merely to answer the patient’s process, thus raising an obligation in the physician that
questions: it is a duty to volunteer, if necessary, the transcends arm-length transactions. From the foregoing
information the patient needs for intelligent decision. The axiomatic ingredients emerges a necessity, and a resultant
patient may be ignorant, confused, overawed by the requirement, for divulgence by the physician to his patient of
physician or frightened by the hospital, or even ashamed to all information relevant to a meaningful decisional process”
inquire…. Perhaps relatively few patients could in any event (Cobbs v. Grant, 1972, p. 513). Berner (1998) suggests that
identify the relevant questions in the absence of prior two key elements are involved with the informed consent
explanation by the physician. Physicians and hospitals have legal standard. First, the “professional element” pertains to
patients of widely divergent socioeconomic backgrounds, information which a reasonable physician would have
and a rule which presumes a degree of sophistication which offered a patient in similar circumstances, and “materiality,”
many members of society lack is likely to breed gross defined as the amount of information the average patient
inequalities” (Canterbury v. Spence, 1972, p. 783). would deem adequate to decide whether to accept or reject
The courts also deliberated on the possibility of patients treatment. Given Berner’s interpretation, the courts will
refusing a specific assessment or treatment and concluded predictably require physicians to provide basic information to
that patients have a right to be informed of the possible all patients and the information must be understandable to the
consequences of rejecting such assessment or treatment particular patient.
procedures. The California Supreme Court, in 1980, One example of informed consent principles passing from
reaffirmed the principles of Canterbury v. Spence and case law into legislation is Indiana’s House Enrolled Act of
Cobbs v. Grant and affirmed that patients have a right to 1984, which articulates, “All patients or clients are entitled to
informed refusal of treatment along with the right of be informed of the nature of treatment or habilitation
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ETHICS: CASE STUDIES I

program proposed, the known effect of receiving and of not Service, 1973). The participants of the study were not told
receiving such treatment or habilitation, and alternative that they were used to research the effects of syphilis given
treatment or habilitation programs, if any. An adult nontreatment. Research procedures were utilized as
voluntary patient or client, if not adjudicated incompetent, is treatment, for example, painful spinal taps were explained to
entitled to refuse to submit to treatment or to a habilitation the subjects as a form of medical treatment. The Public
program and is entitled to be informed of this right” (section Health Service denied any racism in this research, however,
F). These informed consent principles are also clearly only male African Americans were admitted to the program.
communicated in the ethical standards and principles of the A second example is when hospitals may perform AIDS tests
mental health associations. Though a large portion of case on patients without their knowledge or permission,
law pertains to medical practice, examination of Codes of sometimes in violation of state law (Pope & Morin, 1990).
Ethics for mental health practitioners illuminates the In a third case, Stevens (1990) revealed a testing center that
relevance and positive transfer to clinical assessment and administered the Stanford-Binet Intelligence Scale
psychotherapy: facilitating placement of students into appropriate classes at
Social workers should provide services to clients only in the context of a school. The schools received different information than the
professional relationship based, when appropriate, on valid informed
child’s parents. One report, for example, stated the boy
consent. Social workers should use clear and understandable language to
inform clients of the purpose of the services, risks related to the services, should be placed in a class for average students while the
limits to services because of the requirements of a thirdparty payer, relevant parents received a report stating, “David should be placed in
costs, reasonable alternatives, clients’ right to refuse or withdraw consent, a class for superior students” (p. 15). The testing center
and the time frame covered by the consent. Social workers should provide
justified their position expressing, “The report we send to the
clients with an opportunity to ask questions (NASW, 1999, 1.03.a.).
Marriage and family therapists obtain appropriate informed consent to school is accurate. The report for the parents is more
therapy or related procedures as early as feasible in the therapeutic soothing and positive” (p. 15).
relationship, and use language that is reasonably understandable to clients. The concern that providing relevant therapy information
The content of informed consent may vary depending upon the client and
treatment plan; however, informed consent generally necessitates that the
may yield negative client consequences has not been
client: a) has the capacity to consent; b) has been adequately informed of research-supported, instead, an array of studies demonstrate
significant information concerning treatment processes and procedures; c) that informed consent procedures increase likelihood that
has been adequately informed of potential risks and benefits of treatments clients will become less anxious, follow the treatment plan,
for which generally recognized standards do not yet exist; d) has freely and
without undue influence expressed consent; and e) has provided consent
recover more quickly, and be more alert to unanticipated
that is appropriately documented. When persons, due to age or mental negative treatment outcomes (Handler, 1990).
status, are legally incapable of giving informed consent, marriage and family Therapists must strive to inform clients in understandable
therapists obtain informed permission from a legally authorized person, if and unbiased language during their decision process to
such substitute consent is legally permissible (AAMFT, 2001, 1.2).
When psychologists conduct research or provide assessment, therapy,
participate in assessment or treatment as the following
counseling, or consulting services in person or via electronic transmission or Harvard University hospital study illustrates. McNeil et al.
other forms of communication they obtain the informed consent of the (1982) gave subjects the choice of surgical versus
individual or individuals using language that is reasonably understandable to radiological treatment based on actuarial data of outcomes of
that person or persons… (APA, 2002, 3.10.a.).
Counselors explicitly explain to clients the nature of all services provided.
lung cancer patients. For those who chose surgery, 10% died
They inform clients about issues such as, but not limited to, the following: during the operation itself, 22% died within the first year
the purposes, goals, techniques, procedures, limitations, potential risks, and after surgery, and another 34% died within five years. For
benefits of services; the counselor’s qualifications, credentials, and relevant radiation therapy, none died during the radiation treatments,
experience; continuation of services upon the incapacitation or death of a
counselor; and other pertinent information. Counselors take steps to ensure
23% died within the first year, and an additional 55% died
that clients understand the implications of diagnosis, the intended use of tests within five years. When this data was presented in terms of
and reports, fees, and billing arrangements. Clients have the right to mortality (percentage of patients who died), 42% of
confidentiality and to be provided with an explanation of its limitations participants in the study chose radiation. Given the same
(including how supervisors and/or treatment team professionals are
involved); to obtain clear information about their records; to participate in
actuarial data presented in terms of percentage of patients
the ongoing counseling plans; and to refuse any services or modality change who survived at each stage – for radiation, 100% survived
and to be advised of the consequences of such refusal (ACA, 2005, A.2.b.). the treatments, 77% survived the first year, and 22% survived
Pondering how we would feel in the role of a client who five years – only 25% chose radiation. A shift from a
was not given adequate information to make a decision on an mortality to survivability presentation produced a significant
informed basis can increase our sensitivity and appreciation change in subject’s perception and ultimate decision.
of the ethical responsibility to provide informed consent. An informed consent form may have been composed with
The following three examples of failure to provide informed intimidating legalese and bureaucratic terminology to protect
consent illustrate its importance: One of the most frightening the organization from lawsuit, therefore, a therapist ethical
cases involved the U.S. government offering free medical responsibility exists to explain the information to client.
care to hundreds of U.S. citizens from 1932 to 1972 in the Grundner (1980, p. 900) observed that “consent forms have
Tuskegee syphilis study through what ultimately became the valid content, but little effort has been made to ensure that
U.S. Public Health Service (J. H. Jones, 1981; Rivers, the average person can read and understand them.” He
Schuman, Simpson & Olansky, 1953; U.S. Public Health analyzed five forms, with two standardized readability tests,
and concluded that “the readability of all five was

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approximately equivalent to that of material intended for consultant, or videotaped/audiotaped (Corey et al.,
upper division undergraduates or graduate school students. 2007)
Four of the five forms were written at the level of a scientific f) Client’s options if dissatisfied with therapy such as
journal, and a fifth at the level of a specialized academic names/contact information of supervisors, and contact
magazine” (p. 900). information of licensing boards and professional
Comprehension as well as recall of information is not organizations (Welfel, 2006)
guaranteed by client simply reading an informed consent Furthermore, the eight potential legal concerns listed below
form. Robinson & Merav (1976) re-interviewed twenty are recommended to be discussed in informed consent
patients four to six months after they read and signed an material because they could lead to lawsuit if client believes
informed consent form and underwent therapy. All patients therapist has enacted any of the following (Remley &
exhibited poor recall of all aspects of the information on the Herlihy, 2007):
form, including the diagnosis, possible negative outcomes, → Failure to include HIPAA elements – For example, not
and alternate types of management. Cassileth, Zupkis, informing clients of their right to look at their therapy
Sutton-Smith, & March (1980) discovered that only 60% of records.
patients who read and signed an informed consent form → Providing a guarantee of an outcome resulting from
understood the purpose and nature of the procedures one day therapy – Therapist states, “Therapy will save your marriage”
later. A mechanical and obligatory response from clients that but divorce ensues leading to a breach of contract lawsuit.
they understand is not always reliable (Irwin et al., 1985). → Offering a guarantee of privacy without exceptions –
Remley and Herlihey (2007) recommend the following to Therapist explains the ethical and legal responsibility of
be included in informed consent material: protecting privacy to a client who is concerned about privacy
1. The purposes, goals, techniques, procedures. limitations, issues. Client perceives that therapist will not disclose any
potential risks, and benefits of the proposed therapy information under any circumstance. Soon after, therapist
2. Therapist qualifications, including degrees, licenses and breaks confidentiality by informing client’s wife that client
certifications, areas of specialization, and experience reveals suicidal ideation. Client sues therapist for breach of
3. Plans for continuation of therapy services if therapist contract, malpractice, and deliberately inflicting emotional
becomes incapacitated or dies distress.
4. Implications of the diagnosis and planned utilization of → Agreeing to a fee that is changed later – Agreement of a
tests and reports $50 per hour rate is raised to $75 after several months.
5. Billing information and fees Client expresses that the new rate is excessive and therapist
6. Confidentiality and its limitations replies that therapy will be terminated without the new fee.
7. Clients’ rights to receive information about their Client sues for breach of contract and abandonment.
records and to participate in therapy plans → Touching a client without implied or actual permission –
8. Clients’ rights to refuse any recommended treatment During group therapy, therapist directs clients to catch one
services or changes and to be informed of potential another as they fall backward as a sign of trust. A female
consequences of refusal client with various sexual issues reluctantly participates but
Moreover, the following topics are also recommended to be leaves session early and visibly distraught. Client sues
included: therapist for breach of contract, breach of fiduciary duty,
a) The therapist’s theoretical orientation expressed in assault, battery, and sexual assault.
understandable language ( Corey et al., 2007) or → Misrepresenting one’s credentials – Client receives
therapist’s philosophy of the therapy process therapy from a master’s level licensed therapist and writes
b) Logistics of therapy, including length and frequency the checks to “Dr. Smith” while noting fee is for
of sessions, how to make and cancel sessions, policy “psychological services” and the checks are cashed. After
about telephone contact between appointments, method eight sessions, client calls therapist “Dr. Smith” and is
of contacting therapist or an alternative service in case of corrected by therapist. Client is upset to learn he is seeing a
emergency (Haas & Malouf, 1995) master’s level therapist and not a psychologist. Client sues
c) Insurance reimbursement information, including how for breach of contract and fraudulent misrepresentation.
client’s diagnosis becomes part of client’s permanent
→ Failure to indicate the nature of therapy – Client initiates
health record; description of information to be provided
therapy to overcome public-speaking anxiety. Therapist
to insurance carriers and the resulting limits on
assesses the anxiety results from low self-esteem and
confidentiality (Welfel, 2006); and, if appropriate,
treatment targets the delivery of positive reinforcement of
explanation of how managed care will affect the therapy
client’s positive attributes. After five sessions yielding no
process (Corey et al., 2007; Glosoff et al., 1999)
change, client conveyed she expected to learn ways to give
d) Information on alternatives to therapy, for example,
public presentations without feeling anxious through
12-step groups, self-help groups, bibliotherapy,
receiving advice on managing anxiety, reading books on the
medications, nutritional or exercise therapy, or other
subject, and practicing speaking with therapist. Client sues
pertinent options (Bray, Shepherd, & Hays, 1985)
for breach of contract and malpractice.
e) If the case may be discussed with a supervisor or

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→ Failure to warn client about possible stigma – Therapist CLIENT RIGHT TO REFUSE TREATMENT
completes an insurance form after first session, at client’s
request, indicating client had a single episode of depression Clients who disapprove of a therapist’s proposed treatment
and designated the appropriate diagnosis. Therapy continued plans may generally choose to not receive treatment or to
for ten sessions and terminated due to client moving away. pursue alternative care, however, clients confined in mental
Client called therapist two years later complaining that he hospitals, and minors brought to therapy by their parents or
was denied security clearance for a job he applied for guardians may not have such a choice. Several court rulings
because therapist diagnosed him with a mental disorder, have offered direction in this area, for example, in the
without his knowledge or agreement. Client sues for breach landmark case of O’Connor v. Donaldson (1975), the U.S.
of contract, malpractice, and defamation. Supreme Court identified, for the first time, a constitutional
These situations demonstrate the significance of therapist basis for the “right to treatment” for the nondangerous
and client understanding expectations of therapy before the mentally ill patient. Mr. Donaldson was schizophrenic and
process begins. The above issues were avoidable given his father committed him to a hospital for psychiatric care.
therapists fully informing clients of the therapy relationship. Mr. Donaldson refused somatic treatments due to his
The Health Insurance Portability and Accountability Act Christian Science religious beliefs. He was not deemed a
(HIPAA) became effective on April 15, 2003, in turn, danger to self or others, yet, he was confined in the hospital
therapists must give their clients written informed consent for refusing medication. Mr. Donaldson was not offered
documents to sign. HIPAA requires all health care providers alternative treatment such as verbal or behavioral therapy.
who transmit records electronically (which probably includes The ruling indicated that the state could not confine such
all providers) to conform with procedures that will ensure patients without treatment being provided.
consumer privacy. Practitioners must inform health care
recipients in detail of their established rights regarding Case 2-1: Charles Sell, a dentist, practiced in Missouri and
privacy and records. This federal law has evolved a previous had a long history of mental illness. He was hospitalized,
vague notion of informed consent to a concrete format, treated with antipsychotic medication, and discharged, in
including steps taken to ensure client privacy and clients’ 1982, after advising doctors that the gold used in his fillings
signature of a document that they were informed of their was contaminated by communists. Through the years, Dr.
rights. Some essential HIPAA elements for informed Sell experienced several documented episodes of visual and
consent documents indicating clients have been informed auditory hallucinations followed by a U.S. government
about proposed treatment and agreeing to the arrangements charge, in 1997, of Medicaid, insurance, and mail fraud,
and treatment are illustrated below (Remley & Herlihy, alleging he submitted multiple false claims. A court-ordered
2007): psychiatric examination assessed Dr. Sell “currently
• Indicate that your client’s personal information may be competent” but stated “a psychotic episode” was possible in
used and disclosed in order to complete treatment, and the future. In 1998, during a bail revocation hearing, the
information may be presented to health care companies in judge said Dr. Sell was “totally out of control” as he yelled,
relation to payment of your services. insulted and ultimately spat in the judge’s face. Several
• Have a complete written description of your procedures for months later, the grand jury charged Dr. Sell with attempted
keeping and disclosing your clients’ personal information. murder of the Federal Bureau of Investigation agent who
• Advise your client that you have a more complete arrested him and a past employee who was to testify against
description of how you will keep or disclose their personal him in the fraud case. While incarcerated before trial,
information and it is available to view. Inform that client another court-ordered examination found Dr. Sell “mentally
has a right to see the complete description before signing incompetent to stand trial,” hence, the judge ordered him
the consent form. State that your practice may change “hospitalized for treatment” up to four months “to determine
over time and client can review those revisions by whether there was a substantial probability that Sell would
requesting such in writing. attain the capacity to allow his trial to proceed.” After two
• Explain to clients that they may request that you restrict months, the medical staff recommended Dr. Sell take
how their personal information is used or disclosed, that antipsychotic medication but he refused. The medical staff
you will consider their requests, and will inform them pursued permission to administer the medication against Dr.
whether you have agreed to them. Sell’s will.
• Acknowledge that client has the right to revoke his or her In a 6-3 vote, the U.S. Supreme Court ruled that the
consent in writing, except for actions that you have already government can involuntarily administer antipsychotic
taken which were based on prior consent. mediations to a mentally ill defendant thus allowing the
defendant to stand trial, “but only if the treatment is
• Have client sign and date the form.
medically appropriate, is substantially unlikely to have side
• Keep the form for a minimum of six years.
effects that may undermine the fairness of the trail and,
taking account of less intrusive alternatives, is necessary
significantly to further important governmental trial-related
interests.” The Supreme Court also stated that a) in deciding
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if the government maintains an important interest in bringing Therapist explains his options with client, states that he
a defendant to trial, a trial court must determine whether the cannot offer treatment to anyone under the age of 18 without
defendant will be civilly committed or has been detained parental consent, and expresses his duty to report suspected
already for a lengthy period; b) the government must show child abuse to Child Protective Services. Client feels
that the intended medication is considerably likely to render betrayed.
the defendant competent to stand trial; c) the court must Analysis: Generally, with the exception of a small number of
recognize the absence of a less intrusive approach or states (i.e., the Commonwealth of Virginia), a parent’s
alternative as likely to attain the same result of leading a permission is needed to provide psychotherapy with a minor
defendant to competency; and d) the medication must be in client (Koocher, 1995, 2003). In fact, a child generally
the patient’s best interest, including efficacy and side effects cannot refuse treatment authorized by a parent, even if the
(Sell v. United States, 2003). The Supreme Court’s decision proposed treatment is inpatient confinement (Koocher, 2003;
agreed with the American Psychological Association’s Melton et al., 1983; Weithorn, 1987, 2006). The courts have
request that courts should consider “alternative, less intrusive assumed that the mental health practitioner treating the child
means” before forcibly treating mentally ill criminal at the parents request represents an unbiased third party
defendants with medication. Nathalie F. P. Gilfoyle, General capable of assessing that which is best for the child (J.L. v.
Counsel for the APA, stated, “The bottom line is that – the Parham, 1976; Parham v. J.R., 1979).
Court has specifically required that trial courts consider and Therapist K understood that he could not legally accept
rule out nondrug alternatives before ordering involuntary client’s request for therapy and client could not provide
drug treatment.” competent informed consent with all such implications,
including payment for services. Therapist did not, however,
Case 2-2: Nancy Hargrave had a history of paranoid explain limits of confidentiality to client from the start, as
schizophrenia and many admissions to the Vermont State required by HIPAA (Health Insurance Portability and
Hospital. At a time of emotional stability, Ms. Hargrave Accountability Act, 1996). Practitioner knew of the need to
completed an advance directive through a durable power of report suspected child abuse to the proper authorities as is the
attorney (DPOA) designating a substitute decision maker if statutory obligation in all states. He also respected child’s
she again became psychotic and incompetent by reason of rights as a person and client by discussing his action plan
psychosis and she chose to reject “any and all anti-psychotic, (Koocher & Keith-Spiegel, 2008).
neuroleptic, psychotropic, or psychoactive medications”
upon any future involuntary commitment. Case 2-4: A 30 year-old woman called by phone and
The 1998 Vermont state legislature, however, passed Act requested therapy for depression and marital dissatisfaction.
114, a statute allowing hospital (or prison) personnel to seek In the first session, client disclosed that she was a victim of
court permission to treat incompetent involuntarily sexual trauma as an adolescent. It appeared that client’s
committed patients, despite any advance directives symptoms were linked to her adolescent trauma.
requesting otherwise. Ms. Hargrave argued that the new law Analysis: It is recommended that the informed consent
violated her rights under the Americans With Disabilities process address possible negative effects of therapy upon the
Act. The U.S. District Court and the Second Circuit Court of marriage and the spouse. Common trauma symptoms
Appeals agreed with Ms. Hargrave rather than with the state. include disrupted relationships with significant others such as
Addressing the argument that Hargrave and other emotional detachment, lack of intimacy, and impaired sexual
involuntarily committed patients represent a direct threat, the functioning. Therapist wisely informed client that some of
three-judge panel countered that all committed patients do her negative feelings about her marriage may be caused by
not pose a threat to others, as required by the Americans the impact of the trauma, unrelated to the marriage itself
With Disabilities Act, because many became hospitalized (Knapp & VandeCreek, 2006).
only due to danger to themselves. Additionally, the court
stated that those people designated as dangerous to others at Case 2-5: Therapist, working in a mental health agency,
the time of commitment cannot still be presumed as gave client a personalized, pre-made informed consent form
dangerous when seeking to override their advance directives. before the session began. During session, the client, a young
The court resolved that the state statute violated the mother, revealed that her husband gets angry when their
Americans With Disabilities Act (Appelbaum, 2004). infant daughter cries and severely shakes the child to stop the
crying. Therapist advised client that he must report her
CASE STUDIES husband’s actions as possible child abuse, along with
potential outcomes of the report, and that he will continue
Case 2-3: A 13 year-old walks into a Mental Health Center counseling her. Client responded that she would not have
and asks to talk to someone. Therapist K sees client who revealed this situation had she known it would be reported.
indicates many personal and family problems, including Therapist reminded client that she signed the informed
severe physical abuse at home. Client asks therapist not to consent form which clearly stated therapists are legally
discuss the case with anyone, especially his parents. obligated to report incidents of suspected child abuse. Client
admitted to not having read the document, instead, she signed
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ETHICS: CASE STUDIES I

it along with the other paperwork for insurance purposes. hypnotic training, psychotherapy, and perhaps other
Client chose to discontinue therapy because she lost trust in interventions. He described the importance of each stage and
therapist. how collectively they maximize treatment, and that other
Analysis: Therapists should make the effort to ensure clients practitioners may work differently but his method has proven
understand that which they have read in disclosure effective through years of experience with chronic pain and
statements. Informed consent forms can be used to correct depression. Counselor explained that he used cognitive-
misunderstandings before therapy begins, additionally, behavioral principles that are research-tested for improving
written rather than verbal disclosure statements are more pain disorders and associated symptoms, and he would
effective in addressing questions or issues because the intent coordinate treatment with her physician and specialists
of the parties is clearly expressed. Pope and Vasquez (1998) through consent forms to permit communication. Therapist
believe that counselors cannot rely exclusively on standard addressed client’s concern over fees and expected duration of
forms to complete the purpose of informed consent, therapy because she was previously told by another therapist
regardless of the quality of the form. Dialogue is required to that significant pain relief would occur in two or three
ensure client and therapist understand their upcoming shared sessions. Client felt enlightened by the discussion and
encounter. In the case of clients who lack the capacity to appreciative of therapist taking time to explain fundamental
give informed consent, for example, minors, developmentally issues and answer her questions, at no cost; she chose this
disabled, severe thought-disorders, or those not speaking the therapist and was pleased with the outcome.
primary language, therapists take additional steps to promote Upon arrival at her first session, therapist gave client a
understanding as indicated in these Codes of Ethics: printed disclosure statement explaining other aspects of
For persons who are legally incapable of giving informed consent, informed consent in detail, including confidentiality and its
psychologists nevertheless 1) provide an appropriate explanation, 2) seek the
limitations, fees and third-party reimbursement, duration of
individual’s assent, 3) consider such persons’ preferences and best interests,
and 4) obtain appropriate permission from a legally authorized person, if therapy, cancellations and missed appointments, telephone
such substitute consent is permitted or required by law. When consent by a availability and emergencies, collaboration with other health
legally authorized person is not permitted or required by law, psychologists care professionals or psychologists, and interruptions to
take reasonable steps to protect the individual’s rights and welfare (APA,
therapy such as vacations. Since therapist’s practice was
2002, 3.10.b.).
When counseling minors or persons unable to give voluntary consent, HIPAA compliant, he issued client a second handout
counselors seek the assent of clients to services, and include them in indicating her rights and other relevant information required
decision making as appropriate. Counselors recognize the need to balance by law.
the ethical rights of clients to make choices, their capacity to give consent or
assent to receive services, and parental or familial legal rights and
Analysis: Therapist effectively obtained informed consent
responsibilities to protect these clients and make decisions on their behalf before the onset of treatment and informed about the nature
(ACA, 2005, A.2.d.). of the therapy and how it would likely proceed. He
…When persons, due to age or mental status, are legally incapable of giving discussed financial matters, third-party involvement (which
informed consent, marriage and family therapists obtain informed
permission from a legally authorized person, if such substitute consent is
could include previous therapists, family members, and
legally permissible (AAMFT, 2001, 1.2). physicians), and confidentiality rules and exceptions.
In instances when clients are not literate or have difficulty understanding the Therapists can view the informed consent process as though
primary language used in the practice setting, social workers should take they are enlightening a friend or family member about the
steps to ensure clients’ comprehension. This may include providing clients
with a detailed verbal explanation or arranging for a qualified interpreter or
nature and expected path of treatment in an unhurried manner
translator whenever possible (NASW, 1999, 1.03.b.). while addressing questions and concerns (Nagy, 2005).
In instances when clients lack the capacity to provide informed consent,
social workers should protect clients’ interests by seeking permission from Case 2-7: Therapist created a new program for overweight
an appropriate third party, informing clients consistent with the clients’ level
of understanding. In such instances social workers should seek to ensure
people to lose weight for which supporting research in the
that the third party acts in a manner consistent with the clients’ wishes and literature was scarce. The written informed consent material
interests. Social workers should take reasonable steps to enhance such clearly described the procedure and the information was
clients’ ability to give informed consent (NASW, 1999, 1.03.c.). explained again at the first consultation. Counselor informed
clients of very specific risks potentially associated with this
Case 2-6: A 38 year-old woman, experiencing postpartum protocol, that no weight loss might occur even with
depression, chronic pain in her lower back resulting from a compliance to treatment, and the method was too new to
two year-old injury, and worry over her infant’s unusual assure long-term results. He reported the availability of
health concerns, contacted therapist for psychotherapy and many weight loss programs in the area, and in writing and
nonmedical interventions for her pain. Due to media verbally, expressed that participation was voluntary and
misconceptions and a close friend who was experiencing could be withdrawn at any time; with such termination, he
very fast therapeutic progress, client expected relief from her would refer to three other practitioners using different
back pain with one hypnotic session and only a few sessions methods. Clients felt well informed about the novel
to remedy her depression. In their first telephone contact, approach given the printed handouts and verbal explanation
therapist clarified that the process would probably take provided at the outset.
longer than she anticipated, involving history taking, possible Analysis: Therapist informed his clients about the novel
psychological testing, relaxation, biofeedback or self- techniques, interventions, strategies and procedures for which

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supportive research was lacking and not generally accepted evaluation to acquire information that might affect whether
by the mental health community. Informed consent or not he would receive the death penalty. She clarified that
regarding novel treatment includes these elements: in their state, the courts could deem certain psychological
• Explain the experimental or evolving nature of the problems or histories as either mitigating or aggravating
treatment, for example, that you have achieved good factors which would decease or increase, respectively, the
outcomes, if true, but the procedure is yet to be probability of the death penalty. The psychologist
scientifically researched. illuminated that her job was to provide psychological data to
• Inform clients of possible risks such as the treatment may the court which the judge would use to decide and that it was
not be successful, symptoms may increase, or new difficult to gauge the judge’s interpretation of the data.
symptoms or side effects might develop. Psychologist M stated that she would not administer
• Enlighten clients of available alternative treatments for projective tests because people may not be aware of how
their issues, regardless of whether you will offer them. much they are revealing on such tests and she wanted Mr. A
• State that participation is completely voluntary and may be to choose the information to disclose in the evaluation. The
withdrawn at any time (Nagy, 2005). district attorney, who referred the case to Psychologist M,
The APAs Ethical Standard relating to informing clients of was so upset that she disclosed such detailed information to
new methodology states: Mr. A about the sentencing and evaluation procedures that he
When obtaining informed consent for treatment for which generally filed a complaint with the Ethics Committee.
recognized techniques and procedures have not been established,
psychologists inform their clients/patients of the developing nature of the
Adjudication: The Ethics Committee determined that
treatment, the potential risks involved, alternative treatments that may be Psychologist M was ethical and actually exemplary in
available, and the voluntary nature of their participation (APA, 2002, clarifying her role and offering fully informed consent. The
10.01.b.). Committee explained that informed consent obligations are
always important but are intensified when vital and
Case 2-8: By telephone, Therapist L told a prospective irrevocable consequences for the client’s life are involved.
client, who was depressed and anorectic, that individual Important civil and legal rights are involved when
psychotherapy would rapidly relieve her symptoms and conducting an evaluation for the death penalty, a custody or
improve her work performance within nine sessions – competency hearing, therefore, therapists should fully inform
coinciding with the number of managed care sessions clients of the practitioner’s role and purpose of the evaluation
allotted. Therapist L did not mention that: depression is (APA, 1987).
sometimes exacerbated during therapy, treatment may last
longer than expected, a managed care request for additional Case 2-10: Psychologist N performed a divorce mediation
sessions may be needed, there may be a need for psychiatrist with a couple, Mr. and Mrs. B, regarding the custody of their
assessment for antidepressant medication or a need to child. Psychologist N informed the couple of the goals and
coordinate treatment with her referring primary care methods of mediation such that they would meet for eight
physician. Therapist used complex terms in describing her sessions to arrive at an agreeable custody arrangement. They
theoretical orientation, which client did not comprehend, and did not reach an agreement as conflict mounted, hence, the
she omitted discussion of confidentiality, possible need for case was returned to the court for adjudication. Psychologist
hospitalization, fees or frequency of sessions. When client N then voluntarily issued a psychological evaluation report to
arrived for the first session, she was disappointed to learn the court which recommended Mr. B to be granted custody of
that the fees were $175.00 per session and three sessions per the child, partly due to his more acquiescent presentation
week was recommended. Client ended the encounter, felt during mediation, perhaps facilitating allowance of the child
betrayed and ashamed, and delayed contacting another to have unobstructed visitation rights. Mrs. B filed a
therapist for several months. complaint about the report with the Ethics Committee.
Analysis: Therapist L did not inform client of the relevant Psychologist N told the Committee that it was her general
aspects of the proposed treatment or the business practice to submit evaluation reports to the court after failed
arrangements, and she presented the therapy unrealistically mediation attempts and that there is nothing wrong with
through potentially false promises of efficacy and timeframe. doing so.
Generally, clients should understand what therapist has Adjudication: The Ethics Committee declared Psychologist
planned through a) clear description of the proposed N violated informed consent standards by not clarifying her
treatment, b) explanation of significant aspects of the role in the process and not informing the couple of the
services, c) a willing consent to services, and d) therapist purpose and nature of their eight sessions. She did not
documents the consent (Nagy, 2000). indicate, from the beginning, that her role was as mediator
and evaluator, further, she failed to explain to the couple that
Case 2-9: Psychologist M conducted a pre-sentencing the mediation evaluation information might be used in the
psychological evaluation of Mr. A which would assist the custody adjudication, if needed. The Committee determined
court in determining whether to sentence Mr. A to death for that Psychologist N also breached confidentiality by
conviction of murder of two children. Psychologist M releasing information from the sessions without either a court
informed Mr. A that the judge asked her to complete an order or the couple’s permission. The Ethics Committee

18 Continuing Psychology Education Inc.

ETHICS: CASE STUDIES I

censured the psychologist and ordered her forensic practice the psychologist was told that this is standard practice and
under the supervision of a board-certified forensic that he, being an educated person, would understand this.
psychologist, selected by the Committee (APA, 1987). Client filed a complaint with the Ethics Committee
explaining he gave ample notice for the missed session and
Case 2-11: The director of a firm referred an ineffective that no mutual agreement of required payment for cancelled
employee of the firm to Psychologist O for evaluation. The sessions was ever made. The psychologist issued the
firm director and psychologist agreed before the employee’s Committee the same rationale as given to the client.
first consultation that the psychologist would tell the director Adjudication: The Ethics Committee determined that the
whether the evaluation suggested the employee’s job psychologist violated informed consent requirements by not
continuation and if remedial training might improve his ensuring all financial arrangements were clear to client
performance. Employee saw psychologist for several before therapy began. The committee reprimanded the
sessions involving interviews and testing, under the psychologist, authorized the missed session charge be
impression that all shared information was confidential. cancelled, and required more open communication with her
Psychologist O never informed employee of the arrangement clients in the future (APA, 1987).
with the firm. The director fired the employee upon receipt Weinrach (1989) suggested that the two most frequent
of psychologist’s report. The employee deduced the problems for private practitioners involve fees and billing,
psychologist’s involvement and filed charges with the Ethics and late cancellations or no-shows, thus, practitioners will
Committee. Psychologist O told the Committee that he want to be clear regarding payment methods and missed
thought the employer would advise employee of the purpose appointments.
and possible implications of the evaluation, thus, he did not Ethically, informed consent is a recurring process rather
feel a need to raise the issue. than a single event and documenting discussion of informed
Adjudication: The Ethics Committee found Psychologist O consent throughout the therapy process is advised. As
in violation of informed consent standards based on his therapy moves forward, goals, concerns, risks, and benefits
failure to clarify with client the nature of involvement may evolve to a different level, hence, logic dictates that
between the three parties. Practitioner had the ethical clients require updated information to facilitate continued
responsibility to be explicit with client unrelated to sound decisions (Handelsman, 2001).
psychologist’s understanding of the employer’s plans. The Glosoff (1998) recommends therapists to expand informed
Committee censured Psychologist O (APA, 1987). consent information to clients in managed care systems
compared to other clients; discussion would include how
Case 2-12: A clinical agency hired Psychologist P as a clients’ specific plan will affect length of treatment, types of
researcher to design an evaluation study comparing the available treatment, confidentiality limits, development of
effectiveness of two depression-treatment therapeutic treatment plans, and how diagnoses are made and used.
modalities: a behavioral group program and a psychotropic Practitioners are encouraged to know the requirements of
medication program with supportive psychotherapy. The their clients’ managed care company, but if this proves
clinic preferred to randomly assign clients to either treatment impractical, to advise their clients to understand the terms
and psychologist expressed that informed consent is needed and limits of their coverage.
for randomization and participation in the intervention and Obtaining informed consent is research validated to be a
evaluation process. The clinic director, not an APA member, worthy endeavor. Studies show that clients want information
countered that there was no need for the clinic to inform about their prospective therapists (Braaten, Otto, &
clients they were participating in a research study. Handelsman, 1993; Hendrick, 1988); and they perceive
Psychologist P was uncomfortable with this decision and therapists who offer informed consent information to be
with the thought of endangering her position; she requested more professional and trustworthy (Sullivan, Martin, &
guidance from the Ethics Committee. Handelsman, 1993). Moreover, informed consent forms can
Opinion: The Ethics Committee instructed Psychologist P of help prevent some legal problems if allegations of
her responsibility to conform with the Ethical Principles and nondisclosure occur as the client-signed disclosure statement
any relevant state or federal regulations. Continued may exonerate a falsely accused therapist.
involvement in the study was deemed contingent upon
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ETHICS: CASE STUDIES I

TEST – ETHICS: CASE STUDIES I Continuing Psychology Education Inc. is approved by

the Illinois Department of Financial and Professional
6 Continuing Education Hours Regulation as a continuing education sponsor for
Record your answers on the Answer Sheet (click LCSWs and LSWs (License # 159-000806), and
the “Illinois Answer Sheet” link on Home Page for LCPCs and LPCs (License # 197-000108).
and either click, pencil or pen your answers). This course is approved by the Illinois Department
Passing is 70% or better. of Financial and Professional Regulation for 6 hours
For True/False questions: A = True and B = False. of continuing education for LCSWs, LSWs, LCPCs
and LPCs.

TRUE/FALSE

1. Uniform agreement within the mental health field on 11. The Codes of Ethics of the professional mental health
the definition of competence is lacking. organizations serve to educate members about ____.
A) True B) False A) sound ethical conduct
B) professional accountability
2. Therapists have an ethical responsibility to practice in C) improved practice through mandatory and
specialty areas that are new to them only after aspirational ethics
obtaining suitable education, training, and supervised D) all of the above
experience.
A) True B) False 12. Therapist impairment __________.
A) is a deterioration of professional abilities from a
3. Psychotherapists are competent to treat all people previous competent level
for all issues. B) occurs when therapists’ personal problems overflow
A) True B) False into their professional activity
C) decreases therapeutic effectiveness
4. In cases 1-4 and 1-5, both therapists are offering D) all of the above
below-standard treatment resulting from failure
to keep abreast with advancements in the field. 13. Competent professionals uphold two essential
A) True B) False ethical principles: beneficence and ________.
A) nonmaleficence
5. The decision to terminate therapy is based on the B) benevolence
best interest of the client. C) being helpful to client
A) True B) False D) honesty

6. A therapist ethical responsibility exists to explain 14. In case 1-10, Therapist D learned of the ________.
the informed consent information to client. A) need to mirror client
A) True B) False B) importance to seek education, supervision, and
consultation when entering into new specialty areas
7. Ethically, informed consent is a recurring process C) value of comprehensive session notes
rather than a single event. D) benefits of active listening
A) True B) False
15. ____________ is defined as a type of emotional
8. A mechanical and obligatory response from clients exhaustion due to extreme demands on energy,
that they understand the informed consent form strength, and personal resources in the workplace.
is always reliable. A) Depression
A) True B) False B) Melancholia
C) Burnout
9. Studies show that clients perceive therapists who offer D) Dysthymic Disorder
informed consent information to be more professional
and trustworthy.
A) True B) False

10. Informing clients how therapy works demystifies the

relationship and empowers their active involvement.
A) True B) False

22 Continuing Psychology Education Inc.

ETHICS: CASE STUDIES I

16. Studies demonstrate that informed consent

procedures increase likelihood that clients will _____.
A) become less anxious
B) follow the treatment plan
C) recover more quickly
D) all of the above

17. Glosoff recommends therapists to expand informed

consent information to clients in managed care
systems, including _____________.
A) how clients’ specific plan will affect length of
treatment
B) confidentiality limits
C) how diagnoses are made and used
D) all of the above

18. ___________ provides relevant information to clients

regarding expectations of therapy before onset of
assessment or treatment.
A) Informed consent
B) Empiricism
C) Naturalistic observation
D) Deductive reasoning

19. The requirement for health professionals to secure

informed consent from their clientele prior to
rendering services started in the field of _________.
A) dentistry
B) medicine
C) communication
D) linguistics

20. Failure to provide informed consent is illustrated

in the ______________.
A) Coalition of Coal Miners study
B) Federation of Teachers project
C) Tuskegee syphilis study
D) Tennessee Heart Research Project

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