No thinking allowed: Ethics in reverse
May 15, 2014
Out of a fear of some negative regulatory consequence secondary to their professional conduct, there has been a movement by some psychologists away from a conceptual model of ethical decision-making to a rule-based model. These psychologists find a sense of safety in so doing this since they believe that in a rule-based system, they are less likely to make a mistake.
This sense of security, however, could not be further from the truth. While there are some circumstances where rules are vital, like not having sex with clients and not engaging in insurance fraud, the majority of ethical dilemmas do not have concrete correct answers to them.
Because of this reality risk managers and experts in psychological ethics have recommended over and over that psychologists engage in ethical decision making when confronting a dilemma, a process that measures the final choice of conduct against the unique circumstances of the case at hand.
This is because most solutions to questions regarding professional conduct are not that black and white and the “rules” are anything but rules. They usually are nothing more than least common denominator solutions to ethical questions that frequently are not in the best interest of either the consumer or the professional.
In many ways these rules are actually some form of professional myth, the genesis of which is unknown to the professional. I call these rules “practice myths” and would like to review a few to make my point.
The first practice myth is the “I Must Give Three Names Myth.” This rule states that when making a referral to another mental health professional, psychologists always have to give at least three names to the client
Interestingly, there is nothing in our ethical code or in our professional standards that requires this. Regardless, the myth has become a standard of practice without understanding whether such a rule is either appropriate or ethical. We just do it because we were told this was a requirement.
While appropriate referral is a must, giving three names has nothing to do with being appropriate, and doing so arguably might even not be in the best interests of your client. In reality, what we should do is not give the patient three names but make the right referral that fits the circumstance.
The options here are many but could include sending a patient back to their managed care company for the name of another covered professional, since you do not know who is in their insurance network, or sending them to one highly skilled professional who can take the case and meet their clinical needs. Both of these options might be right for a particular client under a particular circumstance.
Interestingly, giving a patient a list of three professionals, some of whom are not in their provider network and some of whom they might not be able to afford to see, actually makes no sense. This type of conduct on the part of the professional is actually defensive risk management which is even questionable from an ethical perspective.
Now, it is true that professionals who always make a referral to three individuals do reduce the likelihood that they could be sued for wrongful referral and three options does give clients more choice, but engaging in such defensive risk management also might not be in the best interest of your client.
Again, what is ethical here is to seek out the right referral(s) for the client which could be one name of a single professional willing and able to take the case or referral back to a carrier to see who is covered and who has the appropriate skill set to meet the client’s needs.
The next practice myth is has to do with the termination of a treatment alliance. I call this the “I Cannot Terminate You Myth.”
This is a rule that is frequently found among psychologists who have never read Standard 10.10 of the APA Ethical Principles or, if they have, they have forgotten it
Key here is the belief that clients must agree with terminations and that if they do not cooperate or agree with termination the psychologist could be charged with abandonment.
The frequent result of operating by this rule is that many professionals place themselves at risk by delivering services that may be clinically unnecessary or potentially of negative consequence to both parties.
As is so aptly pointed out in Denise Davis’ book Terminating Therapy: A Professional Guide to Ending on a Positive Note, this is a complex topic, but psychologists need to understand that they are in control of the professional relationship and, when nothing good is happening, or when another professional could better assist a client, termination is not only appropriate but arguably mandatory.
While this is best done with the cooperation of the client, there are times when psychologists unilaterally must end a professional alliance even over the objections of the client.
Risk here comes from not knowing how to appropriately terminate clients against their wishes or under adversarial circumstances, not from the terminations. Again, under some circumstances termination is not only advisable but is arguably mandatory.
These two rules exemplify some of the common practice myths that exist among psychologists, and there are many more.
These myths do not honor the complexity of human circumstance and are frequently used by those who have moved away from a the benefits of approaching ethical questions conceptually toward utilizing a “black and white” rule system that almost always has exceptions.
Psychologists confronted with questions regarding how to deal with confusing professional circumstances would be far better off by being thoughtful, and answering these questions conceptually, than they would be by looking for some rule that might give them a false sense of security. Actually, exceptions to rules are almost always the rule.
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Jeffrey Younggren, Ph.D., is a clinical and forensic psychologist practicing in Rolling Hills, Calif., and a clinical professor at the UCLA School of Medicine. He may be reached by email at: email@example.com
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