Ethical Decision Making For Therapists - Illustrated with Pope and Vasquez's 17 Step Process
Is the Ethical Choice Usually Obvious?
Ethical Decision Making
In psychotherapy there are many situations that could occur requiring the therapist to determine what the best ethical decision would be in a specific situation for a specific patient. The 17 steps in ethical decision making outlined by Pope and Vasquez, (2011), is designed to clarify ethical dilemmas, ensure all relevant information is considered, and help us make the best decision possible. Below is a scenario which could occur in professional psychology. I have selected a specific ethical dilemma for this scenario and I will use the first 14 steps in Pope and Vasquez’s 2011 ethical decision making model to determine what the ‘best’ solution is for this ethical dilemma. A short discussion on the importance of ethical decision making in professional psychology will follow.
I share an office suite with five other therapists. Each of us has our name engraved on a bronze plaque attached to our office doors, where anyone walking by could see it, to make it easier for our patients to find the right therapists office. When I came in early yesterday I saw David Berkowitz’s office door was ajar and went over to say good morning. Instead of finding David I found that his office had been vandalized and it was a mess. Not only were swastikas and some really nasty racial slurs spray-painted everywhere, but the furniture was tipped over, books were torn up, and confidential client files were thrown all over the floor.
I am not sure but I might know who did it. The first thing that came to my mind when I saw the damage was a client of mine, referred to as Bob Smith for the purposes of this paper, who has been very vocal about his anti-Semitic views. He has expressed strong negative feelings about Jewish people in general during his therapy sessions, as well as sharing his belief that the Holocaust was pure fiction. Most alarming was his admission to having fantasies on more than one occasion about desecrating synagogues in the area. I don’t have any evidence, but what if my patient was the vandal? I know if I asked him he would probably just deny it and any chance of my helping him would be lost, let alone just keeping him as a client.
Step 1: Clearly Define the Dilemma
The ethical dilemma I will be trying to resolve is whether or not I can give my clients name to the police as a possible suspect in the vandalism case and, either way, determining the best way to approach the subject of the vandalism with my client.
Step 2: Who Will My Decision Affect?
At first glance this seems like a simple process, but the longer you think about how one person is connected to another it starts to have a domino like effect with could include hundreds of people. That being the case I decided to concentrate on those who could be affected the most by my decision. First of all, it could affect my client in more than one way. It could affect his therapy as even discussing the possibility of his involvement could damage any trust that he has developed in me as his therapist. It could even effect his employment or freedom if he is charged with a crime and/or found guilty. Since he is married and has a child, they could both be affected if he was charged with or convicted of the crime. If he lost his job there would be financial consequences. Even just being questioned about or charged with this type crime could bring negative attention to him and his family. If he was convicted his family would lose his presence in the home as well as his income.
My partner could also be affected. If I do not give the police my clients name and he committed the crime they might not have the information that they need to consider him a suspect and could potentially fail to catch the perpetrator or charge the wrong person. Knowing whoever did this was still out there could cause my partner stress or anxiety, or even affect his ability to continue his practice at this location. If my client is charged and convicted my partner may assume that I had information that I did not share which could affect his trust in me or his ability to work with me.
The police would be affected because without knowing a possible suspect had access to the building they may not have access to the information they would need to determine that he could be a suspect on their own. This will cause them more work and make it harder for them to solve the crime if my client is in fact the one who committed the crime.
Lastly, I could be affected because whatever decision I make I will have to live with. If I think he did it and don’t do or say anything and he goes on to do something similar or worse I will fill partially responsible. Similarly, if I believe my client is guilty and they arrest the wrong person I will also feel responsible. If I discuss it with my client and that causes him to discontinue therapy I not only lose a client, he might not seek out another therapist and could fail to get treatment. If I do decide to give his name to the police I may not only lose the respect of my peers, but could also lose other patients if they find out and feel that I shared confidential information.
Step 3: Who is My Client?
In this particular situation, while there will be more than one person affected by my decision, there is only one person who is my client. Bob Smith is an adult who is insured through his employer and is paying for any charges not covered through his insurance out of his own pocket.
Step 4: Am I the Right Person to Make this Decision?
In this specific situation I do not think there is a choice. I am the only one who can make this decision as I am the therapist and my client is the person I suspect of committing the crime. I have all the tools and training I need to make the decision and I am qualified to do so.
Step 5: Relevant Ethical Standards
According to the American Psychological Association (2010) code of conduct, standard 4.05, the two types of disclosures when it comes to confidential client information are with or without the clients consent. If the client consents the therapist can disclose confidential information as long as it is not against the law in their state. If they client does not consent the therapist can only disclose confidential information under certain circumstances, when it is permitted by law, and for a valid reason. These reasons include being able to provide needed services, obtain a professional consultation, protect someone from harm, or to get paid for their services. For this particular scenario none of these apply. The crime was already committed and no one was hurt. If I knew ahead of time that he was planning a crime that could hurt someone then I would be able to disclose information needed to prevent the crime.
Step 6: Relevant Legal Standards
According to the United States Department of Health and Human Services (n.d.) HIPAA’s privacy rules are designed to protect personal health information. They also permit the disclosure of personal health information if it is needed for patient care as well as for a few other specific purposes. One of those purposes involves law enforcement. Protected information can be released to law enforcement personnel under specific conditions if they fall under one of the following six situations:
- It is required by law;
- To identify a suspect, fugitive, material witness, or missing person In reply to an official request by law enforcement personnel for information regarding a victim, or suspected victim, of a crime;
- To inform law enforcement of someone’s death if therapist/doctor thinks that criminal activity was responsible for the death;
- When the therapist/doctor is convinced that the protected information is evidence of a crime that happened at its grounds;
- By a therapist/doctor during a medical emergency that does not happen at its location;
- When it is essential to notify law enforcement concerning a crime, the location of a crime or crime victim, or the offender of the crime.
Taking all of this information into consideration I think that it might be legally acceptable for me to give the police information concerning my client as a possible suspect in the vandalism case. Might be legal, and being ethical, are two different things and might be is not a strong enough conclusion when it concerns releasing confidential information and the health and wellbeing of my client.
Step 7: Relevant Research and Theories
While there is a lot of research available on racially motivated crimes, patient who commit crimes, and even on patient confidentiality none of it seems relevant to this specific situation. The only applicable research I could find from a few different studies, including Mermelstein and Wallack, (2008), was that the foundation of the therapeutic relationship is built on the trust that develops between a patient and therapist. This is a well-known concept and something I took into consideration. While psychological theories may explain my patients disorder that is not what this decision is about. I could not find any psychological theories pertaining to releasing confidential information or discussing a crime possibly committed by a patient with the patient.
Step 8: Do I have any Personal Beliefs or Biases That Could Affect my Judgment?
It is hard not to have personal feeling when it comes to racial violence. I’m not Jewish, or overtly religious, but my mother worked at a Jewish Temple for years and I attended many of their celebrations and made friends there. I also learned about the Holocaust in school as well as reading further into it when I was older. My daughter is bi-racial so even though she is not Jewish, I have negative feeling towards people who are discriminatory in nature. My father was a racist and his views often upset me. Even though I do have personal feelings about this situation, my training has allowed me to address these types of situations without letting it affect my judgment.
Step 9: Are There Any Social, Cultural, or Religious Factors to be Considered?
There are no cultural or social contexts, or conflict between contexts, that could change or alter the meaning of this particular situation. My patient, Bob Smith, is a white male with no cultural or social affiliations to groups that would make this behavior acceptable. While religion is obviously a factor in that it involves anti-semantic behavior, I do not think it is a factor in the decision making process concerning releasing his name to the police, but could be relevant in any discussion I have with him concerning this crime.
Step 10: Should I Seek Consultation?
According to Saviano, (2008), there are many complicated laws, both state and federal, that apply to the disclosure of mental health records. That being the case it is advisable that therapists seek legal counsel on a case by case basis if they are unsure of the legal ramifications of disclosing mental health information about a patient in a specific situation. While the most conservative action would be to require patients consent for any disclosure of mental health information, that is not always possible. That being the case, I think consulting with legal counsel would be appropriate in this situation prior to releasing any information to the authorities. As far as consulting with a colleague I am not sure that I would be a good idea. The colleagues I would normally consult with all work in my office and they may have personal feelings about the situation that could affect their judgment. If I am still unsure after working through these steps as far as what the appropriate thing to do from a therapeutic standpoint is I will consult with someone outside of this office.
Step 11: Alternative Courses of Action
There are many different ways that I can respond to this dilemma. First I need to look at the beginning of the dilemma; what, if anything, do I tell the police? I can refrain from telling them anything about any of my clients. I can tell them one of my clients might be a suspect. I can tell them one of my clients has anti-semantic views. I can tell the police Bob Smith might be a suspect. I can tell them that he has expressed anti-semantic views. Next, I need to decide what, if anything, to say to Bob about this crime. I can refrain from discussing it with him at all. I can discuss it with him in generalities without any indication that I might think he was responsible. I can ask him if he would ever do anything like that. I can ask him if he committed any crimes. I can ask him if he committed this crime.
Step 12: Evaluation of Alternative Courses of Action
If I refrain from telling the police anything about my patient than I do not have to worry about whether or not I released confidential information or acted unethically in regards to my client. If I tell them one of my clients may be a suspect or that they have expressed anti-semantic views I am opening up the door to them trying to subpoena all of my client’s records, which would affect all of my clients instead of one. If I give them Bob’s name, with or without details about his views, his records would be subpoenaed and it could be an ethical violation as well as damaging to his therapy. If I refrain from discussing the crime with Bob at all I would continue to feel bad about the situation, but it might not affect him. If I discussed the crime with him in generalities, or asked him if he would ever do anything like that, it could help me determine if he had knowledge of the crime and, either way, it might help him work through some of his feelings. If I ask him about committing crimes or committing this crime it will likely affect the patient client relationship that we have built and end any chance of my being able to help him.
Step 13: Different Perspectives
There are three other perspectives besides my own that I think are relevant to this decision. They are my client, the victim, and the police. My client would probably think that I should maintain confidentiality when it comes to the police, but might want to discuss the situation as part of his therapy. The victim, David Berkowitz, could either think as a victim in which case he would want me to give the police information if it could lead to the criminal being punished, or think as a therapist and want me to maintain confidentiality. The police probably do not care about the confidentiality of a patient and would want me to give them any and all information that could be relevant to the crime.
Step 14: The Decision
Taking everything into consideration I have decided not to share any client information with the police. However I have also decided to discuss the situation with my patient as a part of his therapy. The discussion will focus on the general aspects of the crime and his feelings about it. Unless he admits to the crime, the discussion will be hypothetical in nature and not accusatory.
Is it the Right Decision?
I think this is the best decision. Having taken into account possible laws and ethical considerations there was too much uncertainty about releasing confidential information based on the possibility that my client committed the crime. Discussing the crime hypothetical allows me to address the issues without accusing him of a crime and has less chance of negatively affected his therapy. If he admits to committing the crime I will revisit these steps to ascertain if I need to reevaluate the situation and utilize one of the alternative courses of action instead.
Putting my Decision into Action
My client’s regular appointment is tomorrow. I will discuss this with him then and see where that discussion leads. I have gathered all of the relevant information so that I can use it during the therapy session if appropriate, including pictures of the damage done to David’s office.
The guidelines and ethical concepts pertaining to psychotherapy are often abstract which can make them seem vague and uncertain. Psychotherapy involves interaction between two individuals, and even when the therapist is the same the patients always differ. This makes each patient/therapist relationship unique. Patients seeking therapy have expectations for what that therapy will entail as well as emotions tied into the process. They can be needy, hopeful, scared, or even in danger. Therapy provides patients with the opportunity to change their lives (Pope & Vasquez, 2012). Ethical decision making in professional psychology is so important that the American Psychological Association (2010) included the requirement in their Ethics Code. It states that. “In the process of making decisions regarding their professional behavior, psychologists must consider this Ethics Code in addition to applicable laws and psychology board regulations…If this Ethics Code establishes a higher standard of conduct than is required by law, psychologists must meet the higher ethical standard” (pg. 3). When you take everything into consideration you can see why ethical decision making skills are so important in a field that focusses on helping a vulnerable population deal with psychological problems and extremely emotional situations.
American Psychological Association. (2010). Ethical Principles of Psychologists and Code of
Conduct. Retrieved from http://www.apa.org/ethics/code/index.aspx?item=7
Mermelstein, Hindi T, M.D., F.A.P.M., & Wallack, Joel J, M.D., F.A.P.M. (2008).
Confidentiality in the age of HIPAA: A challenge for psychosomatic medicine. Psychosomatics, 49(2), 97-103. Retrieved from http://search.proquest.com/docview/220348916?accountid=35812
Pope, K. S., & Vasquez, M. J. T. (2011). Ethics in psychotherapy and counseling: A
Practical guide (4th ed.). Hoboken, NJ: Wiley.
Saviano, E. C. (2008). Maintenance and Disclosure of Mental Health Records in the Primary
Care Clinic Setting. Retrieved from http://ibhp.org/uploads/file/MentalHealthRecordMaintenance_article.pdf
United States Department of Health and Human Services. (n.d.). Summary of the HIPAA
Privacy Rule: Permitted Uses and Disclosures. Retrieved from http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html