Clinical Competency and Ethics in Psychology
IN THIS ARTICLE
The American Psychological Association (APA) Ethical Principles and Code of Conduct (2002) have multiple standards on competence. These standards are particularly relevant to clinical psychologists in Illinois given the fact that under The Clinical Psychologist Licensing Act, those licensed in this state are not required to continue their education after licensure. Licensed clinical psychologists will encounter many ethical dilemmas regarding competency during their careers. It is important to understand the meaning of competence and its importance in all fields of psychology. This paper discusses the APA code of ethics as it pertains to competence, current dilemmas regarding competency in psychology, and recommendations to improve competency in clinical practice.
American Psychological Association’s Ethical Principles and Code of Conduct
Psychologists have values and these values are infused throughout their professional work (Bergin, 1991; Meara, Schimdt, & Day, 1996; Prilleltensky, 1997; Remley & Herlihy, 2007; as cited in Shiles, 2009). The purpose of an ethics code is “to reflect an explicit value system as well as clearly articulated decisional and behavioral rules” (Fisher, 2009) in which all members of the group following the code agree to adhere to. Psychologists are allowed to have personal values that may not be addressed within their code of ethics but are assumed to uphold the values that are stated within their code. The American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (APA, 2002) is the standard to which all members and student affiliates agree to comply with. The 2002 Ethics Code consists of the Introduction and Applicability Section, Preamble, General Principles, and Enforceable Standards. Many of these enforceable standards address the area of competence. These standards are as follows:
2.01 Boundaries of Competence
(a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.
(b) Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies.
(c) Psychologists planning to provide services, teach, or conduct research involving populations, areas, techniques, or technologies new to them undertake relevant education, training, supervised experience, consultation, or study.
(d) When psychologists are asked to provide services to individuals for whom appropriate mental health services are not available and for which psychologists have not obtained the competence necessary, psychologists with closely related prior training or experience may provide such services in order to ensure that services are not denied if they make a reasonable effort to obtain the competence required by using relevant research, training, consultation, or study.
(e) In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm.
(f) When assuming forensic roles, psychologists are or become reasonably familiar with the judicial or administrative rules governing their roles.
2.02 Providing Services in Emergencies
2.03 Maintaining Competence
2.04 Bases for Scientific and Professional Judgments
2.05 Delegation of Work to Others
2.06 Personal Problems and Conflicts
(b) When psychologists become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work-related duties. (See also Standard 10.10, Terminating Therapy) (APA Ethics Code, 2002).
Competence within the field of psychology is as important as any other standard and possibly more important inasmuch as the knowledge available to practicing psychologists is constantly growing and changing, making competency a lifelong goal that is never quite satisfied. There is always more to learn and the thought of knowing all there is to know is overwhelming. To aid in this attempt at competency, researchers have developed guidelines for psychologists to remain competent in their field.
Shiles (2009) states that professional competency is not a fixed construct, meaning that psychologists are either incompetent or competent. Instead she argues that competency lies on a continuum and there are many facets to competency which can be expanded through a variety of ways. There are three obligations under the 2002 APA Ethics Code in relation to Standard 2.01 (b) (Boundaries of Competence) (Fisher as cited in Shiles, 2009). The first obligation is becoming familiar with professional and scientific knowledge. Second is acquiring professional skills. Third, psychologists must know when to refer and when not to, thus recognizing when they do or do not have access to obtain the knowledge or appropriate experience required. If a psychologist does not follow these obligations, according to Fisher, they are in violation of the 2002 APA Ethics Code.
The Cube Model (Rodolfa, Bent, Eisman, Nelson, Rehm, & Richie as cited in Kerns et al., 2009) also provides three specific domains, in which any psychotherapist should retain competency during their career. The first domain is composed of foundational competencies. These are the knowledge, skills, attitudes, and values which underlie the function of psychologists. Examples of foundational competencies include graduate coursework, practicum/intern experiences, and the aspirational goals in the APA 2002 Ethics Code. Practicing psychologists should have a firm background in these competencies which is built up in the early years of their career, during graduate school, when one first learns of all the necessary foundational competencies.
The second domain of the Cube Model is functional competencies which encompasses the professional activities of psychologists. This means what does any given psychologist do on any given day? Whether it is clinical, research, educational, or administrative in nature, psychologists are required to remain competent in the specific field in which they practice.
The third domain of the Cube Model is a developmental perspective of competency. This perspective stresses the importance of continued professional growth through a process of ongoing self-reflection and reexamination of one’s competencies and efforts consistent with a commitment to continuing education. Once a psychologist finishes graduate school, receives their license, and is employed, their training does not stop. As in any scientific field, new discoveries are being made constantly and it is a psychologist’s ethical, personal, and professional responsibility to keep up with these new discoveries and utilize them whenever possible to advance the field of psychology.
Another area of competency not outlined by the Cube Model but relevant to all psychotherapists is that of ethical competency (Sporrong et al., 2007). According to Sporrong and colleagues, ethical competence at work requires the ability to integrate perception, reflection, and action, and to understand oneself as being responsible for one’s own actions. Key competencies in ethics include knowing and understanding codes of ethics, being able recognize and analyze ethical situations, and trying to resolve them. It is not enough to understand the field of psychology and its ethics code. One needs to be able to identify unethical situations and have the abilities necessary to correct them.
When psychotherapists face ethical dilemmas, Barnett (2008) states they will seek information from the law, professional publications, and colleagues to guide them in their decision-making. He also states that knowledge of the professional literature in one’s area of practice is an ethical duty for staying up-to-date with chances in practice patterns and recent developments that may change previously accepted practices. At times, ethical dilemmas may be hard to recognize because they are on a continuum between right and wrong; they are on a slippery slope. What is right is right, what is right is kind of right, what is right is kind of wrong, and what is right becomes what is wrong. This ambiguity can be problematic when dealing with ethical decisions, even for the most competent psychologist. It can be stated almost certainly that every practicing psychologist will encounter situations in which their competency and/or ethical foundations will be called into question.
A clear definition of an ethical dilemma is given by Kitchener as cited in Shiles (2009). The definition given states that an ethical dilemma is defined as when “there are good but contradictory ethical reasons to take conflicting and incompatible courses of action” (1984, p. 43). Shiles (2009) argued that there is an ethical dilemma between Standards 2.01(b) (Boundaries of Competence) and 3.01 (Unfair Discrimination) of the APA 2002 Ethics Code. She states that although current literature suggests that when a psychologist is uncomfortable working with a client’s presenting concern, it may be in the client’s best interest to refer him or her with the understanding that the reason for referral is the psychologist is not competent to work with that particular client, this logic is being used to discriminate against clients. A psychologist can refer a client on these grounds without repercussions when the underlying issue is the psychologist does not want to work with that client, whatever the reason may be. For example, if a psychologist is racist against African-Americans, they could refer an African-American client to another psychologist saying they are not competent to work with African-Americans because they do not know enough about their culture. Although this may be true, the true reason for referral is racism.
Another example of an ethical dilemma being debated in current research in regards to competency is what to do when you need a third-party to facilitate in the therapeutic relationship, as is the case with interpreters. According to the APA Ethics Code (2002) it is the psychologist’s responsibility to ensure that interpreters demonstrate competence and professionalism. Although many psychologists will not have the benefit of graduate training or continuing education on working with interpreters, many will need to their services given that currently, 18% of Americans speak a language other than English at home and 8% of U.S. citizens demonstrate limited English proficiency (Searight & Searight, 2009). According to Searight & Searight (2009), psychologists practicing under the APA 2002 Ethics Code will likely have to address the conflict between promoting the client’s welfare and insuring competence when delegating services. Interpreters frequently commit errors while interpreting, may possibly compromise the therapeutic relationship, and may not be accessible in times of emergencies or crises (Searight & Searight, 2009). These are all dilemmas that a psychologist might face when working with clients with limited English proficiency.
The last example of a competence-related ethical dilemma to be discussed within this article is that between the delivery of ethical and culturally consistent therapy (Gallardo et al., 2009). At times the APA 2002 Ethics Code can be in conflict with the client’s best interest, especially if the client adheres to different personal ethics or standards. Gallardo and colleagues (2009) state some of these challenges include negotiating boundaries within the therapeutic context, giving and providing solutions, and struggling with internal personal values when they differ from that of the client. According to the literature (as cited in Fisher, 2009), ethical decision making in diverse cultural settings must be sensitive to cultural attitudes of individualism versus collectivism, historical and contemporary discrimination with society and psychology as a discipline, sociopolitical factors influencing definitions of race, ethnicity, and variations in immigration history, acculturation, cultural/ethnic identity, language, and mixed race/ethnic heritage. Given the multitude of variables involved, it is easy to see how an ethical dilemma may present itself between client and psychotherapist. What the client may believe is ethical behavior may not be the therapist’s opinion or vice versa. Psychologists may unintentionally harm their clients of culturally diverse groups by invalidating their life experiences, defining their cultural values or differences as deviant, or imposing the values of dominant culture upon them (Fisher, 2009). By remaining ignorant and incompetent of clients’ cultures, psychologists risk unethical behavior and harm to their clients.
Ethical Decision-Making Processes
Such ethical dilemmas as those presented above demonstrate the vagueness of practicing ethically and competently. These examples, along with many others, are the ongoing debates within the field of psychology today. The best solutions to these dilemmas are being discussed and published by experts in ethics and experts in specialized areas of psychology as necessary. Therefore, solutions will not be addressed within the confines of this article but rather, systematic ways to address ethical dilemmas and ways to ensure psychologists are practicing competently and with ethical obligation to uphold.
Barret, Kitchener, and Burris (2001) as cited in Shiles (2009) suggest a decision-making model aimed at helping psychologists make ethical decisions that are minimally affected by countertransference. This model involves “the psychologist asking himself or herself a variety of questions to review personal reactions, determine the facts of the case, make a preliminary plan, examine the legal consequences of the initial plan, identify and assess options to refine the initial plan, choose a course of action, and implement the decision and evaluate the outcome” (p. 153). Fisher (2009) outlines a very similar 8-step model for ethical decision making. She also states that ethical decision making involves a commitment to applying the Ethics Code to construct rather than discover solutions to ethical dilemmas. The 2002 Ethics Code states in the Introduction 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” and “lack of awareness or misunderstanding of an ethical standard is not itself a defense to a charge of unethical conduct.” Therefore, ethical dilemmas can be approached and solved by knowledge of psychology and its ethical codes.
Another approach to ethical impasses is analyzing how one chooses to view the situation at hand. Gallardo and colleagues (2009) ask the question, “do practitioners and students begin their therapeutic decision-making process with an ethical lens first and foremost, or do they begin the therapeutic process with a cultural lens at the forefront?” (p. 427). They go on to say that if a practitioner looks through an ethical lens first, they may be compromising the needs of their client by putting their own needs first. The desire to uphold ethical standards, no matter what the cost to a specific client, is in itself unethical. Gallardo and colleagues (2009) referenced Paul (1967) to answer the above question with another question, “What treatment, by whom, is most effective for this individual, with that specific problem, and under which set of circumstances?” (p.429). If that question is answered competently, the psychologist ensures that their client and their presenting problem are being held as the main priorities.
Outside of the decision-making process, psychologists can be proactive in minimizing the occurrence of ethical issues and ensuring that all involved are on the same level of ethical understanding. Sporrong et al. (2007) suggest possible strategies for increasing competence including preparation in primary education, vocational training, policy making, and support by management and research. These strategies can be applied in clinical settings by clinically-based education, ethics consultations, ethics rounds, clinical supervision, and ethics committees.
Although many of the suggestions here are already in effect, increasing the amount of facilities that regularly hold ethics rounds may have a significant impact on the ethical realm of psychology. Sporrong et al. (2007) states that “ethics rounds may be seen as opportunities for ethical discourse, where participants jointly explore their own personal sets of values and seek to balance these with professional value sets, taking into account the moral fabric of the organization and society in moving towards a shared understanding of the issues involved” (p. 832) and they can also help bring up difficult topics to address or hidden conflicts. If every institution providing mental health services, whether it be a hospital, prison, school, or private practice, regularly held ethics rounds, psychologists and other staff members associated with them would be much more knowledgeable about potential ethical problems and how to properly handle them. Also, ethical dilemmas would more likely to be addressed correctly if they had been discussed previously within the confines of an ethics round rather than as one is occurring, at which time emotionality can be high and objectivity can be skewed.
Similar to ethics rounds is program that has been implemented in the education world. The program is titled the Racial and Ethical Sensitivity Training Kit (REST-KIT) and is based upon James Rest’s (1983) four-component model of moral decision making (Rogers-Sirin & Sirin, 2009). According to Rogers-Sirin & Sirin (2009), Rest (1983) suggested that morality is not a unitary process but rather a multifaceted phenomenon. Component I of his model is ethical sensitivity. This is the identification of the salient ethical aspects of a situation. Component II is moral judgment which involves formulating the morally ideal course of action through reasoning. Component III, moral motivation, requires having the necessary motivation or will to act in an ethical manner. Component IV involves moral action and can be described as having the moral character to execute and implement what ought to be done.
The REST-KIT was designed to “(a) improve the ethical and racial sensitivity of school professionals and trainees by grounding ethical decision making, in relation to racism and discrimination, in professional codes of ethics and (b) provide the necessary skills to address the ethical dilemmas in participants’ professional lives” (p. 28). Results from this study suggest the REST-KIT could be a useful resource for trainers and researchers. This study focused on using the REST-KIT with educators but could potentially be applicable for psychologists as well. There is no absolute way to guarantee a psychologist beginning their career has been properly trained in ethics or is competent in the areas in which they desire to work. It is assumed new psychologists received adequate training in graduate school as a student but this assumption may not be accurately. Any facility providing mental health care services should implement some form of training, such as the REST-KIT, to insure the psychologists at that facility are ethically educated and competent to handle ethical dilemmas as they arise.
Ethical dilemmas are not new to the practice of psychology and their resolutions will never be clear-cut answers. Psychologists must remain competent in their field to be able to practice ethically. By staying up-to-date on current research, literature, and practices, psychologists can guarantee they are providing the best possible services to their clients. When a psychologist is faced with an ethical quandary, using the decision making models outlined earlier can help psychologist reach the best decision for their specific issue. By being aware of potential conflicts in ethics beforehand, psychologists can take preventive measures to avoid having to face an ethical dilemma. Again, competence is the key. It is an ethical standard to remain competence throughout one’s psychological career and it is through competency that one can make sound ethical decisions.
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