Kenneth S. Pope, PhD,
Independent Practice, Norwalk, CT
Ethical competence in cognitive and behavioral therapy confronts us with cognitive and behavioral challenges. Both of these challenges are psychologically difficult.
We must meet the cognitive challenges of using informed judgment to find—or sometimes to create—the most ethical path through constantly changing situations. None of these situations is exactly the same as any other. We may be like many other therapists in all sorts of ways, but each of us is unique in important ways. A client may fall into all sorts of categories that include many other clients, but each is unique in important ways. Therapists, clients, and complex situations are not frozen in time—none is exactly the same as last month, last week, or yesterday. To adapt Heraclitus, over the course of our work with a client, we never step into the identical therapeutic situation with the identical client twice. Coming up with the most ethical response to these unique, constantly changing situations forces us to set aside hopes for easy answers, a cookbook approach, or one-size-fits-all solutions. It calls on us to be alert, open, informed, mindful, and actively questioning.
Ethical competence also confronts us with behavioral challenges, because doing the right thing can sometimes be unpleasant, frightening, costly, or virtually impossible. Consider these examples:
Doing what we judge to be the right thing can require us to go against our own financial self-interest, earn us the criticism of our colleagues, and be the very last thing we want to do. We may have to force ourselves to turn away from overwhelming temptations, face some of our deepest fears, and dig deep within ourselves to summon up moral courage we didn’t know we had.
This chapter highlights some of the most important—and often the most troublesome—issues we encounter in meeting the cognitive and behavioral challenges of developing ethical competence and putting it to use in clinical practice. It concludes with a set of suggested steps for thinking through our work’s ethical aspects.
Consider the following scenarios:
You’re talking with a colleague who uses behavior modification to work with the parents of kids who are disruptive at home and school. He tells you that he finds negative reinforcement most effective, so he instructs the parents to administer a gentle spanking whenever an undesired behavior occurs. This, he says, creates what is called a Pavlovian fading of the unwanted behavior. He confides that although the therapy controls the child’s behavior, he is actually covertly conditioning the parents using methods so effective that they produce what Skinner called errorless learning. The more he talks, the more you realize that he has no understanding whatsoever of behavior therapy terms, principles, research, or theory. You grow concerned that he is not competent to do therapy and may be harming his clients. Does the ethics code require you to take any steps? If so, what are they? What do you think you’d wind up doing?
A woman seeking therapy schedules an initial appointment with you. During the appointment, she tells you she is currently seeing a psychologist who uses a psychodynamic approach. She had high hopes for the psychologist initially, but she feels her therapist wastes too much time dredging around in the past, and lately the therapist has started treating her just like her mother used to treat her. She is furious at her therapist and believes she would do much better with someone who uses cognitive behavioral therapy, but she just wants to make sure she has a new therapist in place before she quits her current therapy. Does the ethics code allow you to simply begin treating her right away or are there steps you must take? If there are steps, what are they? What would you actually do in this situation?
You’re using cognitive processing therapy to treat a former professional mixed martial arts fighter with post-traumatic stress disorder (PTSD). However, as therapy progresses you go from being uneasy to fearful to terrified that something might trigger a violent—and perhaps lethal—attack against you. Does the ethics code allow you to terminate by phone or letter without seeing the client again? What would you do?
Ethical competence enables us to make hard choices about what to do in such difficult situations using judgment informed by the relevant ethics codes. The American Psychological Association (APA) and the Canadian Psychological Association (CPA) publish two of the most prominent and influential codes.
The APA’s (2010) current code includes an introduction, a preamble, five general principles, and eighty-nine specific ethical standards. The preamble and general principles (beneficence and nonmaleficence; fidelity and responsibility; integrity; justice; and respect for people’s rights and dignity) are aspirational goals meant to guide psychologists toward psychology’s highest ideals. The eighty-nine ethical standards are enforceable rules of conduct.
As of this writing, the CPA was revising its ethics code. The most recent draft revision (February 2015) follows the prior version in presenting four principles to inform ethical judgments. The CPA orders the principles according to the weight each is to be given, beginning with the most important: principle I, respect for the dignity of persons and peoples; principle II, responsible caring; principle III, integrity in relationships; and principle IV, responsibility to society. Each principle is followed by a list of associated values, and each value, in turn, is followed by ethical standards showing how that principle and value apply to what psychologists do (e.g., providing therapy, conducting research, teaching). The draft code emphasizes that “Although the…ordering of principles can be helpful in resolving some ethical questions, issues, or dilemmas, the complexity of many situations requires consideration of other factors and engagement in a creative, self-reflective, and deliberative ethical decision-making process that includes consideration of many other factors” (Canadian Psychological Association, 2015, p. 2). The draft code suggests a set of ten steps for making ethical judgments in such complex situations.
Ethical competence requires us to know what the relevant ethical codes tell us about the work at hand. It also requires us to understand that codes are there to inform our professional judgment, not to take the place of an active, thoughtful, questioning, creative approach to our ethical responsibilities. We cannot outsource our judgment or our personal responsibility to a code. A code can guide us away from clearly unethical approaches and awaken our awareness of key values and concerns. But a code cannot tell us how to apply those values and address those concerns in a complex, constantly changing situation involving a unique therapist and client, especially when some of the ethical values may conflict with each other.
Ethical competence requires us to know what we’re doing when we use cognitive and behavioral interventions. There is no way to make sound ethical judgments about our work if we don’t understand the work itself and what current research tells us about our intervention’s effectiveness, risks, downsides, and contraindications.
The APA ethics code states that “psychologists’ work is based upon established scientific and professional knowledge of the discipline” (2010, section 2.04). The 2015 draft of the fourth edition of the CPA ethics code emphasizes that psychologists “keep themselves up to date with a broad range of relevant knowledge, research methods, techniques, and technologies and their impact on individuals and groups (e.g., couples, families, organizations, communities and peoples), through the reading of relevant literature, peer consultation, and continuing education activities, in order that their practice, teaching and research activities will benefit and not harm others” (2015, section II.9).
It is not only our own informed judgment at stake but also our client’s. If we cannot explain clearly the current state of the scientific knowledge about the effectiveness, shortcomings, risks, and alternatives to a cognitive or behavioral therapy, we cannot fulfill our ethical and legal responsibilities regarding the client’s right to informed consent and informed refusal.
New research is constantly sharpening—and sometimes completely revising and reshaping—our understanding of cognitive and behavioral approaches. Keeping up is both a responsibility and a challenge. David Barlow emphasizes how fast research can shift our understanding of which interventions are effective, worthless, or even detrimental: “Stunning developments in health care have occurred during the last several years. Widely accepted health-care strategies have been brought into question by research evidence as not only lacking benefit but also, perhaps, as inducing harm” (2004, p. 869; see also Barlow, 2010; Lilienfeld, Marshall, Todd, & Shane, 2014). Neimeyer, Taylor, Rozensky, and Cox (2014) used a Delphi poll to estimate that the current half-life of knowledge in cognitive and behavioral psychology is 9.6 years. Dubin describes the half-life of knowledge in psychology as “the time after completion of professional training when, because of new developments, practicing professionals have become roughly half as competent as they were upon graduation to meet the demands of their profession” (1972, p. 487).
Decades ago many therapists seized on a wonderfully compelling and inexpensive anger management therapy. Clients learned to engage in a simple behavior to deal therapeutically with their anger: they spent time hitting a bag, doll, pillow, or similar target with their fists or a bat. It was easy to come up with theoretical rationales for why the hitting behavior would relieve the anger: it behaviorally discharged the frustration that fueled the anger; it redirected the anger to an acceptable object; it provided a dynamic catharsis; it led to a sense of satisfaction and exhaustion that was incompatible with feeling angry; it created a “vent” for the emotional intensity; and so on. Despite its solid grounding in theory and its popularity, the therapy did have a downside: it didn’t work. Not only did it fail to help clients manage their anger, but studies showed that the therapy tended to make clients even angrier than they had been, raised their blood pressure, left them feeling worse, and increased the likelihood of future angry outbursts. (For research and discussions, see Bushman, 2002; Lohr, Olatunji, Baumeister, & Bushman, 2007; and Tavris, 1989.) We bear an essential ethical responsibility to keep our eyes open for evidence that new, popular, promising—or our own favorite—therapies fail to deliver as much benefit as other approaches, produce no improvement whatsoever, or even cause harm. Clients depend on us to avoid wasting their time (and money) or leaving them worse off than they were when they came to us for help. Discussing the ethics of staying current with research—including studies contradicting the use of certain approaches—George Stricker writes, “We all must labor with the absence of affirmative data, but there is no excuse for ignoring contradictory data” (1992, p. 544).
To understand what current research tells us about an intervention’s effectiveness, downsides, risks, and contraindications involves understanding the research itself rather than relying on brief summaries like “cognitive behavior therapy was found to be effective in treating PTSD.” Understanding a research finding like this includes our ability to answer key questions, such as these: What do we know about the clients and how they were recruited and screened? Was cognitive behavioral therapy (CBT) compared with other treatments, and, if so, were the clients randomly assigned to treatment groups? How was the outcome evaluated? Did the evaluators know which client received which treatment? What percentage of clients, if any, in each treatment group failed to improve? What client characteristics or psychological processes moderated outcomes (e.g., multiple traumas, concurrent social problems, high levels of rumination)? What percentage of clients, if any, in each treatment group were worse off after treatment than at the beginning, and in what ways were they worse off? Are any statistically significant differences between treatments also clinically significant (e.g., effect size)? Could funding, sponsorship, or conflicts of interest have unintentionally introduced bias into how the hypotheses were framed, the methodologies chosen, the data analyzed, or the results reported? (See Flacco et al., 2015; Jacobson, 2015.) How long after treatment was the follow-up, and were there any significant changes in the outcome in the months or years after termination?
Knowing the answers to such questions is one key to fulfilling our ethical responsibility to practice with competence. Like ethics codes, research informs our judgment but does not take its place. Competent practice as well as our clients and others impacted by our work depend on us to make informed judgments about how to help without hurting.
Informed judgment will sometimes guide us a bit beyond techniques that are empirically supported for a particular situation, and we must adapt a technique the best we can for a new use. What is crucial is that we understand both what the research tells us and the limits of that knowledge. Many research findings, for example, are based on statistical differences between groups of people. Part of the inherent limits of our knowledge is that an intervention strongly supported by statistically and clinically significant findings from these statistically based studies may—or may not—“work” with the client sitting across from us. B. F. Skinner highlighted the fallacy of assuming that statistical differences between groups or other statistical associations will automatically translate to a specific individual: “No one goes to the circus to see the average dog jump through a hoop significantly oftener than untrained dogs raised under the same circumstances” (1956, p. 228). Our work with each client becomes similar to an N = 1 study, in which we monitor carefully the effects of our interventions on one particular person.
Littell (2010) adapted Skinner’s insight to the therapeutic situation while underscoring the need to understand the research itself rather than settle for secondhand assurances that a particular therapy is “evidence based”:
Most scientific knowledge is tentative and nomothetic, not directly applicable to individual cases. Experts have stepped into this breach by packaging empirical evidence for use in practice. Sometimes this is little more than a ruse to promote favorite theories and therapies. Yet, wrapped in scientific rhetoric, some authoritative pronouncements have become orthodoxy. (pp. 167–168)
Imagine yourself in the following situations:
You are using CBT to treat a woman with PTSD. Aware of experimental and meta-analytic studies suggesting that CBT decreases the heart rate (HR) of clients with PTSD, you show her how to measure her pulse at the beginning and end of each session and suggest that she chart her HR during the week, particularly when she is experiencing the symptoms of PTSD. She shows steady improvement with this intervention and even mentions that it seems to be helping with the occasional heart palpitations, for which she takes cardiac meds.
Do the laws, licensing rules, legal standards of care, and other governmental regulations consider you to be practicing medicine? Do they require you to be knowledgeable about the physiology, biology, normal functioning, and pathology of the human heart as well as the nature and effects of medications relevant to this client? Do they require you to obtain her medical records prior to initiating interventions that are known to affect the heart or other organs? Do they require you to include information about the possible effects of CBT on people with PTSD in your informed consent process? If yes, can you address this informed consent requirement by just writing in the chart that you discussed it with the client and that the client provided informed consent for the intervention, or are you legally required to obtain the client’s written informed consent? (Note that the relevant regulations vary from jurisdiction to jurisdiction so that what one state or province requires may not be mentioned or even be prohibited by another state or province.)
Your client is an elderly man who came to you for help because he’s become depressed over his chronic medical problems. He constantly worries that his problems will get worse. His days are filled with rumination. After discussing various treatment options, he decides to try mindfulness-based stress reduction. Both of you see improvement by the second session. Unfortunately, prior to beginning therapy he agreed to leave the following week to spend six weeks with one of his daughters and her husband who live in another state. You and your client agree that the weekly sessions can continue uninterrupted via Skype.
Do the laws, licensing rules, legal standards of care, and other governmental regulations require you to be licensed in the state where his daughter lives? Do the laws, licensing rules, legal standards of care, and other governmental regulations of your own state, of the daughter’s state, or both states apply to the therapy (e.g., requirements for competence, informed consent, maintaining records, release of confidential information, exceptions to privilege, and so on)? If the governmental regulations of the daughter’s state apply, are you knowledgeable about them? Do either state regulations or those of the federal US Health Insurance Portability and Accountability Act (HIPAA) and its amendments require that the Skype sessions be encrypted? Do they require encryption of phone calls, e-mails, texts, or other electronic communications between you and the client? If you practice in a Canadian province and the client is in another province, do the relevant provincial regulations, the Canadian Privacy Act, or the Canadian Personal Information Protection and Electronic Documents Act (PIPEDA) require encryption of your communications?
As you begin the first session with a new client, she informs you that she is sixteen and would like some kind of relaxation therapy for her anxiety attacks. She asks you if therapy is confidential, and you say, “Yes, with certain exceptions,” and before you can explain the exceptions she blurts out that she is planning to have an abortion and keep it secret from her parents, and if you tell anyone she will kill herself.
According to the law, is she old enough to provide informed consent, or must a parent or guardian provide consent for her treatment? Does a parent or guardian have a legal right to see her therapy records and to know what she told you? If you have strong religious objections to abortion, does the law allow you to refuse to treat her on that basis?
Ethical competence includes knowing the relevant laws, licensing rules, legal standards of care, and other governmental regulations that tell clinicians in a particular jurisdiction what they can, must, or must not do. This information is key not only to making sound professional judgments but also to ensuring clients’ right to informed consent. For some clients, deciding whether to give or withhold consent to treatment may hinge on whether the therapist must make a legally mandated report in certain situations or whether there are exceptions to privacy, confidentiality, or privilege.
Like ethics codes and research studies, the power of the state—expressed through legislation, case law, administrative regulations, and so forth and enforced by courts, licensing boards, and other governmental agencies—informs our professional judgments but cannot make those judgments for us. When working with a client who is psychotic, developmentally disabled, or under the influence of drugs, the law may require us to obtain informed consent, but it cannot not tell us the best way to inform this particular client, to assess whether the client is offering an informed agreement for treatment, or even to determine whether the client is capable of freely giving informed consent. The law in our jurisdiction may call for a therapist whose client makes a violent threat against an identifiable third party to take reasonable steps to protect the third party, but the law cannot tell us which steps make the most sense with a particular client and third party.
Ethical competence also includes being alert to instances when the law and ethics may conflict with each other. For example, what the law requires may be at odds, in our professional opinion, with the client’s basic rights or with our own belief of what is ethical and “doing the right thing.” Facing such conflicts, we can consult with experts and other colleagues and try to come up with creative solutions that bridge the conflict without violating either ethics or the law. If we are unable to resolve the conflict, we must decide what it means to do the right thing in a given situation, to weigh whether we are prepared to accept the costs and risks of that path, and to accept the consequences of whatever path we ultimately choose.
Imagine yourself in the shoes of the following hypothetical therapists:
Your new client had seen on your web page that you help people change their habitual patterns of thinking, alter the way they respond to situations, and get rid of self-defeating behaviors. He tells you that he was very lucky to find a job and wants your help to hold on to it at all costs because that’s the only way he can support himself and his elderly father who lives with him. The problem, he explains, is that he is the only one of his race and religion who works there, and the other employees don’t respect him, using slurs and telling cruel jokes ridiculing his race and religion. Once he got up the courage to ask a small group of them what they had against him, his race, and his religion, and they all denied ever treating him with anything but great respect or ever using a slur or telling any jokes mentioning race or religion. As soon as he started to walk away, they broke out laughing.
He refuses to consider quitting, bringing up the matter again to his coworkers, making some sort of formal complaint, or suing the company. He just wants you to help him learn not to have such strong emotional reactions at work, to stop dwelling on his coworkers’ behavior, and to find alternatives to responses that are maladaptive and self-defeating in that setting. He’d like to learn how to adopt a more positive attitude and be more accepting of fellow employees. He wants to try either pretending that he doesn’t hear or laughing along good-naturedly when they tell a cruel joke or use a slur.
Do you provide the therapy he asks for? If not, what do you do? If you imagined a specific race and religion for your client, would your reaction be any different if you imagined a different race and religion for the client?
Your soon-to-be new client calls to schedule her first appointment, telling you that she gets anxious and tongue-tied whenever she has to speak to an audience. She wants to learn how to calm herself and be relaxed and at ease when she gets up to talk. During the call you ask how she got your name. She laughs and says that you are the only therapist in her community that is in her insurance coverage network, so it’s you or nothing.
During the first session, she asks what sorts of therapy might help her. You mention self-talk, deep breathing exercises, cognitive behavior modification, and a range of other approaches, and then ask if there are any kinds of talks, settings, or audiences that are particularly frightening or difficult. She explains that she is chair of a new political action committee (PAC) and must ask groups of people for money and support. You realize that her PAC works against some of your most deeply held values. You believe—though many would disagree with you—that her policies, if enacted, would violate some basic human rights and harm many people. If you help her become a more effective speaker, she will likely become more able to enlist support and raise large sums of money to pass laws that diametrically oppose your deepest values.
Do you put the tools of cognitive and behavioral therapy to work helping her? If so, do you disclose your own values? Are there any situations in which you would refuse to work with a client because of your own deepest values? Which of your values, if any, would lead you to refuse?
None of us works in a vacuum. Our work takes place in a variety of contexts that may affect the work we do. Ethical competence includes remaining aware of these contexts and how they affect us, our clients, and the work we do.
The array of attitudes, beliefs, and values in a society, organization, or other setting is one major source of contextual effects. The two hypothetical scenarios above illustrate the ways in which the interventions we use—which some would view as per se value-neutral—can, when viewed in these contexts, be seen to work for or against certain values, policies, or populations and to raise ethical issues.
Davison, writing in the same decade that homosexuality was finally removed from the DSM as a sociopathic personality disturbance disorder, urged the field to pay attention to these contexts and their ethical implications. He focused on the view of homosexuality prevalent at the time both in general society and the profession:
Behavior therapy is nothing if it does not represent a profound commitment to dispassionate inquiry…I want to voice some concerns I have been wrestling with… Any comprehensive perusal of the…literature in behavior therapy…will confirm…that therapists by and large regard homosexual behavior and attitudes to be undesirable, sometimes pathological, and at any rate in need of change toward a heterosexual orientation. And I do not take special issue with aversion therapy since I suggest that the more positive therapies of homosexuality are similarly to be questioned on ethical grounds. (1976, p. 158)
The concerns he was wrestling with led him to make what was at the time a radical proposal:
Since professionals are unlikely to work on treatment procedures unless they see a problem, it is probable that the very existence of change-of-orientation programs strengthens societal prejudices against homosexuality and contributes to the self-hate and embarrassment that are determinants of the “voluntary” desire by some homosexuals to become heterosexual. It is therefore proposed that we stop offering therapy to help homosexuals change and concentrate instead on improving the quality of their interpersonal relationships. Alternatively, more energy could be devoted to sexual enhancement procedures in general, regardless of the adult gender mix. (p. 157)
A second major source of contextual effects is culture. A cognitive or behavioral intervention well suited to one culture may violate another culture’s norms, customs, assumptions, or values. The research supporting the use of an intervention for a given problem may have been conducted on people from a different culture than the person sitting across from us in our consulting room. We may face difficulties communicating clearly with clients if they are from cultures that are unfamiliar to us.
When considering how the client’s culture influences the client and the therapy, it’s easy to overlook how our own culture influences us, our approach to clients, and the work we do. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures (Fadiman, 1997) highlights the dangers of overlooking culture’s effects on everyone involved. The book describes how the staff of a California hospital tried to help a Hmong child whose American physicians had diagnosed with epilepsy. Her parents, however, viewed her problems as being due to spirits. The staff tried to help the girl, but lack of attention to cultural differences derailed the process. The book chronicles the intervention of the medical community that insisted upon removing the child from her loving parents, with horrible results. The book quotes medical anthropologist Arthur Kleinman:
As powerful an influence as the culture of the Hmong patient and her family is on this case, the culture of biomedicine is equally powerful. If you can’t see that your own culture has its own set of interests, emotions, and biases, how can you expect to deal successfully with someone else’s culture? (p. 261)
The degree to which we can think through the complex array of ethical standards, research, laws and regulations, and contexts and come up with the most ethical way to provide therapy that helps without hurting depends on the quality of our judgment. Unfortunately, human cognition often falls prey to a vast array of mistakes in paying attention, making assumptions, selecting and weighing information, reasoning, using language with precision, navigating safely through pressure and temptations, and arriving at decisions. All of us have our vulnerabilities, weaknesses, and blind spots—yes, even you there…you know who you are: the one about to nod off while wondering how many more pages there are in this chapter—along with our skills, strengths, and insights. Ethical competence includes staying abreast of the literature on logical fallacies, pseudoscientific reasoning, heuristics that can lead us astray, ethical rationalizations, and other barriers to critical thinking and sound judgment.
For example, we may find ourselves favoring a particular intervention, relying on studies that support it, while unintentionally ignoring, denying, discounting, or finding ways to discredit evidence of the intervention’s downsides, risks, or inability to match the effectiveness of other interventions. Decades of psychological research reveals an almost endless catalog of shared human tendencies—confirmation bias, cognitive dissonance, premature cognitive commitment, the WYSIATI (what you see is all there is) fallacy, false consensus…and on and on—to overlook, avoid, or ignore whatever fails to fit our beliefs and loyalties (Pope, 2016).
Glitches in judgment can affect us on the group, organizational, social, as well as individual level. In 1973, for example, Meehl published an essay—“Why I Do Not Attend Case Conferences”—that quickly went that decade’s version of viral. He pointed out variations of the “groupthink process” (1977, p. 228) that sends judgment off course and may be familiar to many of us:
In one respect the clinical case conference is no different from other academic group phenomena such as committee meetings, in that many intelligent, educated, sane, rational persons seem to undergo a kind of intellectual deterioration when they gather around a table in one room. (1977, p. 227)
The key to benefiting from the literature on judgment pitfalls is to resist the temptation to apply the information only to others instead of starting with ourselves and using it as a mirror to strengthen our ethical competence. Readings in this area include Kahneman (2011); Kleespies (2014); Pinker (2013); Taleb (2010); Zsambok and Klein (2014); and the chapters “Avoiding Pseudoscience, Fads, and Academic Urban Legends,” “Ethical Judgment Under Uncertainty and Pressure: Critical Thinking About Heuristics, Authorities, and Groups,” “26 Logical Fallacies in Ethical Reasoning,” “Using and Misusing Words to Reveal and Conceal,” and “Ethics Placebos, Cons, and Creative Cheating: A User’s Guide” in Pope and Vasquez (2016).
The following set of steps (adapted from Pope & Vasquez, 2016) may be useful in thinking through ethical dilemmas in a careful and structured way. Eight of these steps (2, 8, 11, 12, 14, 15, 16, and 17) were adapted from the CPA (2015) ethics code.
Davison’s courageous confronting of social biases against homosexuality, discussed earlier, provides us with an example of thinking through an ethical dilemma. He states the question clearly (step 1). He identifies the clients (step 3). He thinks through how personal or cultural biases can impact the therapy given to these clients (steps 8 and 9). Taking the perspective of the stakeholders (step 13), he considers alternative courses of action (step 11). He recommends a clear course of action (step 14). He makes no attempt to disappear into abstractions, professional jargon, or daunting sentence structures but instead assumes personal responsibility (step 16) for his analysis and recommendations through, for example, his use of the first-person singular (e.g., “I want to voice some concerns I have been wrestling with…I do not take special issue with aversion therapy since I suggest that the more positive therapies of homosexuality are similarly to be questioned on ethical grounds.”). He models the kind of careful step-by-step analysis all of us can use to confront difficult ethical dilemmas.
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