Leaders who perceive themselves as highly ethical and moral are likely to focus on ________ .

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Overview:

CE credits: 1

Exam items: 10

Learning objectives:

After completing this course participants will be able to:

• Discuss the limitations of assimilation strategies.
• Discuss the limitations of separation strategies.
• Identify ways to improve adherence to integrated strategies.

Most psychologists strive to act ethically, but all of us are vulnerable to lapses in which we perform in a less-than-optimal way, often without even being aware of it (Bazerman & Banaji, 2004, p. 111).

Some psychologists, for example, may stumble because they don't know the laws or standards governing their profession. Others may place self-interest above public welfare — such as taking on lucrative forensic work without the training to do so. Still others impulsively enter into clinically contraindicated multiple relationships with patients.

We've all heard of colleagues who act in a questionable way but perceive themselves as behaving ethically and even consider their behaviors exemplary. We are not referring to obviously unethical behavior that is rationalized — such as one psychologist who billed Medicare for services he never delivered and claimed he did not attend to the details of billing because his time was consumed as a concerned healer. Instead, we are referring to situations in which psychologists believe they are acting ethically, even though a peer evaluation would suggest otherwise.

We refer to these types of behaviors and attitudes as the dark side of professional ethics. The problem seems to occur because psychologists define professional ethics in different ways. For example, consider this vignette:

A young trainee gave her home phone number to a patient who was in deep distress. The patient called one weekend and the trainee agreed to meet the patient at a restaurant. They talked for two hours and ordered beverages and light snacks. The trainee fully disclosed the events to her supervisor the next day. The instructor noticed wide discrepancies in how the trainee's classmates responded to this event. Some students criticized the trainee for a boundary violation. Others praised the trainee's dedication to her patient. Both groups justified their opinions on the basis of "ethics."

In this vignette, as in many other situations psychologists face, psychologists use the word "ethics" very differently. Some focus almost exclusively on laws, regulations and the enforceable standards of the APA Ethics Code. When asked, "What is the ethical thing to do?" they only want to know the laws or standards that govern the situation. Perhaps their fear of disciplinary action is so great, their training so inadequate or their character so rigid that they place excessive emphasis on the more rigid interpretation of risk management strategies, even if those strategies place unnecessary barriers between themselves and their patients. And, if confronted with such behavior by a colleague, they may even view with scorn those who take a more balanced approach.

Other psychologists define professional ethics by disproportionately emphasizing their own personal beliefs, virtues and value systems. When asked, "What is the ethical thing to do?" they refer to their personal sense of morality and make little reference to the laws, rules or APA Ethics Code. Perhaps their sensitivity to the concerns of their patients is so excessive, their training so inadequate, their confidence so inflated or their self-reflection so superficial that they minimize the importance of laws and standards; they may even disdain those who are more scrupulous about following professional laws and standards.

We consider both of these views of professional ethics to be inadequate and believe that they can lead psychologists into less-than-optimal or even unethical behaviors. We argue that the dark side may manifest itself in two ways. First, it may lead practitioners to focus on rules so much that they risk harming their professional relationships. Second, it may appear in the guise of placing one's personal beliefs above value-based professional standards such that they similarly risk delivering less than optimal services.

The Ethics Acculturation Model

According to the Ethics Acculturation Model, or EAM (Anderson & Handelsman, 2010; Handelsman et al., 2005), the task of becoming a psychologist involves understanding new professional values and integrating them with one's existing moral values. This integration is similar to the way that Berry and Kim (1988) described immigrants' acculturation. Some immigrants accept the new culture wholeheartedly, even minimizing or rejecting their culture of origin; this strategy is termed an assimilation strategy. Others retain as much of their culture of origin as possible, minimizing their involvement with the new culture and avoiding its new norms and standards; this is referred to as a separation strategy. Still other immigrants lose their culture of origin and fail to adopt the norms of their adopted country; this is a marginalization strategy. Finally, some adopt helpful elements of their new culture while retaining the functional and helpful elements of their old culture; this is an integration strategy.

In a manner similar to immigrants, psychology students can adopt assimilation, separation, marginalization or integration strategies as they strive to incorporate both their personal and professional ethics. Berry and his colleagues (Berry, 2003; Berry & Sam, 1997) have found that integration is the most effective acculturation strategy; we contend that this is the case for ethics acculturation as well.

When trainees use an assimilation strategy, they rely too little on their personal ethics and too much on the laws or standards that govern the profession of psychology. In the extreme, strict adherence to the rules is all that matters to them. Students minimize the importance of overarching values — such as feelings of compassion or a sense of fairness — and follow the rules thoughtlessly. The extreme of an assimilation strategy might be summarized as "too much attention to professional rules without enough attention to personal virtue."

Assimilation strategies have appeal because reasonable psychologists have a legitimate desire to be "law-abiding" and they respect disciplinary bodies. However, well-meaning efforts to inculcate a respect for disciplinary authority and conscientiousness in following its rules may inadvertently reinforce assimilation strategies. For example, a trainee who is warned about minor boundary crossings may become overly concerned with trivial or even clinically indicated boundary crossings for fear of sliding down the slippery slope — by, for example, rudely ignoring a patient who says hello in a grocery store out of an excessive concern for avoiding a multiple relationship.

Other trainees may adopt separation strategies, relying too little on the laws and APA's Ethics Code and giving disproportionate emphasis to the sense of virtue that guides them in their personal lives. They may implement values in ways that would be appropriate in their personal lives but harmful in the professional context. Separation strategies have appeal because most professional psychologists enter the field to help others and may have had service, learning, volunteer or other helping experiences well before entering graduate training. However, "learning the skills to properly channel our desires to help others is not easy" (Tjeltveit & Gottlieb, 2010, p. 103). A student's well-meaning efforts to promote caring may inadvertently reinforce separation strategies. For example, a trainee who learns the importance of feeling empathy with patients may not appreciate the additional need to maintain professional distance. Separation could mean ignoring an ethical standard or law and result in a disciplinary action against the psychologist.

Still other students may use marginalization strategies and rely too little on either personal or professional ethics. They ignore professional standards and lack the moderating influence of personal ethics that could prevent them from harming or exploiting their patients.

Ideally, students would use integration strategies in which they know and follow the laws, regulations and standards governing the practice of psychology. Although psychologists can experience serious disciplinary consequences for failing to follow the law to the extent possible, they also act upon these rules with attention to their values of origin. They understand that the role of psychologist requires them to express compassion, fairness or respectfulness in a way consistent with professional values (such as described in the General Principles of the APA Ethics Code) and not through those behaviors characteristic of close relationships among friends and family. The benchmarks of integration strategies would be the extent to which the students adhere to the values of the profession, such as being respectful of patient autonomy, professionally striving to help patients, being transparent in their actions and so forth. We might summarize integration strategies as "sufficient attention given to both personal virtue and professional rules."

To an outsider, some obligations of professional psychologists can appear counterintuitive. A friendship includes mutual sharing of details of one's personal life and the mutual exchange of favors, such as lending money or offering a person a ride. Although the professional relationship has some elements of a friendship, including one person sharing details of his or her life with another, other elements of the friendship are not present and would be contraindicated. Many laypeople do not appear to appreciate this distinction. A person using a separation strategy would believe that the failure or refusal to lend money to a client would represent a failure to uphold moral obligations. However, in the context of the "ethical culture" of professional psychology, separation strategies such as lending money are often problematic. Compassion needs to be expressed in other ways.

The ethical culture of psychology has developed standards because they promote patients' well-being, respect for their autonomy, fair treatment and other overarching ethical goals. Of course, not every rule, regulation or standard in psychology practice perfectly fulfills an overarching ethical principle. For example, the privacy notices required by health professionals covered by HIPAA appear overly legalistic and probably do little to educate patients about their privacy rights. Still, for the most part, the profession's standards, including the APA Ethics Code, represent considered and deliberative approaches to help psychologists fulfill their obligations to patients, students, supervisees, research participants or others.

In the ordinary course of professional practice, psychologists may slip from an integration strategy, even if only temporarily. Sometimes, especially when stressed, they may choose an assimilation strategy and focus excessively on rules and miss opportunities for empathy and compassion. Sometimes they will choose a separation strategy and fail to consider how their feelings of compassion and generosity need to be tempered by the context and boundaries of the professional relationship. Ideally, they can monitor and correct these tendencies. However, at their extremes, or if left unchecked, assimilation or separation strategies can harm patients or violate overarching ethical principles under the guise of "being ethical."

The dark side of assimilation strategies

Although psychologists who use assimilation strategies may believe they are acting in a highly ethical manner, they may not appreciate the impact their behaviors have on patients or others. Assimilation strategies can lead psychologists to interpret rules too rigidly or without compassion, set lower standards for professional behavior or create harm by giving disproportionate attention to certain rules. Below we provide examples of each of these problems.

Interpreting rules too rigidly

The APA Ethics Code standards were developed, among other reasons, to protect the welfare of patients, supervisees, employees, research participants, students and others. However, the complexity of professional practice requires discretion in interpreting and implementing many of these standards. Consequently, the code has a number of modifiers such as "reasonable," "appropriate," "to the extent possible" and so forth in recognition of the need for professional judgment in unique circumstances. For example, Standard 3.05 (Multiple Relationships) states that "Multiple relationships that would not reasonably be expected to cause impairment or the risk of exploitation or harm are not unethical." However, psychologists who use assimilation strategies sometimes act as if the modifiers did not exist; they may also act as if simply following the rules ensures the best ethical practice (Handelsman, Knapp, & Gottlieb, 2009).

Consider the different ways that psychologists may respond to this potential multiple relationship:

A psychologist was treating a medical student suffering from anxiety and loneliness. The student learned that a local church sponsored an organization for young singles that was open to people who were not church members. The psychologist discouraged the student from joining this group because the psychologist was a member of that church and there was a possibility that the patient could become more involved in the church and that their paths might cross.

A prudent psychologist would weigh the extent and likelihood of harm that might occur from such an encounter against the extent and likelihood of benefit to the patient. For some patients, such as those with problems maintaining boundaries, it may be appropriate to discourage such involvement. But this patient had an adjustment disorder with no personality disorder features, was unlikely to be in therapy much longer and had a personality that could tolerate the possibility of future social contact with the psychologist. From the standpoint of an integration strategy for ethics, it appears that the psychologist missed an opportunity to express compassion within the context of a professional relationship.

Acting from an assimilation strategy, other psychologists might interpret the rule against clinically contraindicated multiple relationships so strictly that they would condemn any action that might increase the possibility that the patient's and psychologist's paths could cross if the patient ever decided to become more active in the church. They might decide that any increased risk of a boundary crossing is too risky. Thus, psychologists using assimilation strategies may lose the opportunity to help patients when they fail to weigh thoroughly both risks and benefits in their decision making.

Interpreting rules without attention to overarching values

At times, psychologists apply rules that appear unnecessarily to distance themselves from their patients. For example, a psychologist concerned about boundaries refused to hug any patient under any circumstances. He even rebuffed hugs from little children out of a concern that it might be misconstrued. Another psychologist refused all gifts from patients, even a holiday card with a pleasant and benign holiday greeting. Another psychologist focused so much on getting the informed-consent forms explained and signed that he failed to involve patients adequately in developing treatment goals, thus increasing the risk of treatment failure.

Following rules without considering any exceptions can create barriers between patients and psychologists and may cause psychologists to lose opportunities to improve their relationships with patients and facilitate positive outcomes. Often psychologists can take the lead from their patients on whether to accept or offer hugs. Nonetheless, discretion needs to be used in these situations; at times it may be clinically indicated to refuse to hug certain patients or to refuse gifts beyond those of nominal value. For example, one female psychologist accepted hugs from most patients in recovery from alcoholism, knowing that hugging at the end of meetings is common within the AA culture. On the other hand, she refused to hug her teenage male patients because doing so might have sexual overtones for some of them. However, she would hug small children and, when dealing with a highly sexualized victim of childhood sexual abuse, she discussed hugging with the parents to make the understanding of appropriate (and inappropriate) hugging a part of her treatment.

Helping students develop appropriate judgment is essential for psychology training programs. This judgment involves understanding how principles and rules apply in a variety of circumstances (Beauchamp & Childress, 2009, p. 40) and how to apply rules in context and in the furthering of worthy goals (Schwartz & Sharpe, 2010). Psychologists can demonstrate such judgment by examining the unique demands of the situation, attending to nonrational factors that influence behavior (Rogerson, Gottlieb, Handelsman, Knapp, & Younggren, 2011) and modifying their behaviors to account for unique demands. We can imagine how oppressive an agency, institution or university training program might become if its members were "ethical" in the sense of adopting extreme assimilation strategies. The atmosphere could become characterized by the need to identify others' shortcomings and vigilance to protect oneself from others' accusations. The net effect could be that many supervisors, supervisees, faculty members and students would stop discussing their ethical issues publicly. Thus, chances for productive exploration of some of the most common and grayest of ethics issues would be lost (Gottlieb, Handelsman, & Knapp, 2008; Pope, Sonne, & Greene, 2006).

Setting low standards for professional behavior

Assimilation strategies run the risk of setting low standards for professional behavior. The notion "if it is legal, then it is ethical" applies here. Consider this case:

A psychologist was treating a patient who made a serious threat to harm an identifiable third party. Knowing that this met the threshold for a duty to warn in his state, the psychologist quickly contacted the intended victim. Although the psychologist's actions met the letter of the law, the question arises whether the psychologist had other options to defuse the danger, such as seeking a voluntary hospitalization (if appropriate) or asking the patient for input on other ways to control the situation.

Warning an intended victim is often clinically indicated and may be the most ethical and best clinical response to a situation. However, there is always a danger that a psychologist, in a period of stress, may pick the first "half-way reasonable" and legal solution that comes to mind to quickly reduce anxiety and cognitive load, and to avert loss. In doing so, the psychologist may not have considered less intrusive, equally legal and more clinically effective options. Ideally, the psychologist's actions would have been informed most by the welfare of the third party and the patient, not only his or her own personal liability. He or she would have taken the time to do a detailed analysis of the context in which the violence might occur and sought to engage the patient in a plan to defuse the violence. Paradoxically, the failure to consider other clinical options might lead the patient to drop out of treatment, thereby increasing the risk that the feared violence might actually occur.

Creating harm by giving disproportionate attention to certain rules

Consider the psychologist who included the following statement in his informed consent form (this actually happened):

I recognize that I am here to see Dr. X for professional purposes and that I have no sexual interest in him and will not attempt to involve him in a sexual relationship or even fantasize about him.

It's admirable that the psychologist wanted to avoid sexual relationships with patients, but his manner of addressing the issue appeared to place the responsibility for sexual misconduct on the patient and to raise it to a level of importance that most patients would never have considered. Such statements could also cause patients to wonder if this psychologist had issues with personal control over his own impulses.

Another psychologist made a point of telling all her patients (male and female, young and old) at the start of therapy that sexual contact with psychotherapists is always unethical. This overemphasis on the rules embarrassed and confused many patients who did not know why this issue got so much attention.

The dark side of separation strategies

Psychologists who use separation strategies may perceive themselves as acting in a highly ethical manner but do not appreciate the cumulative wisdom expressed through professional standards. Examples of separation strategies include psychologists who attempt to solicit patients for social causes (intrusive advocacy), fail to maintain professional boundaries or allow personal values to trump professional ones. We consider some examples below.

Advocating intrusively

Intrusive advocacy occurs when psychologists place a social cause or their own personal values above their patients' welfare (Pope & Brown, 1996) and fail to separate personal values from therapeutic ones (Tjeltveit & Gottlieb, 2010). Consider this example:

A psychologist expressed anger at a patient who refused to file charges against an inpatient facility that had, probably inadvertently, violated her privacy rights by giving out information in a nonemergency situation without a proper release or court order.

Other psychologists have tried too strenuously to convince patients to file complaints against previous therapists with whom they had a sexual relationship or to file criminal suits against a parent who had abused them as a child. One psychologist told a patient that the patient had a social obligation to other victims to publicly expose and humiliate the offender. Another psychologist believed so strongly in protecting children that she included campaign literature in her waiting room for a political candidate who was vocal on the need for increased funding for child welfare programs.

Such well-meaning efforts fail to respect patients' autonomy in choosing their own goals and values. The psychologists' role is to establish conditions that allow patients to reach autonomous decisions; focusing on the psychologists' goals instead is likely to lead to a poorer quality of service, including an increase in the number of patients who resist or drop out of treatment. In the extreme, such behavior could also cause harm.

Failing to maintain professional boundaries

Effective professional relationships focus on patient well-being. Consider this situation:

At an initial evaluation, a patient reported that she was coming to therapy to deal with a recent sexual assault. The psychologist immediately shared her own assault history, as she had been instructed to do years earlier when she volunteered in a sexual assault facility.

The general rule for psychologists is to self-disclose deliberately and selectively, based on a patient's need (Sommers-Flanagan, 2012). The psychologist's discussion of her own sexual assault, especially when she did not know the patient well, was ill-considered and potentially harmful. Although this sharing might have been appropriate in a friendship or paraprofessional relationship, excessive self-disclosure early in the professional relationship risks derailing the focus of attention from the patient onto the psychologist (for further reading, see Gottlieb, Younggren, & Murch, 2009).

Allowing personal values to trump professional values

Although it is commendable to respond with concern and loyalty and to assist friends, in professional roles, psychologists should decline some requests for help. Consider these examples:

A psychologist was contacted by an attorney who told him about a man who was alienated from his daughter through no fault of his own, and the court had issued an order for reunification therapy. The psychologist agreed to conduct the therapy, even though he had no training or experience in this modality and was unprepared for the difficulty and the intensity of emotion generated by the case.

Another psychologist was treating a patient with a long history of disruptive interpersonal relationships, including failed treatment relationships with previous therapists. To reassure her patient, who was going through deep depression, the psychologist told her, "I will always be here for you." One year later, the psychologist terminated treatment with the patient who had continually missed appointments, made inappropriate night-time calls, refused to comply with reasonable treatment plans and failed to pay her bills. The patient filed a licensing board complaint noting that the psychologist had lied about always being there for her.

When a former patient was having trouble finding a place to live, a psychologist rented an apartment to her well below market rates. Two years later, the former patient was far behind in her rent and unemployed. When the psychologist attempted to collect the rent, the patient filed a licensing board complaint against the psychologist.

It's important for psychologists to set limits on their assistance and loyalty to patients, especially when such help exceeds the psychologist's competence, misleads patients concerning psychologists' roles or creates clinically contraindicated multiple relationships.

How to protect yourself

We view ethics acculturation as a developmental process that occurs throughout one's career. In that spirit, we offer these suggestions for balancing your personal ethical systems with professional rules, standards, values and principles.

1. Reflect on your behaviors. By reflecting on your professional conduct, you can explicitly link your behavior to both the rules governing the profession (such as the APA Ethics Code, state and federal laws, etc.) and to personal overarching ethical theory, whether that theory be principle-based ethics, virtue ethics, deontological ethics, feminist ethics or a system based upon your religious traditions. You can evaluate behaviors based on both personal and professional standards of conduct and then deliberate in a more comprehensive way (Anderson & Handelsman, 2010). Explicit instruction using the EAM (such as through readings or continuing education) may be one way to better understand how to integrate personal and professional ethics (Gottlieb et al., 2008).

2. Exhibit good ethical behaviors. Graduate students in psychology observe how their professors and supervisors respond to ethical problems. Of course, this knowledge is not transmitted by osmosis (Handelsman, 1986); faculty and supervisors can think aloud when they are confronted with situations that require ethical reasoning and demonstrate how they are linking their behaviors to the values of the profession. These kinds of demonstrations will help students develop judgment and the ability to apply overarching ethical principles of the profession appropriately, depending on contextual factors.

3. Be transparent. Strive for greater transparency with patients and colleagues in your ethical decision making and openly articulate your reasons for decisions. Transparency means more than just identifying the relevant rules, laws and standards — it also means discussions regarding how to implement these rules in ways that promote overarching ethical principles or virtues, such as the welfare of patients, respectfulness and justice. Openly speaking about your questions may reduce the tendency for ethical issues to be driven underground and may reduce the discrepancy between descriptive norms (how people actually behave) and injunctive norms (how people are expected to behave); it may also promote ethically excellent behavior (Handelsman et al., 2009).

4. Respond to feedback. All of us have blind spots (Bazerman & Tenbrunsel, 2011) that can lead us to act in a less-than-optimal manner for reasons outside of our conscious awareness. We can accept the fact that all of us will make mistakes, and when we do, we should acknowledge and try to correct them (Tavris & Aronson, 2007). As part of our lifelong education in ethics, we can strive for humility, use think-aloud processes and welcome feedback.