Ethical Practice in Applied Psychology 0195523105, 9780195523102

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ETHICAL PRACTICE IN APPLIED PSYCHOLOGY

christopher boyle nicholas gamble

ETHICAL PRACTICE IN APPLIED PSYCHOLOGY

ETHICAL PRACTICE IN APPLIED PSYCHOLOGY CHRISTOPHER BOYLE AND NICHOLAS GAMBLE

1

Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trademark of Oxford University Press in the UK and in certain other countries. Published in Australia by Oxford University Press 253 Normanby Road, South Melbourne, Victoria 3205, Australia © Christopher Boyle and Nicholas Gamble 2014 The moral rights of the authors have been asserted. First published 2014 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence, or under terms agreed with the appropriate reprographics rights organisation. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. National Library of Australia Cataloguing-in-Publication entry Author: Boyle, Christopher, 1972– author. Title: Ethical practice in applied psychology / Christopher Boyle, Nicholas Gamble. ISBN: 9780195523102 (paperback) Notes: Includes index. Subjects: Psychology, Applied—Moral and ethical aspects—Textbooks. Psychologists—Training of—Moral and ethical aspects—Textbooks. Other Authors/Contributors: Gamble, Nicholas, author. Dewey Number: 158.0715 Reproduction and communication for educational purposes The Australian Copyright Act 1968 (the Act) allows a maximum of one chapter or 10% of the pages of this work, whichever is the greater, to be reproduced and/or communicated by any educational institution for its educational purposes provided that the educational institution (or the body that administers it) has given a remuneration notice to Copyright Agency Limited (CAL) under the Act. For details of the CAL licence for educational institutions contact: Copyright Agency Limited Level 15, 233 Castlereagh Street Sydney NSW 2000 Telephone: (02) 9394 7600 Facsimile: (02) 9394 7601 Email: [email protected] Edited by Venetia Somerset Text design by Eggplant Communications Typeset by diacriTech, Chennai, India Proofread by Amanda Morgan Indexed by Mei Yen Chua Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work.

‘Primum non nocere’ (First, do no harm)

Contents List of Figures and Tables Preface Acknowledgments Abbreviations

PART 1 1

CORE ETHICAL REQUIREMENTS FOR PSYCHOLOGISTS IN AUSTRALIA

xi xii xiv xvi

1

Why Bother with Ethics?

3

Introduction General perception of psychologists The APS Code of Ethics Ethics, the law and morality An ethical code in practice Chapter summary References

4 4 6 8 9 12 12

2

The Three Keys to Ethical Practice: Competence, Confidentiality and Consent

14

Introduction Competence Confidentiality Informed consent Chapter summary Questions to consider References

15 16 24 29 33 33 33

3

35

Decision Assistance Model for Australian Psychologists

Introduction Ethical decision-making

36 36

vii

viii

Contents

The Decision Assistance Model for Australian Psychologists Chapter summary Questions to consider References

38 54 54 54

PART 2

55

4

MANAGING BOUNDARIES AND WORKING WITH GROUPS

Managing Professional Boundaries

57

Introduction Multiple and dual relationships Boundary crossings and violations Power imbalance Non-exploitation of a client Chapter summary Questions to consider References

58 59 63 65 67 70 70 70

5

72

Working with Clients who Cannot or Do not Give Consent

Introduction Clients who cannot give consent Clients who do not consent to services Other issues when working with clients who may not be able to give consent Chapter summary Questions to consider References

73 73 83 84 86 86 86

6

88

Diverse Clients

Introduction Client diversity Competence with diverse client groups Communication Chapter summary Questions to consider References

PART 3 7

CLIENTS WHO POSE A RISK TO THEMSELVES OR OTHERS

Working with Clients who Pose a Risk to Themselves

Introduction Clients with suicidal ideation Self-harm and behaviours that place the client at risk Dangerous or risky client behaviour that endangers the client Chapter summary

89 89 91 91 98 99 99

101 103 104 105 114 117 119

Contents

Questions to consider References

8

Working with Clients who Pose a Risk to Others

Introduction Clients who pose a risk to others Legal and ethical issues when working with a client who poses a risk of harm to third parties Client criminal activity Legal and ethical obligations in relation to suspected child abuse or abuse of other vulnerable groups Potential risk of harm to psychologists from clients Chapter summary Questions to consider References

PART 4 9

THREE SPHERES OF PRACTICE: RESEARCH, ASSESSMENT AND INTERVENTION

Ethical Issues in Research

Introduction The APS General Principles Shock at La Trobe University, 1973 Gauging risk and the NHMRC National Statement Duty of care and non-maleficence Informed consent Coercion, inducement and deception Conflict of interest Reporting and publication of results Vulnerability Milgram’s experimental legacy Chapter summary Questions to consider References

10

Ethical Assessment and Intervention

Introduction Psychological assessment Psychological testing Cultural diversity and testing Psychological assessment reporting Intervention Therapies involving psychologist–client physical contact

119 119

121 122 122 123 128 129 130 131 132 132

133 135 136 136 138 139 141 142 143 144 145 146 147 149 149 150

151 152 153 155 156 157 159 162

ix

x

Contents

Group therapy Chapter summary Questions to consider References

PART 5

A GUIDE TO GAINING AND MAINTAINING REGISTRATION, AND THE ETHICAL ISSUES IN PROFESSIONAL PRACTICE

11 Clinical Practice: Privacy Legislation, Records, Delegation, Advertising and Finances Introduction Client records Privacy Structure of client records Ownership of client records Access to the client record Storage of client records Office workflow Termination of service Service delegation and other professionals Advertising Financial limitations Chapter summary Questions to consider References

163 164 165 165

167 169 170 170 171 175 179 180 182 184 184 188 190 191 193 193 194

12 Gaining and Maintaining Registration

195

Introduction Pathways to becoming a registered psychologist After registration Practice endorsements Chapter summary Questions to consider References

196 196 198 204 204 205 205

Appendix Annotated APS Code of Ethics General Principle A: Respect for the Rights and Dignity of People and Peoples General Principle B: Propriety General Principle C: Integrity Glossary Index

206 211 231 253 264 273

List of Figures and Tables Figure 3.1 Figure 4.1 Figure 4.2 Figure 8.1 Figure 10.1 Table 10.1

Decision Assistance Model for Australian Psychologists (a map to ethical behaviour) Example of a boundary crossing Dr Robinson’s slippery slope Client harm–risk determination The relationship between psychological assessment and psychological testing Strength of evidence criteria

39 63 68 125 156 160

xi

Preface This book is the coming together of many years of teaching ethics in psychology and working as psychologists in the field. When we were teaching the subject as part of the Postgraduate Diploma of Psychology we became very aware that there was no quality Australian text for our students. We were relying on US texts, which although good in many ways were not based on the Australian Psychological Society’s Code of Ethics. As a result of this, many of the examples and scenarios were not appropriate for our students, so we created our own. With this book we believe that we have created something unique, which benefits both lecturers and students alike—a book on applied ethics in psychology, which directly takes reference from the APS’s Code of Ethics. Throughout this book we have used the gender-specific singular pronouns she, he, him, her instead of ‘they’ etc. as it makes for easier reading. So, sometimes the psychologist will be female and sometimes male. The client will also have the same mix. Therefore, wherever a gender pronoun occurs throughout the book it will have no significant meaning. If you are reading about a female psychologist being ethically problematic in her approach then this should equally be read as a male psychologist. There are 12 chapters in this book and each has a theme based on how the authors approach the teaching of ethics. Over the years we have found this to be the most logical order for teaching the subject. You, as a student or as a lecturer, may change the order of reading; the book is designed so that each chapter is not dependent on any previous material. However, as would be expected, there are references to other chapters throughout the book in order to aid the reader’s understanding of the terms and concepts. Notwithstanding the above, we would suggest that you read Chapter 1 before any others as this sets the scene for ethics in psychology and provides a good base for the other 11 chapters. The design of this book is based around case studies in each chapter which will aid the understanding of the particular ethical situations that are being discussed. You are presented with an ethical scenario and then the authors discuss the issues that are relevant in relation to the APS Code of Ethics. In our experience this method of teaching has brought a higher level of understanding from our students of the various issues of the ethical dilemma. Rather than teaching the Code of Ethics verbatim and then having it completely forgotten after the subject has finished,

xii

Preface

we present an opportunity for readers not only to understand the Code but to be able to apply its principles in various situations. No book on ethics will ever be able to cover all possible scenarios, but the authors hope that by providing some context to various ethical situations this publication will enable the reader to either improve the ethical understanding of practising psychologists or to provide the ethical basis of psychological practice for new psychologists. Chris Boyle, University of New England, Australia Nick Gamble, Monash University, Australia

xiii

Acknowledgments The authors would like to thank the many students whose thoughts, questions and suggestions have motivated us to write this book. It is their requests for a complete Australian ethics text that has resulted in the completion of this work. Thanks to Natalie Ferguson and Alexandra Griffin for commenting on the style of the book. After your well-deserved holiday, hopefully a career in psychology is all you wanted it to be! We would like to thank Debra James and her team at OUP for putting up with us through this long journey and for their support and assistance. We loved the idea that deadlines were there to be broken. We are glad that this was shared by our friends at Oxford University Press. Nick would like to personally offer thanks as follows: Four psychologists have played a significant role in my interest in ethics and the completion of this project. Dianne Vella-Brodrick was my first ethics lecturer and I had the great pleasure of working with her later in my academic journey. You made ethics interesting and showed me its vital importance in all aspects of psychology; hopefully I can do the same for the next generation of psychologists. Thank you my co-author Chris for his immeasurable bravery in taking on the challenge of writing with me. Thank you to Zoe Morris for being my devil’s advocate. Every writer needs one and when it comes to psychological ethics, she is the best! Finally thank you to Oliver Hopkins, your training and guidance showed me what an outstanding psychologist looks like. An enormous debt of gratitude is owed to my mother Joan and my sister Bridget. They not only had to put up with me during this writing process, but were invaluable sounding boards and critics of my ideas and writing. Thank you all! Chris would like to thank one of Australia’s newest eminent psychologists, Sarah Rostron, who informed him that Ryan Gosling would be far more desirable as a psychologist than George Clooney. Chris intended the latter as an example of the desirability of a psychologist (see Chapter 1) but by doing so showed his age. Thanks to Sarah for pointing that one out!! Chris would like to thank fantastic people, some of whom happened to be psychologists and shaped his understanding of psychological ethics. Thanks in particular to Fraser Lauchlan, Elizabeth

xiv

Acknowledgments

King, Richard Rangers, Jacquie Bradley, Heather Rendall, Mark Smith, Elaine Morrison, John Toland, Michael Wilson, Tom ‘Gorbals’ Henderson, Frank Waters, Moira Elita Togneri, John Pugh, Lee Dunnachie, Alicia Chodowicz, Jessica Rowling, Jake Kraska, Alex Graham and Alex Pieterse. Oxford University Press would like to thank the Australian Psychological Society (APS) for the APS Code of Ethics (APS, 2007), reproduced with permission.

xv

Abbreviations ABS ACT AEG AHPRA APAC APP APS BPS CBT DA-MAP DBT ECT EMDR ICP IPT MBCT NHMRC NPP OAIC PCSP PsyBA SFBT

xvi

Australian Bureau of Statistics acceptance and commitment therapy APS Ethical Guidelines Australian Health Practitioners Regulation Agency Australian Psychology Accreditation Council Australian Privacy Principles Australian Psychological Society British Psychological Society cognitive behavioural therapy Decision Assistance Model for Australian Psychologists dialectical behaviour therapy electroconvulsive therapy eye movement desensitisation reprogramming informed consent procedure Interpersonal psychotherapy mindfulness-based cognitive therapy National Health and Medical Research Council National Privacy Principles Office of the Australian Information Commissioner protection, care and support plan Psychology Board of Australia solution-focused brief therapy

PART

1

Core Ethical Requirements for Psychologists in Australia

1

1 Why Bother with Ethics? ‘To err is human.’ —Alexander Pope

CHAPTER OBJECTIVES • • •

To introduce the reader to what is expected of a psychologist with regard to the Australian Psychological Society’s (APS) Code of Ethics To provide insight into the general perception of psychologists in the media and how the public perceive the psychologist To understand the necessity of a professional body having a code of ethics

KEY TERMS APS Code of Ethics Beneficence (benefit) Confidentiality

Decision assistance model Ethics

Non-maleficence Practitioner

3

4

Part 1: Core Ethical Requirements for Psychologists in Australia

Introduction So, why do we bother with ethics? The notion of acceptable or good human conduct has been around as long as we have, and the great Greek philosophers such as Plato spent much time pondering how humans ought to behave in situations that require moral Ethics: The study of moral consideration. Plato supposed that humans could not be trusted to act ethically principles that govern or if they thought they could get away with it, which is emphasised in his story of should govern behaviour. At the Ring of Gyges (Plato 1955). We do not have the space to delve much into the an individual level, it relates to a person’s principles, basis of philosophical ethics; suffice it to say that over a long time it has possibly unformulated, that generally been agreed that we need to create ethical codes in order to dictate underlie his or her conduct. how we ought to act in any given situation. This is the basis of the Australian Psychological Society’s 2007 Code of Ethics (hereafter referred to as ‘the Code’) and any other profession’s ethical code, such as that of medics and the influence that Hippocrates still has over that particular profession. The statement that ‘to err is human’ by Alexander Pope seems to neatly sum up the reason a Code of Ethics is required in any profession but especially in that of psychology. People make mistakes, and those working in the fast-paced world of providing psychology services are no exception. For reasons of client and practitioner safety, some uniformity is required as to what constitutes good practice. When this is provided, the client has an understanding of what appropriate practice is, and the practitioner is able to base her interventions on the minimum standards set out by fellow practitioners. An Practitioner: A person who practises in his or understanding of what one ought to do when various circumstances arise her respective fields. (obscure or otherwise) should be gained through an ethical code. For the A psychologist who practises purposes of this book we will be considering how best to interpret and psychology would be understand the Code, which is also included in a convenient annotated form regarded as a practitioner. as the appendices to this book. This book is split into 12 chapters and will provide you with a discussion of the various aspects of the Code. As psychologists, we all must abide by the Code in order to gain and maintain our registration, so knowledge of the Code is a fundamental aspect of professional development and practice. Each chapter will cover individual topics and the learning will mainly take place through interpretation of the Code through case studies.

General perception of psychologists Psychology as a profession can be regarded in many different ways. Some may regard it as being intriguing and sexy, and we are sure that many of you are hoping that Ryan Gosling gets a psychologist’s movie role pretty soon. Others may see the psychologist as a dark, secretive person who has just as many problems as his clients. Young (2012) indicates that the portrayal of the psychologist in the media has not put the profession in a good light, especially from an ethical standpoint. Young suggests that before 1950 psychologists and psychiatrists were portrayed as ridiculous, silly characters, such as in the eponymous Dr Dippy’s Asylum, while from the 1950s onward there has been an increase in scepticism about the discipline

Chapter 1: Why Bother with Ethics?

of psychology, meaning that many characterisations are negative. However, one thing you can rely on with psych-type characters is that they will be interesting—usually flawed but defi nitely worth knowing. After all, many people want to be psychologists (like most of you), so clearly the negative stereotypes do not put too many people off the profession. Since changing his title from lecturer in psychology to lecturer in education, Chris Boyle noticed an interesting shift in people’s perceptions of him. In the case of the former, people were interested in the job, asking the usual question ‘can you read my mind?’, promptly answered with ‘only if you are open to it’. In contrast, when Chris changed roles for a while and asked what he taught in his role as ‘lecturer in education’ he was often met with stony silence. Suddenly nobody was interested. Being associated with psychology in some form makes most people notice you. That carries some responsibility to ensure that the ‘movie psychologist’ in its negative guise is not portrayed in real-life psychology, which you will soon be involved in, if you are not already. Chris has now changed back to ‘lecturer in psychology’ so that people will be interested in talking to him again. Nicholas, on the other hand, is a big, bearded psychologist—the most socially isolated type of psychologist; people are scared of him on many levels. Pirkis and associates (2006) found that the common portrayal of mental illness on TV and cinema is generally negative. This is similar for psychologists and psychiatrists, where there are myriad jokes about ‘the couch’ and ‘your childhood’. And, of course, it would suggest something if I didn’t mention ‘my mother’! According to Schneider (1987), since 1906 there have been three categories of psychologists in the movies. First was Dr Dippy, generally a bizarre or zany professional portrayed as having more problems than his patients. Second, there was Dr Evil, the sort of person who would gain control over the client and get them to do ‘bad things’—maybe through hypnosis; Hanibal Lecter from Silence of the Lambs would fit into this category and probably you would not want him as your psychiatrist. Third, Schneider suggests Dr Wonderful, who is ‘especially skillful at improvisation, comes up with the appropriate, if often unorthodox, maneuver or interpretation at just the right time’ (p. 997). Others have suggested another couple of new titles that have evolved such as that of Dr Linecross and Dr Rigid (reported in Sleek 1998), but we will let you figure those ones out yourself. In 2005 a study quantitatively reported on how movies made in the USA portrayed the psychologist/psychiatrist/counsellor/therapist type of role. Gharaibeh’s (2005) main fi ndings from his analysis of 106 movies with 120 therapists were as follows: •

71.2% of the therapists were males;

•

50.8% were middle aged (regardless of sex);

•

44.9% of roles included at least one ethical violation;

•

47.5% were portrayed as clinically incompetent;

•

23.7% of therapists violated sexual boundaries; and

•

30.5% violate other ethical boundaries. (p. 317)

When you consider these fi ndings it is a wonder that anyone would voluntarily speak with a psychologist. However, and on a positive note, Gharaibeh states that ‘one bright point in the stereotyped depictions of the psychiatrist/therapist is that they appeared as friendly 63.6% of the time’ (p. 318). A friend in need is a psychologist indeed!

5

6

Part 1: Core Ethical Requirements for Psychologists in Australia

We have understood from this section that psychologists can be portrayed quite negatively in the media, and this seems quite pronounced in some movies where a wayward psychologist clearly makes a good character. The many positives of the services provided by psychologists are not reported in the media, mostly for reasons of confidentiality, Confidentiality: In a as is the case for other professions which receive a negative media portrayal, therapeutic relationship between psychologist for example social workers. Strict ethical codes exist in our profession to and client, certain details prevent many of the breaches that are perceived to occur quite often. We are protected and should should remember that in Australia the instances of psychologists breaching remain confidential between the parties. the Code and going before the Psychology Board of Australia (PsyBA) are very rare.

The APS Code of Ethics1 For psychologists to practise in Australia, they must be registered with the national regulatory body, the Australian Health Practitioners Regulation Agency (AHPRA), which has adopted the APS Code of Ethics. The general purpose of any professional ethical code is to APS Code of Ethics: The offer a uniform guide to good practice, which covers appropriate conduct in overarching document that puts forward the various general situations. It aims to outline what a practitioner should minimum acceptable ethical endeavour to do in any given situation; it is aspirational but not fi xed and must standards for psychological be interpreted depending on the particular event or situation faced by the practice. It provides guidance for psychologists practitioner. No ethical code can ever be expected to cover all eventualities or and demonstrates to apply to all situations, and in the case of the APS it is also designed to be the the public the required minimum standard required from practitioners (Allan 2011). The Code is split standards that psychologists into three sections, which cover the three general principles of Respect, should adhere to. Propriety and Integrity. General Principle A: Respect for the rights and dignity of people and peoples (APS 2007, p. 11) • Psychologists regard people as intrinsically valuable and respect their rights, including the right to autonomy and justice. Psychologists engage in conduct that promotes equity and the protection of people’s human rights, legal rights, and moral rights. They respect the dignity of all people and peoples. General Principle B: Propriety (APS 2007, p. 18) • Psychologists ensure that they are competent to deliver their psychological services. They provide psychological services to benefit, not to harm. Psychologists seek to protect the interests of the people and peoples with whom they work. The welfare of clients and the public, and the standing of the profession, take precedence over a psychologist’s self-interest. General Principle C: Integrity (APS 2007, p. 23) • Psychologists recognise that their knowledge of the discipline of psychology, their professional standing, and the information they gather place them in a position of power and trust. They exercise their power appropriately and honour this position 1

This section uses material from Boyle 2014.

Chapter 1: Why Bother with Ethics?

7

of trust. Psychologists keep faith with the nature and intentions of their professional relationships. They act with probity and honesty in their conduct. The Code expects psychologists to behave in such a way that there is both beneficence (benefit) and non-maleficence (no harm) for the client. It Beneficence: The default is the optimum position where psychologists aspire to practise with the best of ethical position for practising psychologists is intentions. The Code assists in providing benchmarks and a guide to what is that whatever treatment regarded as good practice. Of course, it should not be used as a guide that and/or service is offered, includes all that should or should not be done. Fronek and colleagues (2009, the client should receive p. 18) state this well when they suggest that ‘codes [that] provide a framework some benefit from that interaction. for discipline specific practice…do not necessarily provide clear cut answers with consistency within and across disciplines’. The Code promotes a general consensus within the profession of what is considered appropriate behaviour Non-maleficence: One of the cornerstones of good in professional situations. It would be folly, in a professional setting, to expect ethical practice, in that a ‘list’ of what is good practice—no list of eventualities could be expected to whatever the intervention or service offered, no harm cover the myriad scenarios that our profession can throw up. should come to the client. Complementing the Code, psychologists also have Ethical Guidelines, which are intended to supplement and clarify the more technical legal language that is used in the Code. The APS Guidelines (APS 2012)2 have 23 separate sections, listed by their separate titles in the reference lists for the various chapters, such as: • • •

Guidelines on confidentiality Guidelines on the prohibition of sexual relationships with clients Guidelines on supervision.

This is more in line with providing a guide through foreseeable ethical difficulties so that the practitioner is able to be proactive in avoiding issues that may become ethically problematic. As with any ethical standards and codes of conduct for professionals, it seems that the question of whether you acted ethically or not may only arise if a complaint or challenge is made against your professional practice. At that point you must be able to show that you have behaved within the stipulated and accepted protocols of that registered profession. Contemporary society can be somewhat litigious, so bearing in mind that your practice can be challenged legally and/or professionally should ensure that practitioners take cognisance of their respective ethical codes and guidelines. The chances are, of course, that you will never have to justify your psychological approach to an ethics board, but if you are challenged you must be able to demonstrate that you have followed the general principles set out in the Code. It goes without saying that in order to avert any difficulties you should be working with clients while being aware that your practice could be called into question at any point. Your good practice should be appropriately documented so that a third party could also interpret it in this way.

2

Even though this is the latest published set of guidelines, the APS will also publish updated versions of individual sections of the guidelines, without necessarily updating the ‘paper’ copy.

8

Part 1: Core Ethical Requirements for Psychologists in Australia

Ethics, the law and morality This section will briefly consider the three areas of proper conduct that permeate our personal and professional life. A wise professor once told me that in professional psychology it is not worth trying to pull apart the differences between morals and ethics—I was advised to leave that to the philosophers. This is probably good advice and I will partially adhere to it because at the level of aspiring or practising psychologists the differences are subtle and in some ways pedantic for our purposes. In saying that, there are defi nitions that would acceptably represent the differences between ethics, the law and morality. According to Corey and colleagues (2011, p. 12), ‘morality is concerned with perspectives of right and proper conduct and involves an evaluation of actions on the basis of some broader cultural context or religious standard’. We can see from this defi nition that there is a separation from the professional context and that it concerns a person’s own beliefs and values; that is, how they tend to act based on their internal code of conduct or moralityinfluenced belief system. It could be argued that we all have access to this and that we all exert it, but it is clear that there are societal and personal differences in what constitutes a personal belief system. In the case of the law, this is the method by which we are statutorily obligated to behave, and it is founded on a basic standard. If one does not adhere to this (usually reasonably clear) standard the state can intervene to ensure that the basic standards of behaviour or conduct are maintained for the good of society at large. Ethics, certainly in a professional context, differs from law and morality in that it is a set of standards enforced by a professional body (whether they be representing psychologists, teachers, or real estate agents). In essence an ethical code is created to ensure, as far as reasonably possible, that there is a high standard of conduct upheld by the practitioner, which would reflect well on the profession as a whole. The other side is to ensure that members of the public, who are not expected to be qualified in the profession, are able to access the standards to which the psychologist should be adhering. While a lay person may not be aware of the intricacies of a particular therapy or other aspect of a psychologist’s work, they may be reassured that there is a procedure in place to ensure that these ethical standards are ‘policed’ if a complaint is made. Of course, there are situations in which overlap occurs between ethical, moral and legal standards, and we will briefly discuss some examples here. But these are just a selection of the possibilities and should be used only as a guide to potential issues. Immorality v unethical scenario: A client you are working with has difficulties in being able to pay your fees but you still charge. While there may well be moral issues about whether charging fees to a client who has less means to pay could be regarded as immoral, there is nothing in the Code to suggest that it is unethical practice. It should also be noted that in the Guidelines Regarding Financial Dealing and Fair Trading, ‘psychologists are reminded that in situations where one of their clients has unpaid accounts, their ethical obligations to the client remain unchanged’ (APS 2008, p. 35).

Chapter 1: Why Bother with Ethics?

9

Illegal v moral scenario: You refuse to provide confidential client information to a court, after being subpoenaed to do so, because you feel that the client disclosed certain personal information thinking that this would remain confidential between you and him. This is a breach of the law and the consequences can be severe, but from a moral point of view this approach may be acceptable since the client’s best interests are central to your decision. However, the Code requires reputable behaviour and not adhering to the law could, in strict circumstances, result in a breach. Standard B.12.d of the Code states that to be considered competent we should comply with the law. Also, under standard C.1.2 reputable behaviour is required: ‘psychologists avoid engaging in disreputable conduct that reflects negatively on the profession or discipline of psychology’. In the profession of journalism a refusal to provide the source of information is regarded as being very ethical (some would say brave), even if it results in legal sanctions being taken against that journalist. Legal v unethical scenario: As a psychologist you decide to embark on a sexual relationship with your 30-year-old client while you are still providing a therapeutic service. This is clearly unethical practice which, one would envisage, should carry a severe sanction by the ethical board. In the Code under ‘Non-Exploitation’ (C.4) and in standard C.4.3.a, ‘psychologists do not engage in sexual activity with a client or anybody closely related to one of their clients’. In Australia there is nothing illegal about this scenario, although in some states in the USA it is illegal (for specific details see Koocher & Keith-Spiegel 2008). There are also obligations to the psychologist under mandatory notifications, which will be discussed in more detail in Chapter 12. The important thing to remember with all such scenarios is that these circumstances can occur, in various guises and using a decision assistance model , to ensure a robust ethical standpoint. The Decision Assistance Model for Australian Psychologists is the focus of Chapter 2. In the following section we highlight a case study that describes a scenario where ethics and the law overlap.

Decision assistance model: A model whose purpose is to help a psychologist systematically consider all aspects of an issue before deciding on an outcome which is both ethical and focused on client welfare.

An ethical code in practice In several professions, ethical codes in various levels of detail have been around for many years. As mentioned earlier, it would not be possible to create a list of how to act in any given situation, so we try to act in an ethical manner according to the Code’s general principles. The fictitious scenario of Dr Bright gives a situation where the law and ethics collide, but keep in mind the term ‘non-maleficence’, which means that the psychologist should not do anything that would harm the client. This case study and the subsequent discussion of the real-life Tarasoff case gives an insight into what is involved in trying to protect the public, the client, and of course, you as the psychologist.

CASE STUDY 1.1

10

Part 1: Core Ethical Requirements for Psychologists in Australia

Dr Anna Bright worked as a psychologist on the campus of East Melbourne New University. Dr Bright had just started providing psychological services to Francis, a young male medical student, when she became alarmed at the suggested threats of physical violence that he made against a female student at the university. He seemed to be very clear about the harm he intended to cause to this student. Even though Francis had not named the other student, she was clearly identifiable because he had given details about where she lived, what course she studied, and that they had got to know each other. In further discussion, Dr Bright ascertained that the female student had spurned his romantic advances, which had been the reason for Francis’s anger. Dr Bright decided that it was necessary to break confidentiality and duly informed the supervising psychiatrist, Dr Smooth, of her concerns. Dr Smooth agreed with Dr Bright and the campus police were informed and detained Francis. Afterwards the police interviewed Francis and decided that there was no serious threat and released him. Two months later he murdered the female student about which the original threats were made. The points to consider from this case are whether there were grounds to breach confidentiality and whether the psychologist, in trying to protect the third party from harm, did enough.

The Tarasoff case and the implications for breaching confidentiality As you will notice throughout this book, we use case studies to illustrate ethical dilemmas and how the Code can be applied to these cases. Some of these case studies are based on actual events, while others were a convenient excuse for us to practise our creative writing skills. Whether they are the latter or the former they will be directly relevant to the topic in hand. Case Study 1.1 is not as clear-cut as it seems and, as you will soon discover when we look at professional ethics, not all events can be clearly assigned to the ‘right‘ or ‘wrong’ category. Considering the case it would seem, prima facie, that Dr Bright had taken reasonable precautions and acted ethically in breaching the agreement of confidentiality between client and psychologist. Since the student did end up being murdered, could Dr Bright have done anything more than speak to her supervisor and inform the police? First of all, let us consider Ethical Principle A, Respect for the rights and dignity of people and peoples, and standard A.5 on confidentiality from the Code, which would refer to this situation.

Chapter 1: Why Bother with Ethics?

APS Code A.5.2 A.5.2. Psychologists disclose confidential information obtained in the course of their provision of psychological services only under one or more of the following circumstances: a)

With the consent of the relevant client or a person with legal authority to act on behalf of the client; b) Where there is a legal obligation to do so; c) If there is an immediate and specified risk of harm to an identifiable person or persons that can be averted only by disclosing information; or d) When consulting colleagues, or in the course of supervision or professional training, provided the psychologist: (i) Conceals the identity of clients and associated parties involved; or (ii) Obtains the client’s consent, and gives prior notice to the recipients of the information that they are required to preserve the client’s privacy, and obtains an undertaking from the recipients of the information that they will preserve the client’s privacy.

The scenario in Case Study 1.1 was based on an infamous case which actually took place in California (Tarasoff v. Regents of the University of California, 1976 ) where student Prosenjit Poddar murdered fellow student Tatiana Tarasoff in 1969. This has become one of the most notorious cases regarding the duty to disclose information to a third party. We will not go into the Tarasoff case in depth but good summaries are contained in Corey and colleagues (2011) and Fisher (2013). The following paragraphs are a summary based on the official court documents and various reports of those fi ndings. Poddar had been receiving help from the campus psychologist when, in (what turned out to be) his fi nal session, he disclosed that he wanted to kill another student on the campus. The student was not named but was clearly identifi able as Tatiana Tarasoff. The case psychologist had enough concern to report it to his supervisor and both agreed that Poddar should be forcibly detained and evaluated because of his wayward state of mind. Because of their concerns the police were informed and they subsequently arrested and detained Poddar. The police later released him because they did not believe he was a threat to anyone in the community, and specifically not to Tarasoff. The court papers (Tarasoff v. Regents of the University of California, 1976 ) report that only two months later Poddar carried out his threat and killed Tarasoff. From an ethical point of view one would think that the psychologist would be vindicated and exonerated from any blame as he had attempted to warn the appropriate authorities and received advice from a more senior supervisor. This case has become a popular discussion topic in university ethics classes around the world. The Tarasoff family successfully sued the university and ultimately the psychologist for damages because of the perceived negligence with regard to their duty of care to the students. The salient point was that nobody warned Tatiana Tarasoff about the threats made against her life; nobody had informed her that precautions were necessary.

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If  we return to the scenario in Case Study 1.1, Dr Anna Bright would have followed the Code, which specifically lists ‘If there is an immediate and specified risk of harm to an identifi able person or persons that can be averted only by disclosing information’. What did Dr Bright or the psychologist in the Tarasoff case do ‘wrong’? We would argue that there was not much that they did wrong if you consider the Code and the actions of the psychologist and supervisor. The salient point is that the professionals in either case did not warn the third party about the potential danger, which was clearly regarded as serious. From an ethical point of view you should be aware that merely passing on information to an appropriate other professional (e.g. police or social services) does not necessarily mean that you have completed your duties, although this has not been tested in the Australian legal system. It may be more diligent to remain as the chief professional responsible for ensuring the information is eventually passed on to the third party whom you believed was originally in danger. Of course these situations are not common, but cognisance must be taken of any preventable dangers that you come across in your practice. Chapter 3 on confidentiality deals in more detail with keeping and releasing information. Chapter 8 covers, in some detail, the issue of clients who pose a threat to others.

CHAPTER SUMMARY This chapter has given a general introduction to the APS Code of Ethics and highlighted the three main General Principles: (a) Respect for the rights and dignity of people and peoples, (b) Propriety, and (c) Integrity. We have given some scenarios of where some aspects of the law, of morals, and of ethics can become fuzzy. These examples should not be regarded as finite or definite. As you will discover as you go through this book, many aspects of the Code discuss particular behaviours but they will not cover all possible events, nor should this be expected. The following chapters are designed to help you decide, when you are faced with a scenario, what would be an ethically acceptable response. As a psychologist you will be expected to use the Code, exercise your professional judgment, and seek advice from your supervisor in order to interpret situations appropriately. In Chapter 2, an ethical decisionmaking model is presented and discussed in some detail. This model was designed to provide a more robust method of understanding the potential scenario and acting in an appropriate and ethical way.

REFERENCES Australian Psychological Society (APS) (2007). Code of Ethics. Melbourne: APS. APS (2008). Guidelines Regarding Financial Dealing and Fair Trading. Melbourne: APS. APS (2012). Ethical Guidelines: Complementing the APS Code of Ethics (10th edn). Melbourne:  A PS. Boyle, C. (2014). Ethical considerations for practising psychologists in Australia. In D. Jindal-Snape & B. Hannah (eds) Exploring the Dynamics of Ethics in Practice: Personal, professional and interprofessional dilemmas. Bristol: Policy Press, pp. 167–79.

Chapter 1: Why Bother with Ethics?

Corey, G., Corey, M.S., & Callanan, P. (2011). Issues and Ethics in the Helping Professions (8th edn). Belmont, CA: Cengage Learning. Fisher, C.B. (2013). Decoding the Ethics Code: A practical guide for psychologists (3rd edn). Thousand Oaks, CA: Sage. Fronek, P., Kendall, M., Ungerer, G., Malt, J., Eugarde, E., & Geraghty, T. (2009). Towards healthy professional–client relationships: The value of an interprofessional training course. Journal of Interprofessional Care 23(1), 16–29. Gharaibeh, N.M. (2005). The psychiatrist’s image in commercially available American movies. Acta Psychiatry Scandinavia 111, 316–19. Koocher, G.P., & Keith-Spiegel, P. (2008). Ethics in psychology and the mental health professions: Standards and cases (3rd edn). New York: Oxford University Press. Pirkis, J., Warwick Blood, R., Francis, C., & McCallum, K. (2006). On-screen portrayals of mental illness: Extent, nature, and impacts. Journal of Health Communication 11(5). Plato (1955). The Republic, trans. Desmond Lee. Middlesex: Penguin Books. Schneider, I. (1987). The theory and practice of movie psychiatry. American Journal of Psychiatry, 144(8), 996–1002. Sleek, S. (1999). How are psychologists portrayed on screen. APA Monitor, 29(11). . Tarasoff v. Regents of the University of California 131 Cal. Rptr. 14 (Cal. 1976). Young, S.D. (2012). Psychology at the Movies. Chichester, UK: Wiley-Blackwell.

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2

The Three Keys to Ethical Practice: Competence, Confidentiality and Consent

CHAPTER OBJECTIVES • • • • •

To understand the importance of competency in the provision of psychological services To be aware of AHPRA’s core competencies and additional necessary competencies To understand the core ethical requirement of confidentiality and its limits To recognise the value of confidentiality in the professional relationship with a client To understand the core ethical requirement of the client’s informed consent to any service provision

KEY TERMS AHPRA Client Competency Confidentiality

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Continuing professional development Informed consent Manualised interventions

Peer-reviewed publications PsyBA Supervision

Chapter 2: Competence, Confidentiality and Consent

15

Introduction

Theodore is a forensic psychologist working in a private practice in central Melbourne. Due to his language skills, Theodore’s specialises in working with clients from Asian backgrounds who are involved in proceedings against them in the criminal court system.

The specific competencies needed by these two psychologists will vary greatly, but they will share some core competencies. Sally will have the skills required to work within the  education system with parents, children, teachers and the education department. Theodore will mainly be working with clients who are facing criminal charges, their solicitors and other officials in the justice system. Both of them work in situations that make

CASE STUDY 2.2

Sally is an educational psychologist working in a government school in the rural northern outskirts of Perth. She mainly works with children, parents and schools, assisting children who are at risk of poor outcomes in the transition to the school environment.

CASE STUDY 2.1

This chapter will cover the three key ethical and professional issues of competency, confidentiality and consent. While psychologists work in a range of areas within the broad field  of psychology, using vastly different tools and techniques and with a diverse range of clients, these three concepts remain vitally important to all psychologists. Competency: Having and The issues relevant to each of these key concepts will vary depending on the maintaining the skills needed setting and the client group involved in the service provision. For example, all to practise in the field; psychologists only provide clients should be advised of the psychologist’s skills and competencies, and psychological services in the limitations of confidentiality that will exist in the professional relationship which they are competent. during the informed consent procedure. Consider the two cases below.

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Confidentiality: In a therapeutic relationship between psychologist and client, certain details are protected and should remain confidential between the parties.

confidentiality more complex than if they were working in a small practice dealing with clients on a one-to-one basis. Both will need to negotiate with all parties to determine who is the client and therefore to whom the psychologist owes her duty of confidentiality. In Sally’s situation is it the school as a whole, the teacher, the principal, the child or the parent that is the client? After determining this Sally will need to clarify with all parties her role and what information she is going to be discussing with them. This discussion will form Client: A person or persons part of the informed consent procedure (ICP). As part of the ICP, Theodore receiving a psychological would have to explain to his client if there were any circumstances under service that may involve which he would have to disclose information to the judge or the opposing teaching, supervision, research, and professional solicitors. Theodore would also discuss with the client payment methods, how practice in psychology. they would remain in contact while his client was in jail waiting for trial, and the types of services Theodore would be providing (e.g. counselling for the transition to imprisonment or undertaking forensic assessments of the client’s cognitive abilities). To support ethical practice, the client would need to be fully aware of the conditions of the psychological service and agree to them before any services could be conducted. While the specific issues relating to competence, confidentiality and consent would vary between Theodore’s and Sally’s work settings, they are still the foundation upon which their ethical practice is based.

Competence In psychological ethics, competence broadly means having a sound knowledge of the services being provided and the tools, techniques and theories being used. While there has been extensive discussion of competence it is a difficult concept to defi ne in a field as broad as psychology. Epstein and Hundert (2002, p. 226) give a comprehensive defi nition for the medical  field as ‘the habitual and judicious use of communication, knowledge, AHPRA: The overarching technical skills, clinical reasoning, emotions, values, and reflection in daily government registration body for health practitioners practice for the benefit of the individual and the community being served’. in Australia. Its main Here, competence is a wide-ranging concept that will encompass all aspects of purpose is to protect the a psychologist’s service provision. It is also important to note that competence public in accordance with is not a static concept but is continually shifting as new research and theory each state and territory’s Health Practitioner direct ethical psychological practice (Neimeyer et al. 2012). This will necessitate Regulation National Law. that psychologists consistently monitor, evaluate and update their core skills. As will be seen in Chapter 12, AHPRA , through the Psychology Board of PsyBA: Under the umbrella Australia (PsyBA), sets out the minimum level of continuing professional of AHPRA, the Board that development (ongoing learning) that psychologists must undertake to deals with all matters maintain their registration. Professional development in psychology can take relating to the registration of psychologists in many forms, including reading current research material, taking courses, Australia. Psychologists attending seminars or workshops, and peer supervision. Peer supervision must be registered with for  psychologists relates to the supervision and consultation between AHPRA in order to practise psychologists with the aim of developing and promoting the ethical, psychology in Australia. professional and competent practice of psychology (PsyBA 2011a). Discussion

Chapter 2: Competence, Confidentiality and Consent

of cases, issues or important topics in psychology can occur in a one-to-one or group setting, and every registered psychologist must undertake ten hours of peer supervision yearly. Again, the purpose of this practice is to ensure that psychologists are maintaining and upgrading their skills and knowledge. In this way psychologists can remain competent to practise in their chosen area.

Competency in the Code of Ethics

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Continuing professional development: In order to maintain registration as a psychologist certain educational and practical activities must be undertaken every year so as to ensure recency in the field of practice.

Standard B.1 of the Code details the ethical requirements for the competent practice of psychology.

APS Code B.1 B.1. Competence B.1.1. Psychologists bring and maintain appropriate skills and learning to their areas of professional practice. B.1.2. Psychologists only provide psychological services within the boundaries of their professional competence. This includes, but is not restricted to: (a) working within the limits of their education, training, supervised experience and appropriate professional experience; (b) basing their service on the established knowledge of the discipline and profession of psychology; (c) adhering to the Code and the Guidelines; (d) complying with the law of the jurisdiction in which they provide psychological services; and (e) ensuring that their emotional, mental, and physical state does not impair their ability to provide a competent psychological service. B.1.4. Psychologists continuously monitor their professional functioning. If they become aware of problems that may impair their ability to provide competent psychological services, they take appropriate measures to address the problem by: (a) obtaining professional advice about whether they should limit, suspend or terminate the provision of psychological services; (b) taking action in accordance with the psychologists’ registration legislation of the jurisdiction in which they practise, and the Constitution of the Society; (c) refraining, if necessary, from undertaking that psychological service.

These standards make it clear that psychologists must ensure that they have, and maintain, the skills needed to practise in their field (B.1.1) and that they only provide services in which they are competent (B.1.2). In this form, competence relates to their knowledge, training/education and supervised experience (B.1.2.a), and ensures that the service is based on established knowledge of the field (B.1.2.b); this can be through clinical experience or research-supported practice. The Code also stipulates that competent practice must comply

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with the APS Code and APS Guidelines (B.1.2.c), and government legislation (B.1.2.d). Further, it is important that psychologists maintain their own physical and mental health (B.1.2.e). Psychologists need to ensure that their own mental and physical health needs Supervision: Professional counselling from another are being met to ensure that their services are competently provided. For psychologist, usually in example, a psychologist experiencing severe anxiety or depression may the form of peer advice have difficulty providing competent services. International research has where the various issues of suggested that psychologists practising while impaired are likely to be in practice are discussed in order to improve one’s own breach of their ethical obligations (Mahoney & Morris 2012). practice but also to seek The Code also states that supervision and consultation will form part of advice on current cases. the regular development of a psychologist’s skills and understanding (B.1.3).

APS Code B.1.3 To maintain appropriate levels of professional competence, psychologists seek professional supervision or consultation as required.

Consider the case of Sally the psychologist in the case study earlier. If she was working with a client from an ethnic group that she did not usually work with, consulting a colleague who often worked with that group would be one way of gaining further information and improving her service provision. The fi nal issue in relation to competence in the Code focuses on psychologists’ ability to self-monitor (B.1.4).

APS Code B.1.4 Psychologists continuously monitor their professional functioning. If they become aware of problems that may impair their ability to provide competent psychological services, they take appropriate measures to address the problem by: (a) obtaining professional advice about whether they should limit, suspend or terminate the provision of psychological services; (b) taking action in accordance with the psychologists’ registration legislation of the jurisdiction in which they practise, and the Constitution of the Society; and (c) refraining, if necessary, from undertaking that psychological service.

Psychologists should attempt to critically evaluate their own practice and service provision at all times. However, it can be very difficult for a psychologist to objectively critique their own service provision. Therefore they should discuss and receive feedback on their treatment and intervention practices during peer supervision. It is also possible for psychologists to compare their usual method of providing services with best practice techniques presented at conferences or in the psychological literature. It can be ethically difficult to gather comprehensive information from clients regarding their experience of

Chapter 2: Competence, Confidentiality and Consent

the psychological services. However, informal feedback in sessions regarding the client’s experiences of the service can be ethical and clinically useful to the client’s treatment, as well as useful for the psychologist in self-evaluation. If the psychologist feels that his practice and competence could be improved he must seek additional training or supervision to develop his skills or overcome difficulties he is experiencing. If the issue is affecting his clients adversely, he should discontinue or modify service provision until the problematic aspect of his practice is rectified.

The core competencies for psychologists The PsyBA (2010) has set out the core competencies for psychologists gaining registration from 4+2 (four years study and two years professional internship) and 5+1 programs. The Board has not set out specific competencies for other psychologists apart from their completion of an accredited postgraduate psychology course. However, the competencies required in the 4+2 and the 5+1 models (ethics, assessment, intervention and communication) will form the core of the National Psychology Exam, which may need to be completed by psychologists applying for generalist registration (PsyBA 2012). This exam and which student groups will be required to take it are currently being developed. See for latest information on the exam and the pathways to registration that will be required to pass the exam before being granted generalist registration as a psychologist.

The PsyBA’s areas of competence The PsyBA’s areas of competence, as outlined in the guidelines for the 4+2 and the 5+1 paths to registration (PsyBA 2010, 2012), are listed below. The fi rst six items are also part of the requirements set out by the Australian Psychology Accreditation Council (APAC 2010) as the core capabilities and attributes that should be included in Master and Doctor of Psychology courses. There is a further competency, knowledge of electronic and communication technologies, that has become increasingly relevant for all psychologists: • • • • • • • •

knowledge of the discipline ethical, legal and professional matters psychological assessment and measurement intervention strategies research and evaluation communication and interpersonal relationships working within a cross-cultural context practice across the lifespan.

Additional competencies •

electronic and communications technology (not required by the PsyBA).

These are the key areas of competence that apply to every registered psychologist in all fields. However, as pointed out in Case Study 2.1, the specific details of each competency may differ for each field of psychology.

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Knowledge of the discipline This competency can be thought of as a very broad overarching knowledge of the field of psychology. Many of these skills are developed in the initial three years of university training. For example, knowledge and understanding of the key theorists (e.g. Piaget, Vygotsky, Freud, Watson, Skinner), the key theories and the empirical support for them are all part of the standard undergraduate training in psychology in Australia. Understanding research methods and the connection between research and practice are key parts of psychological knowledge (APS 1996). Also likely to be considered relevant to this area are the basic concepts of perception, cognition, memory, behaviour and emotion. All areas of psychological practice and research rely on a basic understanding of these concepts.

Ethical, legal and professional matters In order for psychologists to maintain their registration, there are a number of specific legal and ethical requirements that must be adhered to. For example, there is specific legislation relating to the registration of psychologists. There are also broad issues such as copyright, privacy legislation, mandatory reporting of child abuse, workplace law and health records, which are relevant to many professional fields. The PsyBA has a number of guidelines for practice and has adopted the APS Code of Ethics (and all of the APS Guidelines by virtue of standard B.1.2.c of the Code) as the minimum standards for the field of psychology. There are a number of ethical issues for psychologists that are set out in this book and that psychologists need to be aware of and consider in their practice. There are also professional matters that psychologists need to consider. Psychologists need to be aware that there are ethical issues in the professional areas of advertising, billing and public behaviour (see Chapters 11 and 12). This is a diverse and complex competency that psychologists must continually develop, as there are frequent changes to the regulatory environment in which they operate.

Psychological assessment and measurement Many psychologists will use assessment tools in their daily practice. While these tools may vary according to the client’s age, gender, cultural background, language and cognitive ability, psychologists must be aware of, and competent in the use of, the assessment tools common in their field of practice. They should be aware of the development process, psychometric properties and empirically supported uses of any assessment tools they are using. They should also have the skills required to ethically conduct and interpret the results of assessment tools for diverse cultural groups. As well, psychologists should be competent in client interviewing and note-taking. For more information on the ethical issues in assessment see Chapter 9.

Intervention strategies As part of their role, psychologists in all fields will assist their clients to achieve their goals and desired outcomes. Psychologists need to be aware of the commonly used and empirically supported intervention strategies in their field of practice. They also need to be able to critically evaluate new or developing interventions and, in some cases, develop and assess their own interventions. Psychologists in Australia increasingly need to be aware of the empirical support for altering the standard procedures for an intervention to suit the specific needs of diverse client groups they are working with in Australia.

Chapter 2: Competence, Confidentiality and Consent

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Research and evaluation While it is not common for psychologists engaged in private practice to be heavily involved in research, an awareness of research methods and the evaluation of research are vital. Reading peer-reviewed publications is one of the key ways that Peer-reviewed psychologists build and maintain their knowledge of the field. When reading, it publications: Any published is important to look at the information being presented with a critical eye. Part material that has been reviewed by peers in the of this process is understanding the impact of sample sizes and distributions particular specialist field. on results. It is also beneficial to understand the statistical techniques being Peer-reviewed material can employed and their purpose. With these skills psychologists can develop their be in the form of books, chapters or journal articles. knowledge and practice through the critical analysis of published research and opinion. For psychologists who do engage in research as their primary function or for those involved in research as well as clinical practice, a more detailed understanding of research design, data collection, analysis and interpretation is needed. These psychologists also need to develop a more complex understanding of the ethical issues in recruitment, supervision of research assistants, and data management.

Communication and interpersonal relationships For almost all psychologists, their key competency is the ability to connect and communicate with  their clients. To provide services effectively they will need to become skilled communicators.  This may be in the form of verbal, nonverbal, written or electronic communication. For psychologists who predominantly work in a one-to-one or group setting, their main method of receiving and disseminating information is verbal and nonverbal communication. These psychologists will need to develop a warm and empathic style to build trust and confidence in their clients. Psychologists working with diverse social, cultural, economic, gender and professional groups will need to tailor their interactions to meet the needs and expectations of these audiences. In some cases these may be developed through university training (e.g. the ability to write reports that are targeted at parents or professionals). In the case of acquiring an understanding of verbal and nonverbal communication norms with a specific cultural group, the psychologist may get their understanding through professional development and in discussions with clients from that group, asking them what makes them comfortable. Psychologists who mainly communicate in written form or electronically should also become experts in this method of communication, paying particular attention to the lack of nonverbal cues in this form of receiving and providing information.

Working within a cross-cultural context It is important for psychologists to understand that different cultural groups may have different norms, customs, requirements and expectations for psychological services (see Chapter 6). It is also important that they are aware that just because an individual is a member of a particular group, it does not mean that she will conform to the group norms presented as typical of the group in the professional literature. Each client should be offered services that meet her needs. However, there may be evidence in the psychological literature that suggests some norms or expectations are held by the majority of a certain group, and psychologists should be aware of these. There can also be some instances of commonality among groups.

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For example, many cultural and religious groups see psychopathology as a punishment from their deity/god(s). It is vital that a psychologist working with a client who holds this as his worldview takes this into account when providing the service. The psychologist does not have to agree with the client’s worldview but will need to consider its implications for the service being provided. Given the diverse nature of the Australian population it will be impossible for a psychologist to have a well-rounded understanding of all cultural groups she works with. Therefore she should discuss with the client (as part of the informed consent procedure: see below) the types of activities that will be involved in the service that she is planning to engage in and check to see if there are any problems. The psychologist should also ensure that the client is aware that the service can be stopped at any time and, that if the client has any issues or concerns, he should raise them immediately. However, this process should be common practice for all psychologists working with all clients. If each client is treated as an individual and is encouraged to ask questions or raise any issues he has about the service being provided, cultural awareness can be maintained and built upon. The only area where this can be at issue is with psychological tests and manualised interventions or treatments. To evaluate their psychometric properties, tests and manualised interventions are typically developed and normed on a particular population. While this norming process has improved over time and now includes a relatively representative population Manualised interventions: sample, it does not always include diverse cultural, linguistic, sexual or Interventions that have a gender groups. Therefore psychologists may have difficulty fi nding standardised procedure for their implantation. These assessment or intervention tools that have been developed for specific interventions have typically cultural groups (see Chapter 9 for more ethical issues relating to assessment). been evaluated in terms of It is worth noting that there is a dearth of cognitive assessment tools available their effectiveness with the that are suitable for the Australian Indigenous population, yet many target group. assessments tools are used regularly with this population.

Practice across the lifespan Psychologists need to be aware of psychological constructs and theories from across the lifespan. Most psychologists will work with clients of varying ages and life stages. The tools, techniques and methodologies used by a psychologist should be appropriate to the client’s age and life stage. All psychologists should be aware of the broad major life transitions and stages. Psychologists working extensively with individuals of a particular age should have a more in-depth understanding of the intricacies of that age. For example, all psychologists should be aware of the transition from late childhood to early adolescence and how this may influence their service provision to these clients. However, educational and developmental psychologists should have a deeper knowledge of the myriad changes that occur in this period. Furthermore, they should be aware of the typical pattern of these transitions and the specific practical and theoretical implications.

Electronic and communications technological competence While it is not included in formal codes or guidelines of the PsyBA, competency in electronic and communications technology is becoming vital for all psychologists (but see APS 2011). With the advances in online and telephone psychological services to clients and the development of

Chapter 2: Competence, Confidentiality and Consent

electronic interventions, there is a need for psychologists to be aware of these technologies. Even for psychologists not using these tools, the electronic storage of records (e.g. spreadsheets that detail client contact or appointment details), email communications (with clients or other professionals) and the implementation of eHealth records require all psychologists to develop some knowledge of these technologies to ensure that ethical standards are maintained. Psychologists also need to consider the security of their computerised files and the security of their laptop, tablet computer or smart phone if they contain any client information. There is also the potential for some electronic devices to automatically back up their data online (cloud storage) in international locations, for retrieval or use on other devices. The security and confidentiality of these storage methods must be considered. While none of these matters are impossible to overcome from an ethical perspective, it is vital that psychologists are aware of the technologies they use in order to deal with the ethical issues involved. Psychologists providing services over the internet need to be aware of the inherent lack of confidentiality these tools often have. They must then set up measures to deal with the lack of security of emails and video communication that are not encrypted. Theoretically, these communication forms are open to view as they pass through the internet infrastructure. Psychologists need to consider this and incorporate safeguards into their planning and consent procedures, or encrypt their data. They also need to consider who will have access to the information transmitted between themselves and the client. Even using email, the least complicated method of electronic communication, how will the client ensure that no unauthorised person views their emails? This could be a family member in the home. If they use their work email address to communicate with their psychologist, a staff member or contractor may have access to the email system as part of their IT support role. Psychologists also need to consider what information is collected by third parties or advertisers if they use online intervention tools or services. These are the kinds of issues that psychologists need to clarify with their technology providers and then discuss with their clients as part of the informed consent procedure. Psychologists also need to consider the technology they use as part of the administration, storage and service delivery in traditional face-to-face practice. Traditionally, client records have been stored in filing cabinets that are easily locked and secured in a psychologist’s workplace. Increasingly, however, psychologists are using electronic means of storage such as note-taking on smart phones and electronic tablets. These devices can be substantially more difficult to secure. If they are securely locked in a filing cabinet at the end of each treatment session they can be as secure as traditional client records. But if phones or tablets are transported, used in multiple locations, used for personal as well as professional activities or connected to the internet, they are substantially less secure than traditional client records. There is an increased risk of their loss, theft or unauthorised access. The use of electronic tools in improving the efficiency and convenience of administration and service provision in psychology is an exciting field, but these benefits need to be considered in conjunction with the ethical issues they present. If the ethical issues are not adequately dealt with, the benefits associated with electronic service provision will be lost.

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Maintaining competency It is important to note that psychologists must continue to maintain their competencies. As will be seen in Chapter 12, continuing professional development is important. Therefore, it is vital that psychologists do not consider themselves competent after the completion of their studies and training, but rather view competence as a career-long evolving endeavour. Ethical practice demands this ongoing development of skills and knowledge.

Confidentiality Confidentiality is one of the key aspects that signifies the professional relationship between a client and a psychologist and is fundamental in the development of a sound therapeutic relationship (Spruiell et al. 2011). Confidentiality is the non-disclosure of information that the client, or third parties, give to the psychologist during psychological services. For the field of psychology, confidentiality is regulated by standard A.5 of the Code and by state and federal legislation. While the confidentiality that exists between psychologist and client is not absolute, most of the information disclosed by a client will never be divulged without the client’s express consent. However, there are some instances when confidential information provided by the client may be discussed ethically. Unfortunately there is only limited guidance from the Code and other sources on when and how to disclose (Kämpf et al. 2008).

Who is the client? Before a more complex discussion of confidentiality can occur, the key issue of ‘who is the client?’ needs to be addressed. Determining who the client is will determine to whom the rights pertaining to confidentiality are owed. While this may be a straightforward process in some settings, it can be more complex. Consider the example in Case Study 2.1 of Sally offering transition to school services. In that case study the state government, the school community, the teacher, the principal, the parents or the child may all legitimately believe that they are the client. Before the provision of any service takes place, and ideally before she commences employment, Sally should negotiate with her employer about the status of the individuals and organisations she works with, and clarify who the client is. Once she is aware of this, she can explain to each individual and group she works with what obligations she has to them regarding confidentiality and other responsibilities (this forms part of the informed consent procedure detailed below). It is important to note that payment and direct contact with the psychologist do not signify client status. For example, an organisation may employ a psychologist to work with its staff. If the psychologist is working directly with the staff to improve productivity in the workplace, the organisation is likely to be the client. If the psychologist is working with the staff to improve their well-being, the individual staff members are likely to be the clients. Both of these situations are ethically sound as long as all parties are aware of their status and its implications. However, it is vital that the psychologist works to inform all parties of their rights and responsibilities before any psychological services are provided. This process can be more difficult when one or many of the parties cannot or will not give consent. Chapter 5 will cover these situations in more detail.

Chapter 2: Competence, Confidentiality and Consent

Maintaining confidentiality While there is sometimes a preoccupation with breaching confidentiality in the ethical literature, psychologists should have an overriding focus on maintaining confidentiality for all clients. That is, in the vast majority of cases psychologists do not disclose any information provided by the client unless the client requests the disclosure. Standard A.5.1 of the Code sets out clearly that psychologists need to maintain the confidentiality of the information given to them by clients while collecting, recording, accessing, storing, communicating and disposing of the information.

APS Code A.5.1 A.5. Confidentiality A.5.1. Psychologists safeguard the confidentiality of information obtained during their provision of psychological services. Considering their legal and organisational requirements, psychologists: (a) make provisions for maintaining confidentiality in the collection, recording, accessing, storage, dissemination, and disposal of information; and (b) take reasonable steps to protect the confidentiality of information after they leave a specific work setting, or cease to provide psychological services.

Psychologists must do this for as long as the information is held, even if the psychologist leaves the workplace or retires (A.5.1.b). This means that psychologists need to either maintain possession of their records or hand over responsibility for them to another psychologist (see Chapter 11 for more details on the creation, storage and disposal of client records). Confidentiality will exist in some form even after a client’s death. As will be seen in Chapter 11, psychologists also need to make provisions to ensure the confidentiality of their records after their death. As part of the informed consent procedure (further detailed below), clients must be informed of the ways in which their information will be used and stored (A.5.3.b).

APS Code A.5.3 Psychologists inform clients at the outset of the professional relationship, and as regularly thereafter as is reasonably necessary, of the: (a) limits to confidentiality; and (b) foreseeable uses of the information generated in the course of the relationship.

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This explanation should be given before the client has provided any private or sensitive information. The client should be informed of how the information will be used by the psychologist and who, if anyone, will have access to that information. Clients expect confidentiality in the therapeutic relationship, so it is important to clarify this before any services are provided (McMahon 2008). Furthermore, if the relationship changes in some way or the service provision changes, the psychologist must inform the client if there will be any change to the confidentiality arrangement. The client would then need to consent to these changes before any further services could be provided. For example, a counselling psychologist is working with a client to reduce her anxiety about getting married. After a number of sessions the psychologist suggests that she might benefit from attending a group session that he runs for other clients with marital anxiety. In this situation the provision of the service to the client has changed specifically in relation to confidentiality. In the initial treatment session the client was only disclosing information to the psychologist. If the client was to take part in the group sessions she would be disclosing information to the psychologist and the other group members. In this situation the psychologist would need to fully inform the client regarding the confidentiality arrangement in the group setting. The client would then need to give consent again before she took part in the group sessions. Client confidentiality extends even to the extent of an individual’s status as a client. The APS (2007, p. 22) Guidelines on Confidentiality suggest that psychologists use a statement such as ‘I cannot comment either way’ when any request for information about a client is not authorised under the law or ethical codes. This is the case even if an enquiry is made about whether a particular individual is a client. In this way the client’s confidentiality is maintained; even his status as a client is protected. Ethically, psychologists should extend this concept further. If a psychologist was to encounter a client in the supermarket or at a sporting event, unless the client initiated contact, the psychologist should politely ignore the client or act as if she does not know him. This strong commitment to confidentiality needs to be explained to the client during the initial discussion about confidentiality in the professional relationship. Clients need to be made aware that this is a standard procedure to protect their privacy and that if they were to acknowledge the psychologist with a wave or a quick conversation the psychologist would respond. Psychologists and clients should also negotiate matters such as what address/phone number/email addresses to contact the client on and whether the psychologist can leave a message on voice mail. By discussing these matters psychologists can ensure that only individuals selected by the client have any knowledge of them accessing psychological services.

Breaching confidentiality As was pointed out above, psychologists should focus on maintaining client confidentiality. But there are a small number of situations when it may be ethical for a psychologist to breach client confidentiality (A.5.2).

Chapter 2: Competence, Confidentiality and Consent

APS Code A.5.2 Psychologists disclose confidential information obtained in the course of their provision of psychological services only under any one or more of the following circumstances: (a) with the consent of the relevant client or a person with legal authority to act on behalf of the client; (b) where there is a legal obligation to do so; (c) if there is an immediate and specified risk of harm to an identifiable person or persons that can be averted only by disclosing information; or (d) when consulting colleagues, or in the course of supervision or professional training, provided the psychologist: (i) conceals the identity of clients and associated parties involved; or (ii) obtains the client’s consent, and gives prior notice to the recipients of the information that they are required to preserve the client’s privacy, and obtains an undertaking from the recipients of the information that they will preserve the client’s privacy.

The fi rst and most common reason to breach confidentiality is as a result of a client request to disclose information (A.5.2.a). This would occur if a client requested that some information be released to a medical doctor. Psychologists may also ethically breach confidentiality when there is a valid legal obligation to do so (A.5.2.b). This may be in the case of a valid subpoena, court order or as part of a mandatory notification (see Chapter 12). The most complex reason for breaching confidentiality is to protect the client or identifi able third parties from harm, when there is no other way for the harm to be averted (A.5.2.c). This may occur if a client threatens to harm herself and the psychologist needs to take steps to protect her (see Chapter 7). The fi nal ethical reason for breaching confidentiality is in the course of supervision, consultation or training (A.5.2.d). When discussing clients in supervision, consultation or education, it is usually possible to do so without giving any information that identifies the client (A.5.2.d.i). If the client does need to be identified, she needs to give consent and the parties receiving the information need to be made aware of their obligations to keep the information confidential (A.5.2.d.ii).

Client request to breach confidentiality Clients may directly request a breach of the information that has been collected during the psychological service. For example, a client may request that certain details of his confidential information are disclosed to another medical professional for follow-up treatment or to a family member to assist with social support. If a client is still receiving a psychological service and requests that information be provided to a third party, it can be wise to discuss with him to whom and how information will be provided. Further, it can be wise to negotiate what aspects of the service provision will be disclosed (e.g. just the treatment of depression or all aspects of the marital breakup that the client is working through). Psychologists should also assist clients to evaluate the potential positive and negative outcomes of divulging confidential information gathered as part of the psychological service. Many client requests may come through third parties such as other healthcare professionals and the legal profession.

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The request must be signed by the client or the legal guardian. Psychologists should also verify as far as possible the authenticity of the request and only provide the information that is requested. For example, if a client through his GP requests a copy of a specific report, the psychologist should at least check that such a GP exists and ensure that only the specific report that is requested is provided.

Legal obligation to breach confidentiality There are a number of situations where a psychologist may be legally obliged to breach confidentiality. These could be in the form of a subpoena or warrant for access to files or for the psychologist to present information to a court. While psychologists are typically, and rightly, hesitant to disclose confidential information, there is in this case a legal and ethical requirement to do so (McMahon 2008). While a psychologist can request changes to the documents requested (e.g. a specific report rather than the whole file) or to the format (e.g. oral evidence in addition to the file) of the information he will need to comply with the court’s decision (APS 2012). Psychologists should always gain legal advice on the validity of any request and what, if any, information should be supplied. Government organisations may also present psychologists with legal requests for client records under their legislative powers. For example, Medicare may audit psychologists who provide services that are funded by Medicare; as part of this audit they may require access to client contact and treatment details (Jewell 2011). Similarly, AHPRA or other regulatory bodies may request access to files as part of an investigation or mandatory notification process (Davidson et al. 2010; PsyBA 2011b). Again, psychologists should seek expert and legal advice before responding to such requests. When third parties request access to a client’s confidential information, the psychologists should typically inform the client. In the case of a valid and legal subpoena, the psychologist will have to provide the information, but the client should be made aware of disclosure. The psychologist may also give the client some background on the process and point out that he is not breaching confidentially voluntarily but because of a legal obligation. This process may limit the damage done to the therapeutic relationship through the disclosure of confidential information.

Disclosure to protect the client or third parties There is recognition in the Code that psychologists may breach confidentiality to protect the client or third parties from harm (A.5.2.c). One of the issues to be considered here is the nature of the harm. Kämpf and colleagues (2008) have suggested that the focus should be on harm that may result in death or serious injury rather than less serious harms. The APS (2005) emphasises that the status of the potential victim should be taken into account. For example, the threshold to disclosing the risk of harm would be lower when the potential victim is a child or other vulnerable person. The type of harm and the capacity of the potential victim will form part of the decision-making process in evaluating whether to breach confidentiality. The decision-making process will also require a psychologist to evaluate the risk to the client and/or third parties against the negative impact of the breach of confidentiality on the relationship between the client and the psychologist. If a psychologist is confident that the risk is genuine she must ensure that she discloses only the relevant information to the

Chapter 2: Competence, Confidentiality and Consent

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appropriate individuals and organisations. Chapters 7 and 8 cover clients who pose a risk of harm to themselves and others in more detail. There are differing legislative requirements for psychologists to disclose confidential information on harm to third parties. Some states and territories in Australia require all persons to report criminal behaviour of a certain nature and/or suspected child abuse; in other states and territories these responsibilities rest with only certain qualified individuals. Therefore psychologists should ensure they are aware of the current requirements in their work location and be aware that these change over time and in each state. Psychologists should check the current government regulations and APS recommendations regularly to ensure that they are complying with current legislation. They should also consult with supervisors and experienced psychologists in their workplace to gain a better understanding of any specific legislation that may be relevant to their workplace.

Disclosure during consultation, supervision or education According to the Code (A.5.2.d.i), psychologists may ethically disclose confidential client information in the course of consultation, supervision or education when the identity of the client is protected. This entails protecting the confidentiality of the individual by not disclosing not only their personal information, but also any other information that may reveal their identity (e.g. disclosing that they have 15 children when there is only one family in the area that has 15 children). If psychologists need to disclose confidential personal or other information that would reveal the client’s identity they need to obtain the client’s consent. They also need to inform the persons receiving the information (e.g. students) that it is highly confidential and cannot be disclosed outside the immediate educational setting. However, wherever possible in supervision, consultation or education, psychologists should attempt to adjust the presentation of information to protect the confidentiality of the client (e.g. using pseudonyms and altering other aspects of the case).

Client confidentiality The confidentiality of client information is one of the key aspects of ethical practice. As was detailed in this section, however, there are occasions when it is ethical to disclose client information to protect the clients or others: when legally obliged to; at the request of the client; and in some limited circumstances for consultation or training. Given these exceptions, in the vast majority of circumstances psychologists should focus on maintaining confidentiality. Unless there is a client request to breach confidentiality, a psychologist should attempt to consult with experienced colleagues and/or gain legal advice before disclosing client information in non-emergency situations. Informed consent:

Informed consent When providing a service to any client, a psychologist must give a detailed overview of her qualifications, the service being provided, the confidentiality of the issues being addressed, the costs associated with that service, and how the service will end. When the client is aware of these factors he can make an informed decision about receiving the service. Consider the case study below.

When the client knows the psychologist’s qualifications, what is being provided, that confidentiality will be maintained, what the psychological service will cost and how it will end, she can make an informed decision about whether to receive the service.

CASE STUDY 2.3

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Bev is a counselling psychologist working in a private practice in suburban Hobart. She owns and operates the practice alone. Chen is a 30-year-old female seeking counselling for anxiety relating to her fear of flying. Bev is competent to provide this service based on her training and ongoing development. After arriving at the practice for the first time, Bev invites Chen into the counselling room and lets her know that before they can discuss her anxiety or began any therapeutic work they need to discuss how the professional relationship will operate. Bev is aware that clients can find this an uncomfortable initial process. Using a warm and comforting style, Bev explains the necessary details concisely and using language that is appropriate for Chen’s level of understanding. Bev begins by pointing out that the professional relationship between a psychologist and a client in practice is not as it is often portrayed in television programs and movies. Chen replies with a smile that she is happy to hear that since all the psychologists in movies seem to sleep with their clients. Bev briefly and genially explains that the Code of Ethics will form the basis for the services she will provide, and this will include the process of informed consent. Bev gives Chen a copy of the informed consent document before she attends the session and gives her time to read it. She discusses the document with Chen before the latter signs it. Bev explains that she will assist Chen to develop the skills and confidence to reduce her fear of flying and that the treatment will then stop, unless there are any other matters that Chen decides need to be addressed. Bev also explains that the treatment will probably take between five and ten sessions based on experience and research studies of the program she used. Each session will involve developing mental and breathing exercises that will help Chen feel more calm in anxiety-provoking situations around flying, and there will also be some homework. Bev informs Chen that there are other methods of treatment but they take longer and involve actual flying. Bev does not offer these services but can refer Chen if she wants to try them. Chen declines this offer as even the thought of flying makes her feel anxious. Each of Bev’s one-hour sessions will cost $120, and a portion of that may be covered by Chen’s private health insurance. Bev explains that Chen may feel some increased anxiety in the first few sessions but that this should decrease in the following sessions. Bev ensures that Chen is aware that she can stop the treatment at any time, but that if she stops before the end of the program, especially in the first few weeks, the anxiety about flying may permanently increase. Finally Bev explains that she will be taking notes and that Chen will be filling out some questionnaires and that all notes and records will be kept securely for seven years. Before Bev can continue Chen asks if anyone else will be able to see her records. Bev then fully details the issues covered in the earlier part of this chapter regarding confidentiality. Bev asks Chen if she has any questions. She does not have any. She agrees to begin the treatment and signs the informed consent documentation.

Chapter 2: Competence, Confidentiality and Consent

The core aspects of consent that are shown in the case study are taken from standard A.3.3 of the Code.

APS Code A.3.3 Psychologists ensure consent is informed by: (a) explaining the nature and purpose of the procedures they intend using; (b) clarifying the reasonably foreseeable risks, adverse effects, and possible disadvantages of the procedures they intend using; (c) explaining how information will be collected and recorded; (d) explaining how, where, and for how long, information will be stored, and who will have access to the stored information; (e) advising clients that they may participate, may decline to participate, or may withdraw from methods or procedures proposed to them; (f) explaining to clients what the reasonably foreseeable consequences would be if they decline to participate or withdraw from the proposed procedures; (g) clarifying the frequency, expected duration, financial and administrative basis of any psychological services that will be provided; (h) explaining confidentiality and limits to confidentiality (see standard A.5.); (i) making clear, where necessary, the conditions under which the psychological services may be terminated; and (j) providing any other relevant information.

These are the core elements of any informed consent procedure. The specific aspects of each of these items may vary depending on the field of psychology, but they will be present in some form for all psychology fields. For more detail on each of the points in A.3.3, please see Appendix A (an annotated version of standard A of the Code). While each of the points listed in A.3.3 need to be included in the consent process, it is also very important that the language and the communication media used are appropriate for the potential client (A.3.2).

APS Code A.3.2 Psychologists provide information using plain language.

For example, in Case Study 2.2, Bev may use a different consent information form for children and their parents, adults, and people from different cultural backgrounds. She may also use an audio version for people with vision impairment or with difficulties reading or writing in English. If Bev provides her services in several languages it will be important to have documentation available in those languages. In all these situations it is also important that Bev checks that the client has read and understood the consent form. This is why the client reads the consent form and Bev discusses it with the client as well. There is often a single signed inform consent document that sets out the basic conditions of treatment, costs and confidentiality of all services offered as the case study demonstrated

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(the Code A.3). However, informed consent is an ongoing process. Each time a tool, technique or service is used, the psychologist should discuss with the client why and how it will be used and what information will be gathered, together with how long it will take and if there are any alternatives. The client should then be offered the opportunity to accept or decline the service based on the described advantages and disadvantages. In this way clients are fully informed about the services they are being provided. When there is complex or lengthy service provision, additional signed consent is recommended. When there is the potential for physical contact as part of the legitimate service provision it is necessary to have signed informed consent (A.3.5).

APS Code A.3.5 Psychologists obtain and document informed consent from clients or their legal guardians prior to using psychological procedures that entail physical contact with clients.

The informed consent process is one of the most fundamental ethical concepts in psychology. It ensures that the client is aware of the risks and benefits of the service being provided and is participating voluntarily. There are very few situations when psychologists can provide services ethically without consent. This may occur as a result of an agreement between a client and the psychologist (A.3.1).

APS Code A.3.1 Psychologists fully inform clients regarding the psychological services they intend to provide, unless an explicit exception has been agreed upon in advance, or it is not reasonably possible to obtain informed consent.

For example, a hospitalised client experiencing severe delusions or hallucinations may  consent to a certain treatment option with his psychologist during a lucid period in his  condition. In this situation the psychologist would not need consent at the time of treatment as there was a prearranged treatment plan. When clients are incapable (e.g. severe cognitive impairment) or unable (e.g. children) the legal guardian of the client should give consent  ( A.3.6).

APS Code A.3.6 Psychologists who work with clients whose capacity to give consent is, or may be, impaired or limited, obtain the consent of people with legal authority to act on behalf of the client, and attempt to obtain the client’s consent as far as practically possible.

Chapter 2: Competence, Confidentiality and Consent

In these circumstances, and when working with clients who by law do not need to give consent, it is important to try as far as possible to inform them of the service being provided and obtain their non-binding consent (A.3.6, A.3.7). The specific issues relating to clients who cannot give consent are detailed in Chapter 5. There are very few situations where there is no legal obligation (A.3.7) of client consent before service provision (e.g. court-ordered assessment).

APS Code A.3.7 Psychologists who work with clients whose consent is not required by law still comply, as far as practically possible, with the processes described in A.3.1., A.3.2., and A.3.3.

When a psychologist believes that consent is not required by law he should gain expert advice from the legal profession and from experienced psychologists in the field, to ensure that his understanding is correct. Consent is a vital component and no service provision should occur until the client has consented to it except in the rare circumstances detailed above.

CHAPTER SUMMARY This chapter has described the three core ethical components of psychology. Competence: psychologists have adequate knowledge and skills in the services they are providing. Confidentiality: psychologists do not disclose confidential client information, even to the extent that an individual is a client, except in the very limited situations allowable under the Code. Informed consent: clients are aware of, and agree to, all aspects of the service being provided by the psychologists before any service provision occurs. If psychologists hold these three fundamental concepts in the highest regard, practice is more likely to be ethical.

QUESTIONS TO CONSIDER 1 2 3 4

In the case study of Sally, the school psychologist in this chapter, who do you think the client is? What technologies pose the greatest risk to client confidentiality? Are there any other competencies that are vital to psychologists in Australia? How can psychologists use technology to improve the informed consent procedure?

REFERENCES APAC (2010). Rules for Accreditation and Accreditation Standards for Psychology Courses. .

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APS (1996). Competencies of APS Psychologists. Melbourne: APS. APS (2005). Guidelines for Working with People who Pose a High Risk of Harm to Others. Melbourne: APS. APS (2007). Guidelines on Confidentiality. Melbourne: APS. APS (2011). Guidelines for Providing Psychological Services and Products using the Internet and Telecommunications Technologies. Melbourne: APS. APS (2012). When the Subpoena Comes: Managing legal request for client files. Davidson, G.R., Allan, A. & Love, A.W. (2010). Consent, privacy and confidentiality. In A. Allen & A.W Love (eds), Ethical Practice in Psychology: Reflections from the creators of the APS Code of Ethics. West Sussex, UK: Wiley-Blackwell, pp. 77–91. Epstein R.M., & Hundert E.M. (2002). Defi ning and assessing professional competence. Journal of the American Medical Association 287(2), 226–35. Jewell, P. (2011). The conflict between accountability and confidentiality in Medicare’s access to psychiatrists’ notes. Australian Psychiatry 19, 489–92. Kämpf, A., McSherry, B., Thomas, S. & Abrahams, H. (2008). Psychologists’ perceptions of legal and ethical requirements for breaching confidentiality. Australian Psychologist 43(3), 194–204. Mahoney, E.B., & Morris, R.J. (2012). Practicing school psychology while impaired: Ethical, professional, and legal issues. Journal of Applied School Psychology 28(4), 338–53. McMahon, M. (2008). Confidentiality, privacy and health information management. In R. Kennedy (ed.), Allied Health Professionals and the Law. Sydney: Federation Press, pp. 108–30. Neimeyer, G.J., Taylor, J.M. & Cox, D.R. (2012). On hope and possibility: Does continuing professional development contribute to ongoing professional competence? Professional Psychology: Research and Practice 43(5), 476–86. PsyBA (2010). Guidelines for 4+2 Internship Program: Provisional psychologists and supervisors.  . PsyBA (2012). National Psychology Examination Curriculum. . PsyBA (2011a) Guidelines on Continuing Professional Development. . PsyBA (2011b) Guidelines for Mandatory Notifications. . Spruiell, G.L., Hauser, M.J., Commons, M.L. & Drogin, E.Y. (2011). Clinicians imagine a patient’s view: Rating disclosures of confidential information. Bulletin of the American Academy of Psychiatry and the Law 39(3), 379–86.

3 Decision Assistance Model for Australian Psychologists

CHAPTER OBJECTIVES • • • • •

To highlight the importance of decision-making to ethical psychological practice To introduce the Decision Assistance Model for Australian Psychologists To highlight the key steps in the decision-making process To introduce the emergency version contained within the DA-MAP To provide a worked example of the DA-MAP

KEY TERMS Action phase APS code of ethics APS Ethical Guidelines (AEG) Checking phase Client

Decision assistance model Decision Assistance Model for Australian Psychologists (DA-MAP)

Ethical decision-making Mandatory notification

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Introduction With the breadth of the field in psychology, psychologists will face a range of clients, situations and challenges far in excess of most professions. The workplace roles and techniques a clinical neuropsychologist engages in will vary substantially from those faced by an Client: A person or persons organisational psychologist, for example. To indicate this, practitioners from receiving a psychological service that may involve both of these specialisations, and many others in psychology, have an teaching, supervision, overarching set of practice requirements set out by the Psychology Board of research, and professional Australia (PsyBA). These include numerous PsyBA guidelines, mandatory practice in psychology. notification requirements (see Chapter 12), the Australian Psychological Society’s Code of Ethics (which the PsyBA has adopted as the ethical code for Mandatory notification: the profession) and government legislation relevant directly or indirectly to The compulsory reporting by psychologists, and other psychologists. To negotiate these diverse workplace issues and situations, healthcare professionals together with broad and extensive practice requirements, psychologists need registered under AHPRA, a systematic process to deliver efficient and ethical services to all clients and of inappropriate conduct client groups. One of the key tools used to achieve this is a comprehensive yet in other practitioners such as intoxication or sexual flexible decision assistance model (many texts call it a decision-making behaviour with a client. model). Whichever term is used, the model presented in this chapter will help a psychologist to make a more informed decision, though the fi nal decision will Decision assistance model: have to be made by the psychologist using their skills and experience. While it A model whose purpose is to some extent an argument in semantics, it is important to focus on the key is to help a psychologist aspect, that it is the psychologist who will have the responsibility to make a systematically consider all aspects of an issue before decision rather than relying on the model. deciding on an outcome which is both ethical and focused on client welfare.

Ethical decision-making: The nature of the psychologist’s role means that difficult situations requiring complex judgment arise frequently and call for broad and extensive practice requirements. Psychologists need a systematic decision-making process to deliver ethical services to clients.

Ethical decision-making

The purpose of a decision assistance model is to help a psychologist systematically consider all aspects of an issue before arriving at an outcome that is both ethical and focused on client welfare. While some texts focus on the theoretical constructs underlying ethical behaviour, this chapter and  the decision assistance model will focus on the process required to develop ethical and client-focused decisions in an applied psychological context; we will put forward a model to assist all psychologists in their decisions. While some decision assistance models are specifically aimed at ethical dilemmas or specific fields of psychology, the model presented here is relevant to all psychologists and all forms of decision-making when working with clients. This can range from what intervention to use with a client to which student the psychologist selects to supervise. Given the range of decisions that psychologists now make that are regulated by AHPRA/PsyBA and the APS, a broad decision-making framework is needed. Many decision assistance models start by directing psychologists to identify if there is an ethical dilemma. This can be a difficult thing to do for psychologists in training and

Chapter 3: Decision Assistance Model for Australian Psychologists

those early in their practice career. Therefore this model allows all decisions to be evaluated using the decision assistance model, regardless of the nature of the matter being considered. Dilemmas about ethics, morals, the law and personal judgments can all be considered and resolved using the model. The decision assistance model provides psychologists with a mental or fully documented written process that they can engage in when making any decision. More complex or important decisions relating to clients should be documented in the client record.

The decision assistance model When psychologists face a complex decision, a decision assistance model can provide a systematic way of arriving at an ethical decision that supports the best interest of the client. If a psychologist is facing any of the situations below it is recommended that they employ such a model: • • • • • • • • • •

Are there competing ethical requirements or client interests? Are the psychologist’s moral, religious or values-based beliefs having an impact on their thinking? Are there legal obligations related to the decision? Are there certain circumstances in this decision-making situation that are influencing the psychologist to consider acting in an unusual way? Are there events in the psychologist’s life that are similar to the client’s issue? Is there a question of competence in working with a client? Is the psychologist struggling with objectivity? Has the client been receiving services for a lengthy period but not receiving the expected benefit? Does the service provision revolve around a value-judgment? Does the service provision revolve around religious or moral issues?

In these situations psychologists should engage in a formal decision-making process (using a decision assistance model) as part of the decision to provide services to the client, to work with a client in a specific situation, or as part of the service provided. If a psychologist engages in this process, ethical and client-focused decisions are more likely to be achieved. The key aspect of a decision assistance model is that it gives psychologists the framework to systematically consider all aspects of the decision to be made and to learn from that decision. But the model should also have enough flexibility that psychologists are not solely required to use checklists and can use their clinical judgment to assist in the decisionmaking process. While some decisions will be made on the basis of the requirements of the Code or the law, many others will benefit from the knowledge and skilled reasoning of the psychologist. This book presents the Decision Assistance Model for Australian Psychologists or DA-MAP as a tool specifically designed for psychologists working in Australia. The following section will briefly detail its framework and subsequent sections will examine each step in more detail and provide a worked example through some elements of the model.

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The Decision Assistance Model for Australian Psychologists The Decision Assistance Model for Australian Psychologists is made up of a checking phase and an action phase. It also contains an emergency decision-making model. As can be seen in Figure 3.1, the lower section of the decision assistance model (the action phase) is similar to most decision-making models and indeed to the way most people DA-MAP: is a specific make decisions. The upper section (the checking phase) highlights the specific decision assistance model that focuses on the issues required to be considered by psychologists in Australia. The emergency/ process required to develop time-sensitive version draws heavily on the main decision assistance model ethical and client-focused and can be seen in the white box located in the action phase. The overall model decisions in an applied aims to assist psychologists in making decisions in the best interests of their psychological context. clients while maintaining their legal and ethical obligations. Checking phase: is an important part of DA-MAP and helps the psychologist make his decision. The checking phase is about the acquisition of professional and ethical knowledge and should be a lifelong process developed over a psychologist’s career. Psychologists should start gathering this information and knowledge in their training and continue to build on it.

The checking phase

The checking phase is about the acquisition of knowledge and should be a lifelong process developed over a psychologist’s career. Psychologists should start gathering this information and knowledge in their training and continue to build on it over the course of their careers. Ethical and legal obligations will have been taught in the four to six years of formal training and will continue to be built upon through professional development. Workplace issues will vary according to the situation, but psychologists should familiarise themselves with the specific tools, resources, challenges and issues in their workplace before they commence employment or as soon as possible thereafter. Over time psychologists should also consider their personal/underlying ethical, values, moral and religious beliefs. They should be aware of the issues that they feel overly passionate or apathetic about. The psychologist’s reflections on previous decisions should feed back into their awareness of these issues. For example, if a psychologist found herself wanting to make value-based judgments or learnt about the ethical issues when working with a child with separated parents, this new self-reflection/knowledge would help inform the checking phase of future decisions. Through their ongoing learning and personal reflection, psychologists can gain the basic knowledge and awareness needed for the checking phase Action phase: is an of DA-MAP. When specific decisions need greater legal or ethical information important part of DA-MAP psychologists will have a clear understanding of their basic obligations and and helps the psychologist make her decision. It is can then focus on the specific issues relevant to the decision. The individual likely to be unique for each steps in the checking phase are detailed later in the chapter. decision that needs to be made. Each decision will require the consultation of literature specific to the client’s situation.

The action phase The action phase of DA-MAP helps the psychologist to make his decision. It is likely to be unique for each decision that needs to be made. Each decision will require the consultation of literature specific to the client’s situation. Even if the

Chapter 3: Decision Assistance Model for Australian Psychologists

same expert is consulted from a previous decision, the questions that the psychologist will ask should be specific to the decision currently being addressed. The consideration of the different potential paths of action will be different for each client, as each client will have his own specific issues and resources, as well as his personal strengths and weaknesses. As with the checking phase, previous decisions should help inform the psychologist about the action phase and how to work with the client and the specific service provision. The individual steps in the action phase can be seen later in the chapter.

Are the psychologist’s individual characteristics or perception of the client’s characteristics, interfering with the objective evaluation of the situation? No

Yes

Seek supervision to address these issues. Unless these issues are resolved ethical and client focused decisions will be difficult to achieve.

No

Yes

Is there clear (and non-conflicting) advice in the Code of Ethics or Ethical Guidelines? No

Yes

Are there workplace issues or physical limitations that make following this advice difficult?

No Yes

When there is a clear legal or ethical obligation, the psychologists should act in accordance with this. However, the psychologist should always attempt to maximise the client’s wellbeing whilst adhering to the legal or ethical requirement.

CHECKING

Is there a legal obligation for the psychologists to act in a particular manner?

Employ full decision making process

Consult with experts, peers and the literature Emergency decision making process

Consider past decisions

Evaluate and act

ɒ *HQHUDWHDUDQJHRIRSWLRQV – Including those suggested by experts /peers in the past – Consider all options including doing nothing ɒ &RQVLGHUSUHYLRXVGHFLVLRQV – Of psychologists – Regarding client/issue ɒ (YDOXDWHRSWLRQVDQGDFW

Review the decision after the outcome

Figure 3.1 Decision Assistance Model for Australian Psychologists

ACTION

Consider potential paths of action (guiding hypotheses)

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Are the psychologist’s individual characteristics, or perception of the client’s characteristics, interfering with the objective evaluation of the situation? To be objective in decision-making is extremely difficult for psychologists. When there are disruptions or events occurring in a psychologist’s environment, objectivity can be even more difficult to reach. If a psychologist is having difficulty considering the situation objectively, it will be unlikely that ethical and client-focused decisions will be made. If a psychologist holds strong views about social or personal issues it may influence her decision-making capabilities. For example, if an organisational psychologist were to believe that all individuals from a certain ethnic background would have difficulties in an Australian workplace, this would impact on all aspects of her interactions with clients from this group. Even if the psychologist used a decision-making model, this overriding prejudicial perception would influence all her decisions. There can be similar problems if a psychologist is experiencing a particular event in her life. For example, if a psychologist is in the processes of adopting a child, her perspectives on children, adoption, pregnancy and parenthood could be altered. When psychologists fi nd themselves in these situations they need to consider if their personal views or situations will adversely affect their interactions with clients. If there is that possibility they should seek supervision (professional counselling from another psychologist) to ensure that their own circumstances are not affecting their interactions with the client. If the psychologist is viewing the client’s circumstance or issues from a slanted perspective she should resolve these issues before working with a client. Once she is comfortable that she needs to make a decision that is not based on her subjective personal values, she should continue with the decision assistance model.

Is there a legal obligation? The fi rst step in addressing an issue or decision is the legal obligations that are relevant to psychologists. These obligations may stem from government legislation or previous court decisions that establish precedence. They include broad legislative issues such as defamation laws, privacy legislation and court orders/subpoenas. These considerations are relevant to many individuals in society, but psychologists should be aware of how these requirements impact specifically on them. They also need to consider legislation that is specifically aimed at healthcare professionals. Examples of this legislation include AHPRA’s mandatory notification requirements (see Chapter 12) and specific mandatory reporting of child abuse in some states (see Chapter 5). In these situations there is a clear legal requirement for a psychologist to take a particular course of action even if it breaches the Code; the psychologist must take the action that is legally required and discontinue the decision-making process. When psychologists must breach an aspect(s) of the Code to fulfil their legal obligations they should do so in a way that minimises the breach, and they should focus on protecting their client and third parties to the greatest extent possible given the legal requirements. For an example, see Case Study 3.1, which we continue throughout the chapter.

Dirk is a counselling psychologist predominantly working with couples. A couple that he provided counselling services to six years ago is now in the midst of a divorce that is currently in the court system. Dirk has received a subpoena to provide access to the client record from the counselling sessions. However, as part of the assessment and counselling procedure, he collected information from extended family members (with the consent of the client) to assist with developing a systematic view of the couple. Dirk feels that the disclosure of this information is not relevant to the case and may cause discomfort to the extended family members if it is made public in open court. Using the methods specified in the correspondence from the court and in consultation with independent legal advice, Dirk requested that the information provided by the third parties could be removed from the file before it was submitted to the court.

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In Dirk’s case the psychologist has attempted to meet his legal obligations while also attempting to conform to the ethical requirements of psychology (see APS 2012). It should be noted, however, that the court would be under no obligation to accept the The APS Code of Ethics: Is psychologist’s request and may require that all information in the file be the overarching document provided. Therefore, while the psychologist should attempt to meet his ethical that puts forward the minimum acceptable obligations and consider the best interest of his client, ultimately legal ethical standards for requirements may require a breach of confidentiality. psychological practice. It is also important to note that to effectively consider their legal obligations It provides guidance for psychologists and in decision-making, psychologists must be aware of these obligations. demonstrates to the public Chapters 5, 11 and 12 give details of some the key issues likely to be relevant to the required standards that psychologists should psychologists in Australia. adhere to.

Is there clear and non-conflicting advice in the Code of Ethics or Ethical Guidelines? When clear guidance is given in the APS Code of Ethics or the APS Ethical Guidelines (AEG), psychologists should act in accordance with this. Standard B.1.2.c of the Code states that to maintain competent psychological practice, psychologists must adhere to the Code and the AEG. Psychologists should also be mindful that on occasions there will be conflicting advice between standards or between the Code and the AEG.

The APS Ethical Guidelines: Designed to complement the Code of Ethics, they go into much more detail and contain more discussion of the issues. There are Guidelines on such issues as confidentiality, supervision and hypnosis.

APS Code B.1.2 Psychologists only provide psychological services within the boundaries of their professional competence. This includes, but is not restricted to: (c) adhering to the Code and the Guidelines;

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This means that to act competently psychologists need to be aware of and follow the advice given in the Code and the AEG. This is important because, under section 41 of the Health Practitioner Regulation National Law Act 2009, disciplinary proceedings can use the Codes approved by the PsyBA. As the Code, and the Guidelines through standard B.1.2.c, are approved by the PsyBA, a psychologist’s behaviour may be evaluated against these criteria (in addition to other AHPRA and PsyBA requirements) in disciplinary hearings. The AEG provides supplementary information that builds on the core standards in the Code. They cover such areas as working with culturally  a nd sexually diverse populations, children, and guidelines for assessment and research practices. In this decision assistance model, psychologists should follow the guidance of the Code or AEG if there is clear and non-contradictory advice. For example, the Code and AEG provide clear expectations on dual relationships, fi nancial dealings and record-keeping. In these situations psychologists should act in a manner that is consistent with the accepted codes and guidelines. However, there will be situations when clear advice or direction from the Code and/or AEG conflicts with the organisational requirements of the psychologist’s employer. In these situations psychologists should negotiate or discuss the conflict with their employer in an attempt to resolve the issue (Davidson 1999). In these situations it can be useful to complete the decision-making process in an effort to meet the organisation’s requirements while acting ethically. However, as standard B.12 of the Code points out, the psychologists must adhere to their ethical obligations within the organisational requirements of the workplace.

APS Code B.12 B.12.1. Where the demands of an organisation require psychologists to violate the general principles, values or standards set out in this Code, psychologists: (a) clarify the nature of the conflict between the demands and these principles and standards; (b) inform all parties of their ethical responsibilities as psychologists; (c) seek a constructive resolution of the conflict that upholds the principles of the Code; and (d) consult a senior psychologist.

In broad terms, psychologists should follow the direction of the documents that regulate psychological practice, but they should do so in a way that minimises any potential negative impact on clients. The codes and guidelines are designed to promote client well-being and do so in most situations. When there are potentially negative outcomes for clients, psychologists should ensure that they are doing everything ethically possible to minimise the harm to clients. Psychologists should also be aware that there will be situations where conflicts will exist between standards of the Code (or between the Code and the AEG). In these situations the full DA-MAP should be used. Consider the continuation of the case study below.

Before Dirk is to attend court or he provides any information, the husband in the divorce proceedings contacts Dirk through his new psychologist. He requests a copy of the report on his cognitive ability that was undertaken as part of the couples counselling but was conducted when his wife was not present, and a copy of the notes taken during the couples counselling on the husband’s depression and the methods they were using to reduce its severity. The new psychologist has a signed consent from the husband to access the files and states that these client records are needed for the husband’s ongoing care after a severe presentation of depression requiring hospitalisation. Dirk responds to the request and securely provides the new psychologist with a copy of the cognitive assessment. Dirk is concerned about providing the notes of the counselling session as both the husband and the wife were present and contributing to the sessions. He also feels that the information might be relevant to the husband’s ongoing care. He is unsure how to proceed.

When legal proceedings are taking place it is important for the psychologist to ensure that there are no court orders that would stop them acting in any way. If psychologists are given any such information, they should get independent legal advice before acting. If there was no legal issue, in the situation presented above, the Code and the AEG make it clear that clients should have access to contents of their record in most situations (see the Code A.6 and APS [2012] Guidelines on record-keeping).

APS Code A.6 A.6 Release of information to clients Psychologists, with consideration of legislative exceptions and their organisational requirements, do not refuse any reasonable request from clients, or former clients, to access client information, for which the psychologists have professional responsibility.

In this case the assessment report into the husband’s cognitive abilities is being provided to another psychologist who has the husband’s consent and will have ethical obligations regarding the report and the husband’s well-being. Therefore there is clear and nonconflicting guidance on the ethically required behaviour. In this situation, ethically, Dirk should provide the information on the cognitive assessment. However, the information relating to the discussion between the couple on managing the husband’s depression is more complex. Broadly, psychologists should not release information unless all clients who were involved in the service provision have consented to the release (APS 2012). In this case Dirk would only be able to release the notes taken in the couples session if both husband and

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wife consented to releasing the information. It would appear, however, that the information was needed to provide ongoing care to the husband and, broadly speaking, the Code and the AEG recognise that clients should have access to their records. In this case, it would appear that the Code and the AEG do not provide clear and non-conflicting advice. Therefore it is necessary to continue on with the full decision assistance model.

Seek advice from experts, other psychologists and the literature The next suggested step in the decision-making process is to discuss the issue or problem with colleagues or an expert in the field, at the same time taking adequate steps to protect client confidentiality. Depending on the decision or issue that needs to be considered, the psychologist should carefully gain advice from experts in the field. He should also consider the views of other psychologists in similar positions within the field. Online networks may allow him to gain international or culturally diverse perspectives. As well, he should consult the vast amount of published literature available when facing a difficult decision. A literature search can yield a wide range of materials from experts who it may not be possible to contact personally. Professional bodies often produce clear systematic resolutions to commonly occurring issues, which could possibly be modified to suit a specific situation. When consulting colleagues and experts, the psychologist should seek advice and input on the steps of the decision-making process that have already been completed, as well as the steps that are ahead of him. In this way he will have external advice from a professional who may have more objectivity about the situation. Experts and colleagues will bring different knowledge and experience that may be important in proceeding through the decision-making process. Experts are likely to have a broad overview of the situation and be able to highlight specific laws or regulations that are relevant; they may also be able to provide information on cultural norms that the psychologist is not aware of. Other psychologists are likely to be able to provide information based on their experiences in similar situations and within the same ethical regulatory environment. Single experts or colleagues should not be relied on exclusively; different issues and circumstances will often necessitate assistance from varying fields and individuals. The psychologist should always conduct his own investigation rather than relying solely on the views of others, as he is responsible for any decision made, regardless of the advice. Psychologists should discuss with peers the basic details of the decision to be made and confi rm that the psychologist’s perceptions of the matter are not being significantly influenced by their values or personal views on client characteristics. Experts can be useful in explaining the legal and regulatory issues involved. Experienced psychologists or academics may be able to provide detailed information on the ethical requirements of complex psychological practice. After discussing the initial steps of the decision-making process with peers and experts, it is useful to gain their suggestions for action. The psychologist must be mindful of the colleagues’ or experts’ knowledge of psychological practice and ethics, but they may provide suggestions that the psychologist would not have considered.

Since Dirk is unsure of the best course of action in relation to the husband’s records from the couples counselling, he seeks advice from experts and colleagues. All the people he speaks to agree that the confidentiality of the client records does raise important issues. He first obtains advice from an independent solicitor (i.e. not from the husband’s or wife’s lawyers). He is told that in this particular case there was no duty or court order that stops him giving the husband access to his records. The solicitor also suggests that releasing the information without the consent of all parties may be inconsistent with the Privacy Act. Advice from a senior psychologist confirms that, ethically, the release of joint records should only occur if both parties agreed. Dirk’s colleague suggests that he should check the original informed consent documentation (signed six years ago) to establish if there was any agreement about availability of information at a later date. A peer-level psychologist suggests that he should provide a summary of the material and with the husband’s consent approach the wife to approve it, and consent to its release, before he then provides it to the husband.

Consider the continuing case of Dirk. As can be seen in this example, experts and peers can provide different types of information useful to the psychologist in their decision-making. Psychologists should also add this knowledge to their future decision-making in the checking phase of the DA-MAP.

Consider potential actions and outcomes In this part of the decision-making process, psychologists need to develop possible actions or paths and evaluate them systematically. It is vital that the client and her specific characteristics, needs and individual differences are the focus of this process. Two clients receiving a similar service, presenting similar ethical difficulties for the psychologist, may require entirely different ethical decisions to maximise their outcome. For example, if a client has a closeknit supportive family, these family members could prove to be a valuable resource that may influence decision-making. If the client does not have a supportive family environment the psychologist may need to consider alternative support mechanisms. Therefore it is vital that the potential actions that a psychologist considers take into account the client’s individual situation—there should be no ‘default’ decision in psychology. When facing a situation of conflicting ethical requirements the psychologist should focus on resolving this conflict to maximise the client outcome while adhering to any legal or ethical requirements. When psychologists are attempting to make other decisions they should consider a broader range of options. They should fi rst set about developing a set of potential

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actions. This process should include actions that are impractical or unethical, as these may stimulate the development of ethically appropriate possibilities. In complex decisionmaking situations where the process is being documented, each option should be presented for evaluation in a manner that the psychologists prefers (e.g. written, diagrammatically, spreadsheets, decision trees). As long as client confidentiality is maintained, psychologists can discuss the issue they are facing with people from various professional or social settings to gain alternative viewpoints or opinions. Increasingly, psychologists are engaging with psychologists and other healthcare workers through electronic communication. This can be an ideal method of seeking advice or options for decision-making (although, see Chapter 2 about the possible lack of security in electronic communication). The experts and peers who were consulted in the previous steps may also have made suggestions that should be considered. A fi nal note is that, as with all aspects of decision-making, the psychologists will need to evaluate all advice personally before acting.

Consider the case of Dirk. In this step of the decision-making process, Dirk should generate as many possible actions as is practicable. These might include: • Do nothing • Release the records to the husband without the wife’s consent • Seek the wife’s approval for the release • Create a summary of the counselling records and seek approval from the wife for its release • Create a summary of the counselling records and release it to the husband • Refuse to release the records but offer to take the husband as a client • Disclose the husband’s information to the new psychologist but not to the husband.

Consider previous decisions that were similar to the one currently in progress In their current decision-making, psychologists should also consider previous decisions they have made. However, this is a highly complex process and includes scrutiny of any problem areas, blind spots or value-judgments that may have influenced the process. Psychologists should also consider any previous decisions involving the current client to learn about what has worked well with that client previously. Importantly, they should not attempt to use previous decisions in their entirety in current decision-making; each decision should be tailored to the specific needs of the client.

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Previous decisions by the psychologist

Dirk considers how he responded to cases such as this previously. He finds that when courts were involved he typically acted more cautiously. He finds that his usual inclination when there was a clash in ethical obligations was to give clients access to their information.

Previous decisions about the client It can be useful for the psychologist to consider the outcome of decisions she has made in regard to a client previously. If the psychologist has a sound understanding of how the client thought and behaved in previous situations, she can use this to make better decisions  in  the  future.  For  example, if a client did not respond well to a particular intervention  she  might use this information to make better decisions about future interventions.  However, psychologists should consider reflecting on the specific elements that did not work well with the client rather than the intervention as a whole. If, for example, a psychologist understands that a client did not respond well to homework or the client enjoyed observing the behaviour of others as a learning technique, she can tailor the intervention to the individual, but there should always be empirical support for the use of such a tool or technique with the particular client.

CASE STUDY 3.1, CONT.

Psychologists should evaluate their decision-making after each decision (detailed in the fi nal step below). This evaluation can then feed back into future decision-making. For example, if a psychologist regularly fi nds that she takes a certain position (e.g. using CBT) more often than other techniques and this results in negative outcomes for clients, she could take this into account in the current decision-making process. Alternatively, if clients have more positive outcomes when a certain colleague or expert gives advice on the decision, it could help her identify the elements of this person’s advice that complements her decision-making and how she could emulate this. The aim of this step is not to encourage psychologists to make the same decision every time. Its purpose is to help them understand more about how they make decisions. Once a psychologist understands that she has certain predispositions in decisionmaking, she can ensure that she takes this into account when making decisions.

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When engaging in this process it is important to remember that there will also be environmental, cognitive and random issues that will influence a client’s reaction to past decisions, and psychologists need to consider this. Understanding a client’s previous reactions can be useful but needs to be considered in context. If the client was in the process of withdrawing from drug use or suffering from a severe psychological disorder, his response to a previous decision could be a very poor predictor of his current reactions.

Since Dirk has not worked with the clients for six years, he should be very cautious about relying on previous information. While he is aware of the divorce proceedings and the husband being treated for depression, he is not aware of any other aspects of the former clients’ situation. However, Dirk may find information on their general responses to intervention. He may also find specific information on whether the couple added an agreement to the consent form that might influence his decision regarding the information gathered as part of the couples counselling.

Situational considerations It can also be useful to consider previous decisions on specific topics, services or issues. As was detailed above, if a psychologist can start to understand his own natural inclinations in decision-making, these can illuminate current decision-making. Does the psychologist tend to treat anxiety disorders conservatively and obsessive compulsive disorders in creative ways using new techniques? What is the impact of this on his clients, and can an awareness of this lead to better decisions being made for all clients? Through increased awareness of this, the psychologist can evaluate the empirical support for these techniques for different client groups and ensure that the best possible service is provided for each client. As shown above, the DA-MAP can be used for all forms of decisions by psychologists because many aspects of practice, for example advertising, are covered by the Code, the AEG and PsyBA/AHPRA regulations. This may include what psychological tests to purchase when starting a private practice or which office manager to employ. In these situations psychologists can use information from other purchasing or hiring practices to aid in decision-making. For example, does the psychologist usually base purchases on price? Does he only purchase commonly used tools? Or does he base purchases on psychometric

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In this case the specific issues to be considered would focus on confidentiality and working with couples. Is there a pattern in the psychologist’s decision-making regarding these issues? Does Dirk feel a stronger connection to a particular type of individual (e.g. wife, more aggressive partner) and does this influence his decision-making? How strongly does Dirk usually defend the client’s confidentiality? Does he view confidentiality as an important concept, or is it simply a necessity for the therapeutic relationship to exist? Through considering these issues Dirk will gain a clearer understanding of them as they relate to the decision being made in this case.

Evaluate options and act Given the options that have been generated and the information gathered from previous decisions, the psychologist is now in a position to make a decision. The overwhelming focus should be on ethical behaviour and client well-being. However, consideration for third parties, the safety of the psychologist and others, and the perception of the field of psychology should be taken into account where relevant. Given the particular circumstances, a psychologist will need to evaluate each potential action that was developed earlier in the model. This should be done by considering client outcomes (short- and long-term), ethical issues, third parties, the safety of all involved and of the broader community. Psychologists will need to consider the likely outcome of any decision and the potential positive and negative impacts on the individuals and groups detailed above. This process will require a systematic approach using the analytical skills and insights developed through formal training and practice. Psychologists will also need to draw on their knowledge of their clients and the key theoretical and empirical foundations of psychology. The decision-making process may involve formal documentation of each of the steps in the model; experienced psychologists may work through these steps automatically. Using a method such as this, however, psychologists should be able to make ethical decisions that promote the welfare of their clients.

CASE STUDY 3.1, CONT.

properties? By understanding these patterns, psychologists can make better decisions. In client-based decisions, psychologists should develop an awareness of their ‘favoured’ outcome and their reasoning for this, and critically evaluate the empirical support and the impact on client outcomes.

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Dirk then evaluates the options developed in previous steps in the decision-making process that related to the information requested by the husband in relation to the couples counselling: •

•

•

•

•

•

•

Do nothing – It is possibly ethical in this situation. Without the partner’s consent the information in the couples sessions should be kept confidential. Dirk also considers that in past decisions he was somewhat more likely to act conservatively when the courts were involved. He therefore takes this into account when evaluating this option. Release the records to the husband without the wife’s consent – Unethical. Given the situation, it is almost inevitable that Dirk would be reported and punished or reprimanded by a disciplinary board. Dirk is also mindful that during the counselling the husband had been an active and open part of the process and the wife had been more reserved. Dirk ensures that the different dispositions of the clients are not affecting the decision-making process. Seek the wife’s approval for the release – Ethical. However, Dirk would first need the husband’s approval to contact the wife. This might be difficult, depending on his condition, and the wife may decline the release. Create a summary of the counselling records and seek approval from the wife for its release. – Ethical. However, Dirk would first need the husband’s approval to contact the wife. This might be difficult, depending on his condition, and the wife may decline the release. Create a summary of the counselling records that excluded information that the wife provided in the couples session. – Ethical. However, in group and couples sessions this can be extremely difficult to achieve. Removing all aspects of the wife’s interactions and communications could render the remaining information meaningless. Refuse to release the records but offer to take the husband as a client or act as a consultant to his current psychologist. – While this may be ethical in some situations, Dirk does not have the skills to treat a client with severe depression, so this may not be an ethical option. There could also be the perception that Dirk is financially exploiting the client, which would be unethical. Verbally disclose the husband’s information to the new psychologist but not to the husband. – Technically this would still require the wife’s consent. However, if it was an emergency situation and the disclosure was needed to protect the client from serious harm it may be the best form of disclosure. It would protect the client from harm but limit the release and possible misuse of the information by the husband in the legal proceedings.

Chapter 3: Decision Assistance Model for Australian Psychologists

•

Verbally disclose the husband’s information to the new psychologist, but not the husband, with the wife’s approval. – This may be an overly complex outcome but it may prove to be the most likely to satisfy the ethical requirements of the psychologist, be approved by the wife and meet the husband’s needs.

Given the circumstances, Dirk seeks the husband’s approval to contact the wife in an attempt to get her to approve the release of the information in full, in summary or in verbal form. Given that, in this situation, most of the interaction was between the wife and husband during the sessions, the completion of a meaningful summary of the husband’s contributions in the sessions is not possible. If the wife refuses and the husband’s condition deteriorates to the point where the information is needed to prevent immediate harm, Dirk decides he will verbally disclose limited information to the other psychologist to protect the welfare of the husband. Without the wife’s approval or an emergency situation, Dirk will not disclose the contributions or discussions of the wife collected as part of the couples counselling.

Review the decision made The review process should have two phases. The first should be to review the decision-making process in relation to the particular client involved. This can then aid future decision-making in relation to that client. It also provides a method of evaluating the provision of a service where an evaluation is appropriate. By gaining more information about the client, his reactions to events and the overall outcome, better decisions can be made in relation to that client in the future. The second phase of the review should consider the psychologist’s actions and her involvement in the decision-making process. From this, a psychologist can develop a better understanding of her strengths, weaknesses and blind spots when making decisions.

Client review The client review would be part of the client confidential record. Initially, the client review can act as an outcome measure of the service being provided. If the decision-making process was being used to determine the best method of helping a client with his anxiety, the client review could help the psychologist to evaluate the success of the service. Through the decision-making process and the client records, the psychologist would be aware of the expected service provision and the client outcome. This could include the number of sessions, therapies or techniques used, the number of relapses, or any other outcome measure. If a psychologist was using the decision assistance model to determine the best course of action when faced with competing ethical obligations, the objective would be to maximise the client outcome while acting in the most ethical manner possible. With hindsight the psychologist could consider if the desired outcome occurred for the client. In the review process the psychologist should highlight those aspects of the service provision that worked well with the client and those that did not. She should also note any unexpected client reactions or behaviours and how these influence the outcomes. For example, consider a psychologist working with a client with an autism spectrum disorder. If the client displayed substantially more social interaction than was expected in the school

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CASE STUDY 3.1, CONT.

environment as compared to previous interventions at home, the next time the psychologist was making a decision with or about the client she would take into account the differing client behaviour in multiple locations. This information could prove very useful in future decision-making regarding the client.

In this situation Dirk will undertake only a limited review as there is no direct contact or service provision and the decision involves former clients. However, he will include a copy of the decision-making process documentation and copies of any correspondence, including any reply from the wife, in the client record. He may also make a note of the contact details for the husband’s new psychologists, Dirk will also note that the cognitive assessment report was provided to the new psychologists. Dirk will also be mindful of the fact that he may be required to present the client file to the court and appear as part of the divorce proceedings. He will keep copies of all correspondence with the court in the client file.

The psychologist’s review

CASE STUDY 3.1, CONT.

The psychologist’s self-review of the decision-making process would relate to her thinking and judgment. It would not be kept in the client’s confidential record as it would not contain specific or identifiable client information. The aim of this part of the review is for psychologists to gain a better understanding of themselves when they are engaged in decision-making. Through the review process they can gain a better understanding of their natural predispositions (e.g. risk-averse or creative), client presentations that they find difficult to work with (e.g. personality types, particular disorders) or social issues (e.g. divorce, religion). Once psychologists have an awareness of these issues they can pay particular attention to them and ensure that they do not have a significant influence on their future decision-making.

In his review of this decision process, Dirk may consider the eventual outcome and how he arrived at it. He should try to reflect on his thinking that led to the decision. Was there a particular action that was appealing to him despite the fact that it was unethical? Why was this action appealing? Dirk should also consider how the advice from others influenced the decision. Did they provide insights that Dirk was unaware of? How could Dirk work to develop these skills himself? Through this process Dirk can gain a better understanding of how his thinking influences his decision-making.

Chapter 3: Decision Assistance Model for Australian Psychologists

The decision-making model in practice The decision-making model that has been proposed in this chapter allows psychologists to make considered and meaningful decisions in all aspects of their practice. It emphasises the highly regulated environment in which psychologists operate and the range of decisions that are now regulated by the Code, the AEG and PsyBA/AHPRA requirements. The initial steps focus on psychologists making objective observations of their situation. Consideration of the legal and ethical requirements preceded the more flexible decision-making process, as these are the core behaviours that psychologists must focus on. Through the use of this method, psychologists are more likely to make decisions that are client-focused and ethical. One of the key issues with many decision assistance models is the time they can take to use. The model presented here can be completed quite quickly when there are peers and experts in the workplace; if the psychologist needs to contact external experts, the process may be more difficult to enact quickly. However, if there are important or complex decisions, psychologists should try to avoid making them without time to fully consider their outcomes. The main exception to this is in the case of emergency decision-making.

Emergency and time-sensitive decision-making Many psychologists will fi nd themselves in situations where there is limited time to make a decision. Some of these decisions will relate to clients at risk of immediately harming themselves or others (see Chapters 6 and 7 for more on these clients). In this situation the emergency decision-making relates to the psychologist deciding if there is a need to evaluate the client immediately or contact authorities, so that a full risk assessment can be completed. The psychologists may only have a few minutes to decide if the client requires a full assessment or is not at risk. Psychologists should always err on the side of caution in these situations and conduct a full decision-making process where possible. There are also a range of decisions that a psychologist will make every day that are time-sensitive. These may be things such as which cognitive assessment tool to use, how long before a client needs to be seen again, or even what type of coffee to have on the way to work. In these situations a psychologist needs to make a quick considered decision, not because these are emergency situations but for the sake of efficiency. If all of these decisions were put through the decision assistance process the psychologists would spend the entire day working through the model. In these situations it is suggested the psychologists use the brief version of the decision-making model, which can be seen in the white box in the action phase in Figure  3.1. This brief model gives psychologists a structure to make a quick decision. It is based on the above steps of considering potential paths of action, considering past decisions, and evaluating the possible paths of action and acting that are part of the full decision assistance model. This gives psychologists a very brief structure to work with when decisions must be made quickly. It relies on psychologists having a clear awareness of the legal and ethical obligations related to their field of practice, as these elements are not included in the model. As was emphasised above, the checking phase should be a careerlong process that allows the psychologist to be aware of the key legal and ethical issues in his practice. If the psychologist is unsure of the issues involved he should conduct the full decision-making process, gaining additional information from a range of resources.

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CHAPTER SUMMARY This chapter has set out a structure for psychologists to make decisions that are ethical and focused on the well-being of the client. It centres on the need to be comprehensive yet flexible. The Decision Assistance Model for Australian Psychologists allows for the psychologist’s knowledge and expertise to be used within the legal and ethical framework in Australia and encourages psychologists to gain advice from peers and experts. Further, it has a strong focus on evaluating decisions for useful information about future decisions. The model is made up of the checking and the action phases. The checking phase is a career-long process of self-awareness and knowledge of the legal and ethical obligations of psychologists. This becomes the basis on which all decision-making occurs. The action phase is the process of consulting, developing and considering potential paths of action and finally making and reviewing the decision.

QUESTIONS TO CONSIDER 1 2 3 4 5

How can psychologists gain an awareness of their personal/underlying ethical, values, moral and religious beliefs? What are the risks in seeking advice from peers, colleagues or experts? What factors might have influenced your decision in Dirk’s case? Would you have come to a different outcome in his case? Use the DA-MAP to make a decision about the following case: • Jill, a psychologist with several years’ experience, has been approached to provide professional services to a hearing-impaired client. The client has requested a cognitive assessment, which Jill is competent to provide. Jill is not sure if the potential communication difficulties pose a serious issue.

REFERENCES APS (2012). Psychologist’s records: Management, ownership and access. . Davidson, G. (1999). Advice for members whose employment raises matters that appear to violate the APS Code of Ethics. InPsych 21(2), 15. .

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4 Managing Professional Boundaries Ethics is knowing the difference between what you have the right to do and what is right to do. —Potter Stewart

CHAPTER OBJECTIVES • • •

To understand the potential risks in practising as a psychologist, especially in therapeutic work To be aware of different types of boundary breaches To gain knowledge of the Code in relation to how you should manage boundary issues

KEY TERMS Boundary crossing Boundary violation

Informed consent Multiple relationships

Suicidal ideation

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Introduction

CASE STUDY 4.1

The part of the APS Code of Ethics relevant to this chapter is General Principle C: Integrity. The chapter will cover the area of boundaries in professional psychology practice, an area of the utmost importance to psychologists. As with the other chapters in this book, this one will use case studies to highlight ethical issues from the various perspectives of the psychology specialisms. Whether the focus is rural or urban, children or adult, clinical or forensic, the authors will try to provide potential scenarios and show how to stay within the recommended guidelines. Under the banner of professional boundaries we will cover the various aspects of this topic. Avoiding multiple relationships, where a psychologist may be involved with the client in another domain, will be discussed, along with the issues surrounding boundary crossings, which can be acceptable in certain situations, and boundary violations, which can never be regarded as good practice. Within the therapeutic relationship between psychologist and client there is always a potential power imbalance—after all, clients can be vulnerable, hence the reason they are seeking help. Non-exploitation of the client should always be at the forefront of professional practice and, as will be discussed later in this chapter, sexual relationships with clients are a clear abuse of practice.

Felicity Childs is a registered general psychologist who works with adolescents and adults, and rents an office in a large set of suites in Melbourne. Marjorie Hands has the office next door and provides massage therapy, specialising in remedial stress-reduction techniques. They have got to know each other fairly well and are known to enjoy a glass of wine at the iconic Esplanade Hotel in St Kilda on a Friday afternoon. Both Felicity and Marjorie have decided that they could boost their respective businesses and help their clients by cross-referring. For example, while a client is receiving a massage she may discuss some psychological issues, which might mean that a referral to a psychologist is in order. It follows that a client working with Felicity may be urged to seek some remedial stress reduction at Marjory’s practice across the hall. Clients seem to have appreciated this service and there is some anecdotal evidence that this is, indeed, the case (see the section ‘Boundary crossings and violations’ below for a specific discussion of this case).

Dr Jim Robinson has been a practising clinical psychologist at Coogee Beach in Sydney for around 15 years. He specialises in traumatic event recovery, especially in situations of domestic violence. By all accounts he is popular with his clients and he is regarded as being very good at what he does. On a visit to his favourite beachside coffee shop Latte Pronto, he bumps into Jennifer who, until about 18 months previously, had been one of his clients. They share a coffee together and Jennifer talks about how well the recovery has gone and says that she feels Jim has done a marvellous job and she has completely recovered. Jennifer is so happy that she insists on paying for coffee and invites Jim out for dinner the next evening, but only to thank him, she says clearly. They subsequently met for dinner and the situation developed into a romantic relationship. They have been dating for the past six months. According to friends, a trip to the Elvis Chapel in Vegas may be on the cards.

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As we go through the different sections we will refer back to these case studies and discuss how the different situations evolve and the implications for the psychologists in relation to the Code.

Multiple and dual relationships As we all know, the psychologist is in a position of trust and power when working with clients in our various fields, whether that be a sports psychologist working with a football team on motivation, a clinical psychologist working with a client who has generalised anxiety disorder, or an educational and developmental psychologist trying to improve students’ attributions for success and failure in learning. According to the APS Guidelines, Multiple relationships occur when a psychologist, rendering a psychological service to a client, also is or has been: a)

in a non-professional relationship with the same client;

b)

in a different professional relationship with the same client

c)

in a non-professional relationship with an associated party; or

d)

a recipient of a service provided by the same client. (APS 2008a, p. 98)

Multiple relationships: Multiple relationships occur when a psychologist providing a psychological service to a client may also have had or is having another kind of relationship with the client. The APS guidelines give several examples of this, one of which is that the psychologist is ‘a recipient of a service provided by the same client’.

The role can vary but the position of trust transcends any difference in psychological practice. As expressed in previous chapters, there are many parts of the Code that make us aware of the need to ensure we maintain ethical practice. In this chapter and, specifically, in this section, the topic requires psychologists to be aware of the potential conflicts in the therapeutic relationship that may occur if the psychologist and his peer supervisor do not carefully monitor multiple relationships. The Code directs us to show respect to our clients and this is outlined in the box below.

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APS Code A.2 A.2 Respect A.2.1. In the course of their conduct, psychologists: a) communicate respect for other people through their actions and language; b) do not behave in a manner that, having regard to the context, may reasonably be perceived as coercive or demeaning; c) respect the legal rights and moral rights of others; and d) do not denigrate the character of people by engaging in conduct that demeans them as persons, or defames, or harasses them.

In a 2011 study Anderson and associates asked whether or not it was acceptable to play basketball with your client. They highlight different points and perspectives about whether this can ever be regarded as ethically sound behaviour, but the rurality issue was prominent. There is a difference between rural and urban situations in the likelihood of dual or multiple relationships. In the city it is arguably more straightforward to avoid these situations, as there are many opportunities to avoid the need for a dual relationship to exist; for example, in cities there are more book or sports clubs, so there is less excuse for these relationships occurring or continuing. Hammond (2010) relates a story of a psychologist who arrives at a dinner party with her husband and ends up being placed across from one of her clients. The psychologist and the client had not discussed what they should do if they met by accident. This is always a recommended conversation in your fi rst session with a client so that if the scenario does occur, being ignored by either party will not be offensive—never mind the story that you or the client might be forced to make up to avoid an embarrassing situation if you met in a supermarket with your partner. Returning to the dinner party story, in order to avoid a boundary violation the psychologist promptly left, making what would seem like a lame excuse to her husband as she could not disclose the real reason even to him, because this could have been a breach of confidentiality. Dual relationships can occur in many different environments. In a workplace you could be employed as the organisational psychologist also be a middle manager to various colleagues. In situations such, as this conflicts could arise if you are conducting performance development as well as giving counselling to the same person. This would be problematic and should therefore be avoided. In social situations, you may discover you are a regular in the same drinking establishment as a client and, in a one-pub town, it would be difficult to avoid this conflict. In an urban situation, however, it would be easier to avoid this type of scenario by attending a different bar. In a slightly different case you would not agree to take on a client who is also in your social network unless it was either an emergency or there was no alternative service available. It is very possible that you will be approached by a friend or family member at some point about an issue that they have. If they are seeking your advice as a psychologist you must be ethically aware of the situation. The family Christmas party is usually a time of drinking, crying, fighting, reconciliation, and inevitably more drinking (or perhaps that was just Chris Boyle’s experience growing up in the mean streets of Glasgow). Nevertheless, you

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are approached by your uncle and you discuss serious psychological issues. He knows that you are very skilled in working with suicidal ideation, and in your conversation he confides to you that he has experienced such thinking. It transpires that your uncle is Suicidal ideation: The idea seriously considering harming himself and that he cannot speak to any other that a client entertains of member of the family. Ordinarily, crossing this particular boundary would be taking his own life. extremely problematic in that your objectivity may be compromised. However, the APS Guidelines (2008a) are very clear on this: ‘It is only in the absence of other feasible options and when harm is imminent if action is not taken, that psychologists provide a psychological service to family or friends’ (p. 95). In this particular scenario one can understand why a psychological service should be provided to the uncle, but it would be advisable to urge the uncle to see a recommended psychologist as soon as feasible, since it would not be suitable to continue this relationship for any longer than was necessary. As we have mentioned, although they should be avoided where possible, dual relationships may at times be inevitable. The following is a list of possible strategies that should be considered if you fi nd yourself in such circumstances. 1. 2.

3.

4.

5.

Clear boundaries should be set at the outset of any intervention so that the Informed consent: When the client knows client is aware of the potential difficulties of such a position. the psychologist’s As with general good practice, and in order to protect yourself as well as the qualifications, what is being client, you must receive informed consent from the client as to what your provided, that confidentiality psychological intervention entails. This should be a written document (contract) will be maintained, what that would highlight some of the issues inherent in a dual relationship. the psychological service will cost and how it will end, A written contract or agreement is the optimum position, but other methods she can make an informed may be employed depending on the circumstances. A tangible document decision about whether to can always be produced at a later date if required. A note of an agreement receive the service. (in whatever format) should be made contemporaneously, in the case file. As mentioned in Chapter 2, the psychologist should be receiving supervision and this particular situation requires that a specific discussion takes place. If a direct supervisor is not available, then a senior colleague should be consulted on the potential problems. Taking advice in one of the formats in point 2 affords the opportunity to consider and identify problems that may arise in the client–practitioner relationship. Again, good practice dictates that you would take full notes and ensure all documentation is in good order. Alongside a senior colleague and/or your supervisor, you would ensure that your practice is constructively scrutinised, arguably more so than normal, because of the specific issues that dual relationships can bring to the therapeutic connection. In such a situation, reflecting on your own practice is necessary and you should constantly ponder the benefits of maintaining the relationship. Is it clearly the client who is still benefiting or has this altered so that the psychologist is the main beneficiary? If it is the latter, then steps would need to be taken, along with the supervisor, to address this and thus ensure that the client experiences no harm through the psychological intervention.

A cautionary tale about a psychologist’s poor management of boundaries and unprofessional conduct was heard by the Victorian Civil and Administrative Tribunal after a psychologist was brought to the attention of the Psychologists Registration Board of Australia (2008). Even though this is in the public record, it is given here as an example

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of how a dual relationship can end up being less than ideal. We will call the psychologist Dr Linecross and his client, Jessica. It is worthwhile for the reader to consult the full document (see reference list) and gain full details of all the events that led to Dr Linecross having his registration suspended. Jessica was receiving therapeutic intervention from Dr Linecross for depression, anxiety and issues with her self-esteem, particularly when in relationships with men. During the therapy she would discuss her place of work. Dr Linecross applied for a job at the same workplace (even sending his application to Jessica, whose job was to process these applications) and was ultimately employed at that fi rm. During the course of his employment he was still treating Jessica as her psychologist. He would attend some work social events, which were reported by both parties as being professional between them. One of the main areas of complaint against Dr Linecross was that of what Jessica regarded as inappropriate texts. They arranged many of their appointments by text message. It is reported in the Tribunal documents that these text messages became more casual during a two-year period but eventually Jessica terminated the therapy, as some of the emails were directly sexual and others inappropriate for other reasons. One text sent from Dr Linecross, which is quoted in the tribunal documents, is ‘I understand your [sic] probably angry and disappointed, however I wonder if you can fi nd it in yourself to put.  .  .this behind us, and reconsider’. In this particular case it is the content of the message that was the problem, rather than the mode of communication. This description is based on an actual case but only limited details of a complex set of circumstances are presented here, so that you get the gist of it; full details are contained at Psychologists Registration Board of Victoria v Pallini (2008). It is unlikely that Dr Linecross set out to behave unethically but this case shows the dangers of creating dual or multiple relationships and not managing them ethically. If we consider applying for a job at a client’s work, this is clearly folly on the psychologist’s part, especially when it is known that he would have direct contact with his client in his new employment, in a role that was not a part of their therapeutic relationship. The argument for applying for this type of position and thus putting the therapeutic relationship under strain would be affected by matters such as the size of the company (in a very large company the chances of interaction with the client are drastically reduced), the location of the company (maybe there are many branches in locations different from the client’s), or rurality (if there are only a few employers of that type then this dual relationship maybe unavoidable). Another obvious error in judgment in Dr Linecross is to have conversational contact with his client through text messages, as this can lead to a casualisation of the therapeutic relationship. Even though it might seem like a reasonable thing to do, making appointment scheduling easier for you and your client, professional barriers must be maintained. If you are working as a sole psychologist without reception facilities it can be harder to arrange appointments, but email is still an easy way to keep in contact for both psychologist and client and can be kept to a professional dialogue. Dr Linecross failed to manage the boundary between him and his client, thus increasing the probability of professional difficulties. So, in short, it is the professional nature of the communication, whatever the mode, that is the key to appropriate ethical contact between client and psychologist. Multiple relationships with your clients should be avoided if at all possible, but if they are in existence measures should be taken to ensure they are properly managed. The next section considers boundary breaches between the psychologist and client and suggests ways to avoid difficult situations.

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Boundary crossings and violations This section considers problems that arise when boundaries between the psychologist and the client are crossed and violated. Figure 4.1 gives a graphical representation of the difference between boundary crossing and violations. A boundary crossing is generally regarded as being a departure from commonly accepted practices but one that could Boundary crossing: potentially benefit clients. An example of this is a client who is an avid football A boundary crossing is fan but who experiences bouts of social anxiety. By attending a match and generally regarded as being carefully managing the situation there is an excellent opportunity to offer a departure from commonly accepted practices but support to this client as a part of a therapeutic intervention. The client would which could potentially pay for this session at the match and the psychologist would record the benefit clients. intervention in the client record. A violation of professional boundaries is a severe breach that damages the therapeutic relationship and inevitably results Boundary violation: A boundary violation of in harm to clients and is therefore unacceptable and unethical. Examples of professional boundaries is a these are taking a client out for dinner or attending a client’s Christmas party severe breach that damages with her family. In the previous section, the case of Dr Linecross is an example the client–psychologist of a clear boundary violation. As is shown in the APS Guidelines (APS 2008a), therapeutic relationship and inevitably results in harm seemingly small violations can lead to more serious breaches; this is known to clients and is therefore as the slippery slope phenomenon and is discussed in more detail later in the unacceptable and unethical. non-exploitation section of this chapter.

BOUNDARY CROSSING A boundary crossing is a departure from commonly accepted practices that could potentially benefit clients

Good Ground Example: Your client has severe bouts of social anxiety and is an avid football fan. By attending a match as part of a paid treatment session, there is an excellent opportunity to offer support to this client as a part of a therapeutic intervention.

A boundary violation is a serious breach that results in harm to clients and is therefore unethical. Example: Slippery Slope — where seemingly small violations (as above) can lead to more serious breaches, e.g. dating the client, relative of, Christmas dinner with the family.

Figure 4.1

Example of a boundary crossing

Dodgy Ground

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I am not sure how many of you are familiar with the music of the Beach Boys, a US band who were one of the most popular bands in the world in the 1960s and 1970s, whose lead singer was Brian Wilson. He became quite unwell with depression for many years and eventually his friends and family enlisted the help of ‘psychologist of the celebrities’ Dr Eugene Landy, a licensed clinical psychologist. This story is quite well known and there are various sources throughout the internet on it, but Woo (2006) provides a good summary. Landy’s therapy, for which he coined the phrase ‘24 hour therapy’, meant that he was constantly working with his client and ultimately controlled Wilson’s life. This went on for a number of years and there have been several allegations that Landy was receiving excessive payments and had fi nancial control over Wilson’s affairs. Ultimately, Landy lost his licence to practise in California in the late 1980s because of what was regarded as exploitation of his client. During their therapeutic relationship Dr Landy became Wilson’s business manager and also co-wrote much material for a solo music album of Wilson’s. This was a clear breach of the ethical code, and the wellbeing of the client did not seem to be paramount in the psychologist’s thinking. There is a 30-second YouTube clip (www.youtube.com/watch?v=G-K-n5op9nI) of Brian Wilson and Dr Landy that is worth watching. You will notice, among other things, that Landy has his arm around Wilson, which seems to be wholly inappropriate in a client–psychologist relationship. If we consider the Code regarding conflicts of interest (see the Code C.3 below) it is clear that Landy violated many of these points and his objectivity with his client was seriously impaired.

APS Code C.3 C.3. Conflict of interest C.3.1. Psychologists refrain from engaging in multiple relationships that may: (a) impair their competence, effectiveness, objectivity or ability to render a psychological service; (b) harm clients or other parties to a psychological service; or (c) lead to the exploitation of clients or other parties to a psychological service. C.3.2. psychologists who are at risk of violating standard C.3.1., consult with a senior psychologist to attempt to find an appropriate resolution that is in the best interests of the parties to the psychological service. C.3.3. When entering into a multiple relationship is necessary due to over-riding ethical considerations, organisational requirements, or the law, psychologists at the outset of the professional relationship, and thereafter when it is reasonably necessary, adhere to the provision of standard A.3. (informed consent) C.3.4. Psychologists declare to clients any vested interests they have in the psychological services they deliver, including all relevant funding, licensing and royalty interests.

The Dr Eugene Landy and Brian Wilson situation is an extreme version of what can happen when there are boundary violations, which can quite often begin with innocuous boundary crossings. The APS Guidelines (APS 2008a) point out that the psychologist should be aware that

Chapter 4: Managing Professional Boundaries

an erosion of professional boundaries could be taking place. They suggest that a simple set of questions will help the psychologist to determine if a boundary violation may be in danger of occurring. These questions that the psychologist should ask himself are as follows: 1.

Am I operating within my limits of competence?

2.

Am I avoiding any topics?

3.

Am I showing any uncharacteristic behaviours?

4.

Do I have discomfort with boundaries?

5.

Am I self-disclosing more than usual?

6.

Am I taking into account any current personal difficulties?

7.

Is there the possibility of a conflict of interest developing? (APS 2008a, p. 92)

Power imbalance As we have discussed before, the vast majority of the client group for whom we provide psychological services can be vulnerable, so we have to beware of the power dynamics that exist in therapeutic relationships. If we return to Case Study 4.1, in which psychologist Felicity Childs and massage therapist Marjorie Hands make recommendations to their respective clients to seek each other’s services, we can see that this puts the client in an awkward situation. It may leave the client feeling vulnerable and feeling obliged to follow the psychologist’s advice even though she might not require the alternative service or have the means to pay. The question here is that there is potential for exploitation and coercion of the client because of the power dynamic. Can this recommendation to see another professional be based on the client’s best interests? It does not seem so. Case Study 4.2 has Dr Jim Robinson in an arguably more potentially vulnerable situation as there is at least a concern regarding a power imbalance between him and Jessica, his former client. Even though 18 months have elapsed since the last session, the powerful position that Dr Robinson was in with regard to treating Jessica cannot be discounted. This is one of the reasons that the APS Code states that there should be at least two years from the last session and then only after the vulnerability of the client is discussed in full with a supervisor or senior colleague, should an intimate relationship be considered (see the Code C.4 quoted in the next section). When a there is a power imbalance there is always the possibility that clients can be in a position where they are potentially vulnerable even though they might not be aware of it themselves. The box below shows what is expected of the psychologist in considering the welfare of his clients. The main points are that of (b), (c), and (g) in that the onus is on the psychologist to ensure that any decisions that are made do not lead to a potentially exploitative situations, whether of a sexual nature as was the case with Dr Robinson (Case Study 4.2), or a conflict of interest in relation to a business issue as was the situation with Felicity Childs.

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APS Code B.3 B.3. Professional responsibility Psychologists provide psychological services in a responsible manner. Having regard to the nature of the psychological services they are providing, psychologists: a) act with the care and skill expected of a competent psychologist; b) take responsibility for the reasonably foreseeable consequences of their conduct; c) take reasonable steps to prevent harm occurring as a result of their conduct; d) provide a psychological service only for the period when those services are necessary to the client; e) are personally responsible for the professional decisions they make; f) take reasonable steps to ensure that their services and products are used appropriately and responsibly; g) are aware of, and take steps to establish and maintain proper professional boundaries with clients and colleagues; and h) regularly review the contractual arrangements with clients and, where circumstances change, make relevant modifications as necessary with the informed consent of the client.

The Felicity Childs case would also imply that there was a serious danger that the objectivity of the psychologist was greatly compromised. Furthermore, the arrangement that the two practitioners had would mean that Ms Childs, having received a referral through that method, would be unlikely to properly assess whether a psychological intervention was indeed necessary. If the psychologist continued on, deciding that this was not necessary, despite the arrangement with massage therapist Ms Hands, it could be argued that the reputation of at least one of these practitioners could be harmed. However, this may be a moot point as the issue is about whether objectivity can be maintained in any situation where there is a conflict of interest or a power imbalance. Of course, the primary issue is that the psychologist should do no harm to the client. The final word on this is that psychologists ought not to engage in this sort of relationship. Certainly there is a conflict of interest. A professional link-up with a massage therapist may start introducing business matters and undermine the therapeutic relationship. Also, it is very likely that client referrals to and from this other therapist may be driven by self-interest rather than the client’s best interest. Finally, how would you know how good the massage therapist is? Are there better ones? There is nothing unethical in suggesting that a client may consider an intervention in another area such as yoga or the like, but this is only ethical if there are no conflicts of interest and it is a clinically based and thus professional piece of advice to your client. Normally you would recommend about three professionals of that type rather than just one. At least the power is with the client, who is in a much better position to make an informed decision about whether to take the advice of the psychologist and from whom to buy a service.

Chapter 4: Managing Professional Boundaries

Non-exploitation of a client This is one of the areas where the Code is particularly clear about certain expectations when working with clients. As can be seen from the box below, there is no room for manoeuvring with regard to this aspect of the Code, nor should there be. We, as psychologists, deal with a vulnerable group and we are in a trusted and privileged position, so it is essential that we practise with integrity and respect. As well as the specific points contained under General Principle B: Integrity, cognisance should also be given to the need for psychologists to ‘take steps to establish and maintain proper professional boundaries with clients and colleagues’ (APS 2007, p. 20).

APS Code C.4.3 C.4. Non-exploitation C.4.1. Psychologists do not exploit people with whom they have or had a professional relationship. C.4.2. Psychologists do not exploit their relationship with their assistants, employees, colleagues or supervisees. C.4.3. Psychologists: (a) do not engage in sexual activity with a client or anybody who is closely related to one of their clients; (b) do not engage in sexual activity with a former client, or anybody who is closely related to one of their former clients, within two years after terminating the professional relationship with the former client; (c) who wish to engage in sexual activity with former clients after a period of two years from termination of the service, first explore with a senior psychologist the possibility that the former client may be vulnerable and at risk of exploitation, and encourage the former client to seek independent counselling on the matter; and (d) do not accept as a client a person with whom they have engaged in sexual activity.

Inherent in the Code is the need to protect and recognise the vulnerability of clients. The potential for exploitation is greater than for other professional and client relationships because of the nature of the service we provide: help with feelings, general cognitive functioning, bereavement and suicide, among others. Any form of relationship would attract a power imbalance and that should be avoided at all costs. The most obvious potential for exploitation is that of a sexual relationship with a client where the level of emotional interaction is high, thus carrying a serious risk to the client when the situation inevitably goes awry. This is why it is clear in most professional codes of ethics that a sexual relationship with a current client is prohibited (in some US states this is also illegal; Koocher & KeithSpiegel 2008). The Code 4.3.a stipulates that any form of sexual relationship with relatives or people who would be regarded as being close to the client is also prohibited. It is important to note that psychologists ‘engaging in sexual misconduct in connection with the practice of

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the practitioner’s profession’ is one of the mandatory notification conditions under AHPRA (PsyBA 2010, p. 2; and see Chapter 12). The main reason for this is so that a power relationship does not develop, in that a relationship with the best friend of a client may lead to difficult situations and may mean that the client has less support from either the friend or the psychologist, which may affect the treatment’s effectiveness. Poor judgment is evident in the psychologist who breaches the Code in these situations; the question would be whether the psychologist who allows herself to be compromised in this way could be regarded as acting in the best interest of the client. The Code is also very clear about previous clients and anyone closely associated with that client. It is obvious from the APS Guidelines on this area that any form of sexual relationship with a former client is not a good idea, even though it is allowed under certain circumstances (outlined in the Code C.4.3). If a former client requires psychological services, but he has started any sort of non-therapeutic relationship since concluding the psychological service, he is going to be at a disadvantage because he will need to fi nd a new psychologist. Relationships with anyone closely associated with the client can also be problematic for the client. Consider the impact on an 18-year-old client if his psychologist started any form of close relationship with the young man’s mother. Would the client suddenly feel uncomfortable being open and honest with his psychologist? If we consider Case Study 4.2 of Dr Jim Robinson, what seemed to be a fairly innocuous meeting ended up being much more than was originally intended—after all, what harm can having a cup of coffee with a former client have? This situation is known as the slippery slope phenomenon (Gabbard 1996), when what can seem like an innocent set of events ultimately leads to a serious breach of the Code, and is depicted in Figure 4.2.

Coffee

Dinner

Dating = potentially exploitative relationship and is a breach of the Code

Figure 4.2

Dr Robinson’s slippery slope

In this scenario Dr Robinson has innocently bumped into Jennifer, a former client, and had coffee, but as is implied by the slope metaphor, this event can quickly become something more significant. Having a sexual relationship with a former client does not necessarily mean a breach of the Code, as you can tell from the Code C.4.3. However, Dr Robinson has not taken

Chapter 4: Managing Professional Boundaries

steps to ensure that his former client is psychologically able to fully consider the consequences of this course of action, notwithstanding that his relationship with Jennifer began less than the required two-year period between finishing the professional relationship and the beginning of something further. The main point is that by embarking on a relationship with his former client, Dr Robinson is immediately depriving her of any future professional help from him. It was clear that Jennifer felt that the psychologist had really helped her, so there is the possibility that if there were a recurrence of her original problems she would not be able to seek professional help from the person whom she felt had provided a sound psychological service. The APS Guidelines specifically state that having a sexual relationship with a former client, even after two years, ‘negate[s] the possibility of the client resuming the professional relationship with the psychologist, to the possible detriment of the client’ (APS 2008b, p. 102). The psychologist’s actions in and out of the therapeutic relationship are built on the premise of non-maleficence to the client, and it can be seen that in this example this is a potentially harmful situation to the client. It is not difficult to understand why there are important ethical considerations in place before a relationship with a former client would be able to proceed, after the stipulated twoyear period since the termination of psychological service. But the psychologist is required to seek advice from a senior colleague to ensure that the client is not in a state of vulnerability and that her future psychological well-being will not be affected. It would be fair to say that having a sexual relationship with a former client is not advised under any circumstances. For example, the Royal Australian and New Zealand College of Psychiatrists (RANZCOP) does not allow its members to have sexual relationships with either former or current patients under any circumstances. According to the APS Guidelines on the Prohibition of Sexual Relationship with Clients (APS 2008b), the main reasons why the restrictions are in place are paraphrased as follows: • • • • • •

Clients who are involved in a sexual relationship with their psychologist ‘are frequently adversely affected by the experience’. If a psychologist becomes involved with a client his objectivity and ability to therapeutically interact with the client is severely impaired. Under no circumstances can sexual contact ever be a legitimate part of therapy. The client–psychologist relationship is built on trust. A sexual relationship impinges upon that trust. Due to the nature of the client’s vulnerabilities (reasons for seeking psychological help) the psychologist is de facto exploiting that client. A sexual relationship with a former client ‘may be exploitative given the previous power differential’ that existed in the previous professional relationship.

The relationship between the psychologist and the client is fiduciary, and any form of relationship with the client has the potential to be exploitative and a breach of that trust. The clients that we work with must always be considered as being vulnerable and we, as psychologists, have to be willing to understand the potential damage that can be caused, directly or indirectly, to the client. Especially with regard to a psychologist having sexual relations with a client, the latter is in a position to be much more damaged as a result than the former. We have a duty to protect the well-being of the client and that must always be our primary focus in the therapeutic alliance between psychologist and client.

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CHAPTER SUMMARY This chapter has shown the importance in maintaining proper professional boundaries with clients and understanding that the clients we work with are potentially vulnerable by the very fact of their seeking psychological intervention. We should never engage in a sexual relationship with a current client and we should avoid engaging in a sexual relationship with a former client. As we discussed with the case study of Dr Jim Robinson, who began dating his former client, this is permissible but must be after two years of an intervention and after appropriate consultation at supervision. Dr Robinson was dating the client after 18 months, a clear violation of the Code. Multiple and dual relationships can be acceptable between a client and a psychologist but only in certain circumstances. They should be avoided if possible but in certain situations, such as rural environments, they could happen. In such cases they must be carefully managed and monitored.

QUESTIONS TO CONSIDER 1

2

3

4

In Case Study 4.1 the psychologist and massage therapist engaged in cross-referring. What should be considered to ensure that these types of business relationships are ethical and that the clients’ interests are always at the forefront of any referrals? Why does the Code advise avoiding multiple or dual relationships if possible? What steps should be taken if such a relationship exists to ensure that the client is not exploited? Dr Jim Robinson, clinical psychologist, was involved in a relationship with a former client. What steps should he have taken to ensure that he complied with the Code in this regard? Anderson and associates (2011) raised the issue of whether you should play basketball with your client. Obviously they were making a general point about dual relationships and if these are ever appropriate. What steps should you take to avoid harm to the client if a multiple relationship is unavoidable? Consider both rural and urban scenarios in your response.

REFERENCES Anderson, R., Pierce, D. & Crowden, A. (2011). Should we play basketball with our patients? Professional boundaries and overlapping relationships in rural Australia . A paper presented at the 11th National Rural Health Conference, 13–16 March 2011, Perth, Australia. APS (2008a). Guidelines for Managing Professional Boundaries and Multiple Relationships. Melbourne: APS. APS (2008b). Guidelines on the Prohibition of Sexual Relationships with Clients. Melbourne: APS. Gabbard, G.O. (1996). Lessons to be learned from the study of sexual boundary violations. American Journal of Psychotherapy 50, 311–22.

Chapter 4: Managing Professional Boundaries

Hammond, S. (2010). Boundaries and multiple relationships. In A. Allan & A. Love (eds), Ethical Practice in Psychology: Reflections from the creators of the APS Code of Ethics. Chichester, UK: Wiley, pp. 103–22. Koocher, G.P. & Keith-Spiegel, P. (2008). Ethics in Psychology: Professional standards and cases (2nd edn). New York: Oxford University Press. PBA (2010). Guidelines for mandatory notifications. . Psychologists Registration Board of Victoria v Pallini (Occupational and Business Regulation) [2008] VCAT 2632 . . Woo, E. (2006). Eugene Landy, 71: Psychologist criticized for relationship with troubled Beach Boy Brian Wilson. Los Angeles Times.

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5 Working with Clients who Cannot or Do not Give Consent

CHAPTER OBJECTIVES • • • • •

•

To understand the potential impact of a client’s age and ability on informed consent and confidentiality To be aware of the ethical issues relating to consent when the client is under 18 years of age To be aware of the issues involved in working with older, young and other clients who may not be able to give consent To understand the issues associated with clients whose service provision is court-ordered To be aware that even if the individual the psychologist is working with is not the client, he or she is still fully informed in regard to the service provision and the issues relating to confidentiality. To understand the ethical issues in psychology that relate specifically to client age

KEY TERMS Client Confidentiality Court order service INconsenting adults

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Informed consent Legal guardian Mandatory reporting of child abuse

Mature minor Minors

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Introduction Chapter 2 detailed the sometimes problematic question of determining who is the client and described the typical informed consent procedure. It also emphasised the importance of the informed consent procedure as it sets out the rights and responsibility of all Client: A person or persons parties. However, when the client cannot legally give consent (e.g. children or receiving a psychological service that may involve impaired adults) or not give it voluntarily (e.g. court-ordered assessments), the teaching, supervision, ethical issues are more complex. In these situations psychologists need to research, and professional carefully navigate the issues of consent and confidentiality to ensure that all practice in psychology. parties are aware of the situation and their rights and responsibilities. This chapter will focus on the ethical issues of working with individuals who are Informed consent: receiving psychological services but are potentially incapable of giving When the client knows the psychologist’s consent or do not give consent.

Clients who cannot give consent

qualifications, what is being provided, that confidentiality will be maintained, what the psychological service will cost and how it will end, she can make an informed decision about whether to receive the service.

Psychologists in most fields of psychology will work with some clients who cannot legally give consent. These can be children who have not developed the required cognitive abilities to understand and make informed decisions about their involvement in psychological services. There are also adults who through injury, agerelated decline or temporary condition do not have the cognitive abilities and/or emotional stability to make informed decisions. For some of these groups their inability to make informed decisions will be lifelong, and well-established procedures may be set up by their guardians. For other individuals, their impairment is temporary and procedures will need to be implemented to facilitate the informed consent procedure. Whether the impairment is temporary or lifelong, however, if a client cannot give consent, a legal guardian will have to make any decisions about psychological services rather than the person receiving the service. The only exception is in the case of emergency care, when consent may not always be necessary. In this situation it is ethical for a psychologist to provide care to a client without consent if the client’s presenting issue is so serious (e.g. risk of serious harm to himself or others) as to need immediate attention. When working with individuals who cannot give consent it is important that psychologists are mindful of competing priorities. For example, parents may have different and/or competing ideas about the psychological services that should be available to their child. If the parents are separated the matter can become even more complex: there could be court involvement or differing views between the parents. However, the psychologist should focus on the welfare of the individual she is working with (APS 2009, 2.3). That is, the well-being and the psychological health of the young person or adult who cannot provide consent should be given a higher priority than the legal guardian if they are in conflict. This may mean that the psychologist does not provide the service requested by a parent because of concerns for the child. However, through communication and negotiation the psychologist should try to develop a solution that all parties can agree to and benefit from.

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Working with young people Minors: Generally minors are regarded as persons under 18 years of age and therefore not legally able to make decisions about psychological treatment. The exception is someone classed as a mature minor. Confidentiality: In a therapeutic relationship between psychologist and client, certain details are protected and should remain confidential between the parties. Legal guardian: A person appointed by a court to act legally on behalf of another person who is deemed to be vulnerable.

When working with minors (young people under the age of 18 years), there are additional ethical issues that need to be considered. The most important one is, who in the service provision is granted the status of client? When working with young children (0–8 years), it is their legal guardian who will be the client. Therefore the responsibility for all decisions is with the parent and the psychologist owes her obligations (e.g. confidentiality) to the parent. When working with older children (8–14 years) there should be some negotiation between the psychologist and the parent to develop an agreement regarding confidentiality and consent in the relationship between the child and the psychologist (APS 2009). For young people over the age of 14 years, psychologists will need to consider if the young person is capable of making her own decision or if her legal guardian is still needed to consent to the service provision. Psychologists also need to consider the status of the parental relationship. If the parents are separated or there are court orders in place regarding the custody or guardianship of the child, the psychologist will need to consider the implications of these matters before commencing any service provision.

Working with children (0–8 years)

When working with young children (0–8 years), the legal guardian of the child (typically parents) is the client in relation to the psychological service (APS 2009). This means that all rights and responsibilities typically associated with being the client lie with the parent of the child the psychologist is working with. Therefore it is the parent that consents to any service provision to her child and the psychologist owes all confidentiality obligations to the parent not the child. However, as standard A.3.6 of the Code suggests, psychologists should also attempt to gain the consent of the child.

APS Code A.3.6 Psychologists who work with clients whose capacity to give consent is, or may be, impaired or limited, obtain the consent of people with legal authority to act on behalf of the client, and attempt to obtain the client’s consent as far as practically possible.

This may be in the form of explaining the process of what is going to occur as part of the psychological service provision and letting the client know that she can stop whenever she wants to. Technically, however, it is the parent who has the right to stop the service provision, though if the child is unwilling to be involved it may be very difficult for some service provisions to occur at all. In this situation it is crucial that the psychologist is communicating with the parent to clarify the issues involved in the child’s desire not to be involved. The child’s cognitive and emotional state also needs to be considered. Also, fi nding out if the child specifically does not want to be part of the service provision, or if the child is shy or unable to

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understand the process, will be important in determining consent. However, it again needs to be stressed that in this age group it is the child’s legal guardian who is the client.

Working with older children (8–14 years) When a psychologist is working with older children, the concepts of consent and confidentiality become more complex. By this age many children are starting to develop their own sense of self and are interacting with the world around them with increasing independence. In the therapeutic setting, however, it is still the parent who is considered the client (APS 2011). That said, it will be vital for the effectiveness of any service provision that the psychologist and the legal guardian discuss these issues and potentially develop an agreement to allow some level of confidentiality between the child and the psychologist (APS 2009). This may be in the form of a signed agreement detailing the conditions under which the psychologist can maintain confidentiality with the child. For example, in the case of a 12-year-old child displaying problematic behaviours in the classroom, the parent and psychologist could negotiate an agreement about confidentiality. They may agree that all communication between the child and the psychologist would remain confidential unless the client made specific reference to drug use, sexual behaviour, self-harm or suicide. The child would also be made aware of this arrangement (in language he could understand) and thus could decide whether or not to raise these issues. In this way the child would be free to discuss most issues with the psychologist, knowing that she would not disclose any information to his parent unless it related to one of the areas set out in the agreement. However, a parent is under no obligation to develop or approve such an agreement. Regardless of any agreement, it is still ethically acceptable (the Code A.3.6) for the psychologist to discuss with the child, while being mindful of his age and understanding, the details of the psychological service, why it is occurring, what other treatment options there might be, and the limits to confidentiality (both the requirements in the Code and any arrangements with the parents). In this way, while the child is not formally consenting to the service provision he is still aware of the risks and benefits of the service, what is expected of him and the level of confidentiality. He can then decide what level of communication and openness he will provide to the psychologist.

Mature minor (14+ years) When working with a young person the key issue that needs to be clarified is the ability of the young person to give consent. Adults over the age of 18 years are presumed to have the ability to make informed decisions, and at the age of 15 years and above individuals can obtain their own Medicare card (DHS 2012). Young people between 14 (approximately) and 18 years of age may have the ability to make informed decisions about access to psychological services (McMahon 2006). It would be an unusual situation where anyone under the age of 14 could be considered a mature minor and more likely that those aged over 16 are Mature minor: A person considered mature enough to make their own decisions (APS 2011). However, who is under 18 who can chronological age alone should not determine mature minor status in Australia make an informed decision about giving consent to (Department of Health Western Australia 2009). When working with young treatment or psychological people in this age range, psychologists need to evaluate whether the young assessment. person has the ability to understand the risks, benefits and complexities of the

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service potentially being provided. The complexity of the presenting issue and the client’s decision-making that led to this situation may give the psychologist key information about the client’s maturity. For example, if a young person is seeking treatment for problems that are, in part, related to his extreme risk-taking behaviour or his inability to link actions with consequences, it may indicate a lack of maturity in decision-making. If the client is seeking treatment for a severe psychological disorder, a psychologist will likely require a higher level of maturity than if a basic service provision is to take place (APS 2009). If the young person is considered to be the client, all rights and responsibility will rest with the young person, not his parents. However, if he is not considered mature enough to make these decisions, it is his legal guardian who is technically the client (APS 2009; Jifkins 2011). The APS Guidelines for Working with Young People points out that the following matters should be considered when assessing the ability/maturity of a young person to make informed decisions: the young person: • • • • •

can understand the nature of the proposed psychological service; can understand the benefits and risks of the proposed psychological service; can understand the consequences of receiving or not receiving the proposed psychological service; has the capacity to make an informed choice; and can understand the limits to confidentiality. (APS 2009, p. 186)

CASE STUDY 5.1

The importance of these considerations comes from the proceedings in the High Court in Re: Marrion (1992). Psychologists need to consider these matters when deciding if a young person can be considered the client and have the rights and responsibilities associated with it. Consider Case Study 5.1.

Philippa is a 15-year-old female who has sought out the services of Suli, a psychologist, who is employed by a charity organisation involved in job placement in inner Sydney. As part of his role, Suli uses assessment tools and interviews to screen clients’ potential suitability for job vacancies and help clients apply for positions. Suli also offers advice on training and skills development to help clients improve their vocational opportunities. During the intake procedure Suli discovers that Philippa is only 15 years old. Before continuing with the informed consent procedure Suli explains that since she is under 18, he might not be able to complete the assessments and job placement assistance without parental approval. However, he explains that there are some circumstances when he would be able to provide the services but will need to ask Philippa some questions first. He asks Philippa why she is looking for employment. She explains that she has had a difficult relationship with her parents and is trying to get a part-time job to earn some extra money to show them that she is responsible enough to get her learner’s permit, something her parents don’t think

Chapter 5: Working with Clients who Cannot or Do not Give Consent

she should do. Suli asks Philippa what she believes the job placement process might involve. She replies that she has already Googled the organisation and the website said that people looking for work usually do some tests and interviews to work out what sort of jobs they should do. When asked if she thinks that everybody who used the service got a job straight away, she replies that she knew that a few of her friends had been looking for a job for a while but hadn’t got one. They had used lots of services like this, so she guessed it was a combination of being a good fit for the job and being a bit lucky to be in the right place at the right time. Finally, Suli asks Philippa what she thought her parents would think of her being at the job agency and why she didn’t think that it would be appropriate for them to be involved in the process. Philippa replies that she thinks her father would be happy that she was trying to get a job but her mother still thinks of her as a little girl and tries to control her behaviour. She wants to go though the application process without their input but would discuss it with them before actually accepting any position. She feels that in this way, if she got a job offer, it would be through her efforts alone.

In this simple and low-risk service provision it would appear that Suli could consider Philippa to be capable of consenting to the psychological service. In a case like this, the psychologist would need to use his clinical skills to evaluate the honesty and the intent of the interaction and responses from the young person. He would need to consider if the young person was attempting to deceive, or was interacting in a genuine manner. Any time psychologists are trying to determine a potential client’s maturity they need to be aware that they cannot conduct any formal assessment because this would require consent. In the case above, the psychological service was relatively low-risk; in the case of higher risk (e.g. depression, schizophrenia) the psychologists may require a higher level of maturity or be more confident about their assessment of the young person’s decision-making ability before considering them to be mature enough to make their own decision. In more complex cases the experienced psychologist should use his clinical skills to assess the ability of the young person to make her own decisions. These cases will be unique and the psychologist will need to consider the presentation of the client as well as her ability to deal with the psychological issue. Also, the psychologist may take into account the supports that the young person has around her in dealing with a more complex psychological issue. The psychologist might also take into account non-family support. The decision to consider a young person a mature minor is not a simple one. There are several considerations a psychologist will need to take into account. However, if the psychologist does consider the young person to be capable of making her own informed decisions and designates her as the client, all rights and responsibilities rest with the client (APS 2009, A.5.2.3). The psychologist then cannot disclose information to any other individual or organisations, as the consent provisions in the Code dictate and the agreed terms in the informed consent process. This would also be the case if a client began receiving services from the psychologist at a young age (not capable of making informed decisions) and continued to receive services until she reached the maturity of being able to make informed

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decisions. At this point the psychologist would need to inform all parties that the young person was considered the client and not the parent. In both these situations parents or legal guardians may not be comfortable with this arrangement, believing that they should be making the decisions for their child and maintaining the family unit (Joyce 2010). When the psychologist has not met the parents but decided that the young person is mature enough to make her own decisions, he needs to ensure that he does not disclose information about the client to any unauthorised person. This would include not disclosing to the young person’s parents, if they were to contact the psychologist, that the young person was receiving psychological services. If the psychologist was still seeing the client, he would inform the parents of the unauthorised person’s contact and discuss if the client wanted this person to have any involvement in the psychological service. When a young person has been seeing a psychologist with the parent as the client and the psychologist judges that that she is now capable of making her own decisions, a more complex discussion will need to take place. The psychologist will need to discuss with all parties why this decision has been made and the implications of it for all parties. This can be a complex area and there is the potential for substantial conflict between the parties involved. It can become more complex when the service provision occurs within larger organisations such as schools. The section below covers some of these issues. It is vital that psychologists have a clear understanding of the ethical issues involved in the consent of service provision to young people and communicate these to the relevant parties in an appropriate manner. Early-career psychologists or those involved in complex situations should consult with supervisors and experts in the field to develop their competencies in working with young people.

Parental relationship When working with children it is important for psychologists to consider the relationship status of the parents. It is relevant from a service provision perspective (e.g. are both parents actively engaged in the behaviour treatment program?) as well as from a consent perspective. Psychologists should discuss with parent(s), when it is the parent(s) rather than the child who are giving consent, the legal status of decisions about the child. Unless there are court orders pertaining to the custody of the child, both parents will have parental responsibility, even if the material relationship has been dissolved (APS 2009). It is ethically sound to ask a parent before the provision of services to a child, who cannot give consent, if there are any court orders or legal proceedings that are relevant to the custody of the child (APS 2009, 3.6). If there are existing court orders the psychologist must abide by any judgments in regard to parental rights relating to the child. The only exception would be in the case of emergency care to ensure the physical well-being for child or identifiable third party. The APS Guidelines also point out that when there are no court orders, a parent that engages, pays for, consents to and/or seeks the psychological service for the child can be assumed to have the legal ability to do so. This can legally occur without the knowledge of the other parent (APS 2009, 3.7). From an outcome perspective and in ideal ethical circumstances both parents would be aware of the psychological service and would support it. In some circumstances this is not possible or even desirable (Jifkins 2011).

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Avril is an 11-year-old girl with school refusal. Avril’s mother has taken her to see Pete, a developmental psychologist. In the preliminary discussion Avril’s mother tells Pete that she will only go ahead with the treatment for Avril’s school refusal if Avril’s father is not informed. Pete asks about Avril’s living arrangements, because part of the typical treatment for school refusal involves intensive routines and preparations before the child leaves for school each morning. Avril’s mother informs him that they all live together, but that Avril’s father thinks that her school refusal isn’t a major issue. His view is that Avril’s mother should just leave her daughter alone to get over her problems about school.

In this case there could be substantial obstacles to the implementation of any form of treatment without the involvement of both parents. This would be the case even if Avril’s parents were separated and Avril was having the same problems when leaving either parent’s house. However, if Avril was only anxious when staying with one parent, it might

CASE STUDY 5.2

When the psychologist is aware of a dispute regarding the treatment between parents who are not separated, or one parent specifically asks that the other parent is not informed of the service, the psychologist will need to carefully consider the situation before proceeding (APS 2009, 3.11). In this situation the well-being of the child should be the psychologist’s primary concern. If the child is clearly in need of urgent care or if the service was very low-risk and brief, the psychologist might be more likely to provide the services despite the potential or actual objection of the other parent. If the service requested was an extensive educational assessment that was both time-consuming and non-urgent, the psychologist might engage in discussions with the parent requesting the service, and the potentially unhappy parent if they have been directly in contact, to discuss the matter. It is beneficial to have both parents supportive of the service provision because if they are not they are unlikely to implement any interventions or suggestions that are part of the psychological service. When the parents are divorced or separated, without specific court orders in place regarding health/medical decision-making, and one parent requests psychological services for the child, that parent is typically considered to have the legal authority to do so (APS 2009, 3.9). As part of the informed consent procedure, the psychologist should clarify with the parent seeking the psychological service what if any involvement the other parent or step parents have in the service (APS 2009, 8.1). If the parent requesting the service directs the psychologist not to disclose any information to the other parent, the psychologist is obliged not to disclose this information (Jifkins 2011). When any parent seeks psychological services and does not want the other parent involved or made aware of the service provision, the psychologist will need to discuss and clarify some issues before the service begins. For example, consider the case of Avril.

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be possible not to have the involvement of the other parent. In extreme situations, bearing in mind the child’s well-being, the psychologist might refuse treatment until the parents have resolved their differences (Jifkins 2011). The psychologist would also need to discuss with the parent requesting the service whether the child would have to keep the sessions a secret from the other parent. Depending on the age and psychological state of the child, this could be extremely stressful for the child and lead to increased discomfort, in addition to the presenting issues. The psychologist would also need to consider the impact on all parties if the child did let the other parent know of the service provision (APS 2009). Depending on the type of service being requested, the psychologist would need to consider all aspects of the relationship between the child, the parents and the psychologist, understanding the increased complexity if the parents are separated, and determining what if any form of service provision is in the child’s best interest. These matters would then need to be discussed and negotiated with the parent(s). However, the primary focus would be the welfare of the child. It is important to note that the issues raised in this section only apply if the young person is not capable of making his own decisions (see Mature minor section above). If the young person is capable of making his own informed decisions, and is considered the client, then no information would be disclosed to either parent unless there was a prior arrangement (see the section below on other age-related issues) or the client requested the disclosure.

Mandatory reporting of child abuse A fi nal important matter when working with young people is mandatory reporting of child abuse. In Australia, mandatory reporting of child abuse relates to the legal requirement in some states for psychologists to report actual or suspected child abuse to the Mandatory reporting of appropriate authorities. Mandatory reporting should not be confused with child abuse: The legal requirement in some mandatory notifications, which relate to psychologists, and other healthcare Australian states for professionals registered under AHPRA, reporting inappropriate practitioner psychologists to report conduct (intoxication, sexual behaviour with a client, impairment or actual or suspected child departures from professional standards) to AHPRA (see Chapter 12). The APS abuse to the appropriate authorities. (2012) states that there are differing requirements for each state and territory in Australia in relation to who is required to report child abuse and what forms of abuse must be reported. Psychologists must be aware of their legal requirements in the location of practice. This matter is covered in more detail in Chapter 8. Even without mandatory reporting requirements, there are very few instances in which it would be ethically acceptable not to report the suspected abuse of a child or other INconsenting adults: Adults who are incapable vulnerable person under the Code. of consenting to service provision, not unwilling to do so. These adults may be legally allowed to make decisions but a psychologist may have some concerns about their ability to make informed decisions.

INconsenting adults While adults are presumed to be capable of consenting to receive psychological services, there are a small number of individuals over the age of 18 years who psychologists may need to consider as INconsenting adults. This means that they are incapable of consenting to service provision, not

Chapter 5: Working with Clients who Cannot or Do not Give Consent

unwilling to consent to it. In many cases these adults are legally allowed to make decisions but a psychologist may have some concerns about their ability to make informed decisions. INconsenting adults may have lifelong or brief psychological impairment that results in their inability to give consent. Their impairment may be from an acquired brain injury, a personality disorder, age-related cognitive decline, etc. or a combination of these issues. For many adults with a lifelong inability to make informed decisions such as consent to psychological services (and a wide range of legal and medical issues), courts or tribunals may have appointed a legal guardian. Their legal guardians will have developed a process of giving consent and could be well aware of the issues related to it. The guardians will have legal documentation that establishes their status as the INconsenting adult’s legal guardian. For INconsenting adults who cannot give consent, someone with the legal authority to do so will be considered the client and make decisions for the INconsenting adult. The legal situation in each state and territory is different in relation to guardianship. Psychologists should be aware of the relevant issues in their practice location. For more information psychologists should consult their State Department, the Federal Department of Health and Ageing (www.health.gov.au) or the non-governmental Australian Guardianship Law website (www.austguardianshiplaw.org). When working with an INconsenting adult, the psychologist would need to inform the legal guardian of the service provision and consider that guardian the client. However, as with young people unable to give consent, it is important to inform the INconsenting adult about the nature of the service and the relevant confidentiality issues (standard A.3.6 of the Code) in language that is appropriate to him. Psychologists should also maintain a strong focus on the well-being of the INconsenting adult they are working with and ensure that any services provided are primarily in his best interests rather than his guardian’s. Individuals with a severe psychological disorder may be incapable of giving consent when this presenting issue disrupts their ability to make informed decisions. If the psychologist is working with this client in a hospital or correctional setting, the provision of immediate psychological services may be vital to the client’s well-being. In these situations psychologists could be considered to be providing emergency psychological services; here the Code (A.3.1) asserts that consent is not required, as it is not reasonably possible to gain consent.

APS Code A.3.1 A.3. Informed consent A.3.1. Psychologists fully inform clients regarding the psychological services they intend to provide, unless an explicit exception has been agreed upon in advance, or it is not reasonably possible to obtain informed consent.

However, if an individual in these circumstances was in need of ongoing service provision and was still INconsenting, the psychologist would need to consider the question of consent. Consider the case of Shane.

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CASE STUDY 5.3

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Shane is a 22-year-old male experiencing psychosis related to cannabis use and has been recently hospitalised due to his risk of harm to others. Shane has been hospitalised for ten days, his withdrawal symptoms from the cannabis have subsided, but the psychosis is still present. Shane appears to be responding well to the emergency care, but decisions need to be made about his ongoing care. When the staff psychologist tries to complete any kind of process explaining Shane’s condition and presenting treatment options for his ongoing care, Shane loses interest and tells the psychologist to just do ‘whatever’. Each of the proposed treatment options has significant risks or limits to freedom. Based on a full assessment by another psychologist, the treating psychologist believes that Shane is not capable of making an informed decision about his ongoing healthcare, at least in the short to medium term.

In this case, while Shane has the legal authority to make his own decisions (i.e. a court /tribunal has not removed them), it would appear that he does not have the ability to make an informed decision about his treatment. It may be necessary for an alternative legal guardian to give consent. This could be a family member, friend or independent person, any of whom would need to be appointed as legal guardian by an appropriate legal authority. While it can be a long and complex process, there needs to be somebody with the client’s best interests as his focus, making decisions on behalf of the client if the client cannot. It is vital that psychologists working in situations where individuals who have severe psychological conditions that may affect their ability to consent are aware of the ethical issues involved in working with INconsenting adults. Psychologists must also be aware of any organisational policies in place that negatively impact, protect or support clients who cannot give consent and how these relate to psychological ethics. As individuals age there is usually a slow decline in cognitive abilities. At some point these declines may impact on an individual’s ability to give consent. However, it is vital that psychologists do not link a diagnosis of dementia or other form of cognitive decline with an inability to give consent (APA 2004). When working with any client, the psychologist should consider the client’s decision-making ability in isolation from any other diagnosis. If the psychologist believes that the adult is incapable of making an informed decision about his service provision, the psychologists should seek a legal guardian to do so. Again, in these circumstances a psychologist should, to the greatest extent possible, explain to the INconsenting adult the service being provided and the issues relating to confidentiality. Psychologists and legal guardians, as in the case of older children, may make agreements about the confidentiality of the sessions and what information may be kept confidential between the INconsenting adult and the psychologist. Psychologists also need to be mindful of the ethical issues that arise when working with a client they consider to be capable of making his own decisions, yet another person is his legal guardian. In each of the situations above, psychologists need to be aware of the negative impact of the status of INconsenting adult on a client. The situation of needing somebody else to make

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decisions may compound the presenting issue for most individuals seeking treatment. If the psychologist has some doubt about the ability of a client to provide consent, he could perhaps negotiate with the client to have a friend, family member or carer present to assist with the decision, without the need to initiate a process that may lead to a binding legal decision to have a guardian assigned. Alternatively, the psychologist could structure the informed consent process in a way that allows more time and uses visual cues or flow charts that allow the client to receive information in other ways. Where possible psychologists should attempt to uphold the decisions made by the individuals they are working with, unless the need for a legal guardian is necessary to protect the well-being of the INconsenting adult. In these types of complex cases an ethical decision-making model should be used and experts should be consulted to ensure that all measures are set up to protect the client.

Clients who do not consent to services

Sally has been convicted of an assault, and as part of her sentence she has been required to undertake 20 hours of a specific dispute resolution course that the judge has chosen. Part of these classes involves working with a psychologist on developing her awareness of her anger, and developing tools and techniques to help her manage these issues. If she does not attend these classes she will be sentenced to six months in jail.

In this case, given the imposition of a jail sentence if she does not attend the course, Sally is being coerced into attending the sessions with the psychologist. While Sally may be keen to develop her skills in dealing more productively with her negative behaviours, she has little real choice but to attend the sessions.

CASE STUDY 5.4

There are some limited situations where an individual may not be able to give voluntary consent, not because of their inability but because of circumstances. The most common situation for this is court order services that do not require consent. For example, a court may Court order service: order an individual to undergo a psychological assessment to determine if he A situation where the court instructs a certain is capable of standing trial. A court may also require a convicted individual to psychological service to be attend a particular psychological service (e.g. anger management classes). In carried out without client many cases, while the person involved in the services could consent, genuine consent; a court may order informed voluntary consent is not possible because if that person did not agree a psychological assessment to determine if someone is to take part in the psychological services there would be an extremely negative capable of standing trial. consequence. Consider the following case.

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In these situations a psychologist must ensure that she still completes a full informed consent procedure as directed by standard A.3.7 of the Code.

APS Code A.3.7 Psychologists who work with clients whose consent is not required by law still comply, as far as practically possible, with the processes described in A.3.1., A.3.2., and A.3.3.

This ensures that the individual she is working with is fully aware of the service being provided and the consequences of not being involved. This can be even more complex when the service being provided is an assessment of some kind for the court. This could be an assessment to determine some aspect of an individual’s risk, ability or development before, during or after legal proceedings. In these situations it is typically the court that is the client rather than the person being assessed. When this is the case it is vital that the psychologist discusses and informs (see Chapter 2 for the issues related to informed consent in standard A.3.3 of the Code) the person she is assessing of the purpose of the assessment and the potential uses of the information. It is vital that the client is aware of whom the information will be provided to and that the assessment is being completed for court purposes, not to provide a therapeutic or other service to the client. When the person receiving the service is aware of these matters he can make an informed decision on regarding his level of participation. As noted above, even if he appears willing to be involved, it is important for the psychologist to be aware that any individual compelled to be involved in services cannot be considered capable of voluntary consent. When working in these complex fields psychologists should always maintain their competency (especially in relation to practising within the legal system) and discuss the relevant ethical and practice issues with experienced legal and psychology colleagues.

Other issues when working with clients who may not be able to give consent Many psychologists work in either the education system or aged care system. Organisations in these systems (schools, kindergartens, care facilities etc.) often have policies that can affect the ethical provision of services. Some schools have signed agreements with parents at enrolment regarding the provision of psychological services to children at the school. These agreements set out how and when students can access these services and when or if parents will be notified. The agreements may even set out a parent’s right to access the information in the client record. This is highly problematic ethically. Psychologists must be fully aware of these procedures and must inform the individuals they work with. In some schools that provide education for all ages, the same agreement from kindergarten may apply through to the fi nal years of high school. It is foreseeable that a psychologist working at a

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school may be contractually expected to report confidential information to a parent when providing psychological services to an 18-year-old student. This is not an ethical practice for psychologists (APS 2013). Psychologists should discuss this issue with school principals and administrators. A system should be in place that allows parents, or the child if she is capable of giving consent, to be fully informed of the service being provided and the uses of the information before each service provision (APS 2013). When working with any client, but specifically clients who cannot consent, clients or guardians may try a number of different psychologists. This could be in an attempt to gain a diagnosis or service provision that they believe is appropriate but the previous psychologists did not. This may have substantial impact on psychological services. For example, the repeated exposure to some psychological assessment instruments invalidates their results due to practice effects. When working with older and younger clients, psychologists need to consider the use of appropriate tools and techniques, given the client’s age. The psychologist needs to ensure that the tools or techniques have been developed and normed for the age group of his client. Psychologists also need to consider any sensory issues such as poor hearing. The use of prescription and/or illicit drugs among older and younger clients can also influence the provision of some services. When working with clients, especially older or younger individuals, psychologists need to be aware of how the individuals perceive psychology as a field. Children, adolescents and older adults may have an image of psychologists gleaned from the media, television or outdated stereotypes (see also Chapter 1). This can include viewing psychologists as mind readers, witch doctors, cranks, as all-knowing, or as unethically having sexual relationships with clients or using electric shocks as their primary method of treatment. These sorts of attitude or preconceived incorrect assumptions can contribute to people not wanting to be involved in psychological services. This is particularly true for clients who associate psychological treatment with high levels of negative stigma. There are also circumstances where a client can view a psychologist as a person of authority who must not be contradicted or disagreed with. It is vital that psychologists help all clients develop accurate expectations of their psychologist and point out that psychological services are a collaborative process, with the client being the expert on her own situation. When clients seem unwilling to be involved in the service provision, it is important that psychologists clarify their role and ensure that clients understand what will occur and that clients are not misunderstanding the process. Finally, when working with any client group it is important not to focus too strongly on their age. Chronological age is only one measure of development and an individual’s cognitive, social, emotional or creative development only approximately relate to a client’s age. Even when empirical research fi nds links between age and particular characteristics or outcomes, this only increases the statistical likelihood that that link exists for individuals broadly, not for the specific client. This is true for younger and older individuals; one of the key ethical necessities is to consider all clients as unique, regardless of age, culture or diagnosis. By focusing on each client and their unique collection of strengths and weaknesses, psychologists can provide ethical and effective services.

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CHAPTER SUMMARY This chapter has highlighted some of the key issues that arise when working with older and younger individuals, and others that cannot meaningfully give consent. The primary issue that needs careful consideration is that of clients’ ability to give consent to the service provision. This could be because their age, cognitive ability or the nature of the service limits the ability to give voluntary consent. If the individual is not capable of giving informed consent then it will be their legal guardian that will consent and be considered the client. However, the psychologist should still provide information relating to the service being provided and confidentiality information to the individual receiving the service. There are a number of specific ethical issues that are commonly associated with working with individuals who are required to undergo psychological services as part of a court order. These clients cannot voluntarily consent as they have little choice but to receive the service because of the negative consequence if they do not. Psychologists who work with individuals in this situation need to be aware of the ethical issues involved. When working with younger and older people, psychologists need to be aware of the specific ethical issues that are more commonly found in service provision to these groups. Psychologists should continue to develop their skills and communicate clearly with these groups to ensure the ethical and effective delivery of services.

QUESTIONS TO CONSIDER 1 2 3 4 5 6

As a psychologist, how would you overcome your personal values/moral judgments influencing the consideration of mature minor status? Should children between the ages of 15 and 18 be given the implicit legal authority to make their own decisions regarding psychological services? Would you have difficulty refusing to disclose the information given to you by a mature minor if her parent requested it? Who should act as a legal guardian for adults who cannot give consent for their psychological service provision? Their family or an independent advocate? Should psychological treatment be offered to convicted offenders in place of punishments? How would you lessen the ethical issues relating to consent if you were working with an individual undergoing a court-appointed assessment?

REFERENCES APA (2004). Guidelines for psychological practice with older adults. American Psychologists 59(4), 236–60. APS (2009). Guidelines for Working with Young People. . APS (2011). Professional Practice Handbook. .

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APS (2012). Guidelines on Reporting Abuse and Neglect, and Criminal Activity. . APS (2013). Psychologists in NSW Schools: Client information sharing. . Department of Health Western Australia (2009). Working with Youth: A legal resource for community-based health workers. Perth: Department of Health Western Australia. DHS (Department of Human Services) (2012). Medicare Card. . Jifkins, J. (2011). Legal aspects of working with children of separated parents. InPsych 33(4), 30–1. Joyce, M.R. (2010). Reviewing the APS Code of Ethics with young people in mind. In A. Allen & A.W. Love (eds), Ethical Practice in Psychology: Reflections from the creators of the APS Code of Ethics. West Sussex, UK: Wiley-Blackwell, pp. 123–34. McMahon, M. (2006). Confidentiality, privacy and privilege: Protecting and disclosing information about clients. In S. Morrissey & P. Reddy (eds), Ethics and Professional Practice for Psychologists. Melbourne: Cengage Learning. pp. 74–88. Re: Marrion, Department of Health and Community Services (NT) v JWB and SMB, 1992.

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6 Diverse Clients

CHAPTER OBJECTIVES • • • • • • •

To understand the potential impact of a client’s membership of a diverse group in the community affecting the psychological service To be aware of the communications issues that can exist when working with clients from various groups To be aware of the ethical issues that exist when using interpreters To understand the issues associated with working with clients who are Indigenous To understand the issues associated with working with clients who are women To understand the issues associated with working with sex and/or gender-diverse clients To understand the issues associated with working with clients who are lesbian, gay or bisexual

KEY TERMS Body language Client diversity Competency

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Media portrayal Respect

Sex and/or gender diversity Stereotypes

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Introduction Psychologists in every workplace in Australia will provide services to a diverse range of clients. These clients will vary in their physical and cognitive abilities, their cultural and ethnic background, their religious or spiritual beliefs, their location, their sexual orientation and their gender. These are some of the core aspects of each individual’s identity. Clients will also have a tremendous range of worldviews, interests, occupations, hobbies and views. Working with clients of varying ages will also have specific ethical issues; these are covered in Chapter   5. This chapter will focus on the ethical issues of working with clients from various groups. However, it is important to remember that each individual will be unique and may or may not exhibit the behaviours and characteristics statistically expected from the literature on the group.

Client diversity Client diversity: Clients who vary in their physical and cognitive abilities, their cultural and ethnic background, their religious or spiritual beliefs, their location, their sexual orientation or their gender.

Lexi is a psychologist working in Darwin; she is a married 32-year-old with two children. She has lived in the Northern Territory her entire life, as has her husband. Lexi’s great grandparents emigrated from Scotland but she has never left Australia. She is currently working with two clients, Cecil and Kate. Cecil is a 58-year-old first-time grandfather who is working with Lexi to build his grandparenting skills as he was absent for much of his own children’s upbringing because of work commitments. Cecil, who was born in East Timor, has worked in the oil and gas industry in and around northern Australia, Indonesia and the Torres Strait all his life. Kate is a 21-year-old student originally from Sydney who is seeking assistance with her study habits. While initially she was only seeking help with her studies, the treatment has moved on to addressing her drug-taking. She reports that she left Sydney to get out of the party scene and multiple problematic sexual relationships with males and females.

CASE STUDY 6.1

Client diversity is a facet of psychological work that all practitioners face at one time or another. It is vital that in considering this diversity they cater appropriately to clients’ specific needs in relation to the service being provided. Psychologists also need to consider their personal views and potential prejudices when working with every client, and should not assume that they know or understand a client’s situation, expectations or mindset. Consider the following situation.

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As can be seen in these cases, Lexi will have some common and some divergent life experiences with these two clients. It is important that the psychologist does not let the aspects that she has or does not have in common with her clients overly influence her interactions with them. For example, both Lexi and Kate have always lived in Australia, but Kate’s party lifestyle in inner-city Sydney may have less in common with Lexi’s than Cecil’s life in various locations in and around the Torres Strait. While Lexi may think that her parenting skills may be useful in assisting Cecil with his grandparenting, the cultural differences between them may render her tools and techniques entirely inappropriate. Lexi may not need to develop her knowledge of living and working on an oil rig, Stereotypes: Gross but she may need to investigate and develop her understanding of working generalisations about with a client whose sexual orientation is different from her own. certain character traits or With such examples in mind, psychologists need to balance their cultural nuances that are scientifi c understanding of groups in the community with ensuring that presumed in a large group of people where there is they consider each client’s unique personality, situation and worldview; in no evidence that this is this context a scientific understanding relates to an empirically supported the case. or expert knowledge of a group. Psychologists also need to be aware of and understand stereotypes and media portrayals of groups. These portrayals, Media portrayal: together with their expert knowledge, can help a psychologist begin to A particular presentation develop a meaningful understanding of the various lifestyles, events and of a person or group developed through the social experiences groups in the community may experience. Through media that may or may not this process, they can work to meet the needs of their clients and ensure be accurate; psychologists that they are not discriminating against them because of a poorly informed should be aware of the understanding of the client’s group membership. Standard A.1 of the Code of potential for this. Ethics highlights this ethical requirement.

APS Code A.1 A.1. Justice A.1.1. Psychologists avoid discriminating unfairly against people on the basis of age, religion, sexuality, ethnicity, gender, disability, or any other basis proscribed by law. A.1.2. Psychologists demonstrate an understanding of the consequences for people of unfair discrimination and stereotyping related to their age, religion, sexuality, ethnicity, gender, or disability. A.1.3. Psychologists assist their clients to address unfair discrimination or prejudice that is directed against the clients.

Except in very unusual working environments, psychologists will not be experts on every group they work with. In these situations psychologists will need to develop their awareness and understanding of a group before working with a client (see the discussion of competence in Chapter 2). There are a number of APS guidelines that are relevant to working with a range of groups and there are several relevant APS Interest Groups (www.groups. psychology.org.au/igs) that can be an important resource.

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Competence with diverse client groups As with all services and skills, psychologists must show competency in their Competency: Having and practice. In the case of diversity psychologists must have a broad understanding maintaining the skills needed to practise in a of the groups they will be working with. If a psychologist is working branch of psychology; extensively with a small number of groups he should undertake extensive psychologists only provide training and development to be aware of the nuances in the issues facing these psychological services in groups. When a psychologist encounters a level or type of client diversity that areas in which they are competent. he is not competent to deal with he should undertake further research or training to develop his skills. Referrals to another professional should only occur if the psychologist is not competent to deal with the client and/or issue. Psychologists must constantly be considering their competencies and undertaking professional development to extend their knowledge. They should also be mindful of their personal views about members of various groups in the community and ensure that these are not influencing their practice. If the psychologist’s personal views are influencing the practice she should seek supervision to rectify this immediately. Psychologists should also ensure that they maintain a current knowledge (competence; B.1 of the Code) of the groups they work with. For example, how psychologists were trained in client diversity 30 years ago would likely be entirely inappropriate today.

APS Code B.1.1 B.1. Competence B.1.1. Psychologists bring and maintain appropriate skills and learning to their areas of professional practice.

Communication Client diversity can have a substantial impact on the communication between psychologist and client. If the psychologist is working with a client who is deaf or a client who does not speak a language the psychologist is fluent in, she will need to adjust her communication. However, if the client is from many other groups in the community, no specific adjustment may be necessary in relation to language, but the psychologist may need to alter other aspects of her interactions (e.g. eye contact). The key ethical focus for psychologists is to ensure that they are using a communication medium in which they are fluent and the client is comfortable using. Broadly, psychologists should refrain from any language that may be considered derogatory or judgmental, and biased comments (including jokes or off-the-cuff comments)

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regarding a client’s membership of any group (APS 2008, 2010, 2012). This is emphasised in the justice standards of A.1 of the Code. While this should of course be common practice for every psychologist working with any client, it has the potential for even greater harm when working with diverse clients. Not only is such behaviour illegal in some situations, but it is also likely to cause the client distress and the distrust of psychologists more broadly. Psychologists should increase their knowledge about the groups they regularly work with. They should also be honest with their clients about their lack of knowledge of a client’s selfidentified group membership. For example, they should explain in the initial sessions the types of activities and communications that will occur as part of the service provision and ask if the client is comfortable with them or if any of the tasks and communications would be considered inappropriate. Then they should negotiate the use of terms and processes with their clients so that both parties are comfortable with the communication style and defi nitions being used.

Language skills Given the diverse cultural groups in Australia, most psychologists will work with clients who do not have enough English language skills to let them communicate with the psychologist. In these situations the psychologist will need to be proficient in the client’s preferred language or, if not, use an interpreter. Psychologists who offer their services in any language need to be highly proficient in not only the verbal skills but also the nuances of the language; for example the use of body language, eye contact, and understanding the slang and informal uses of the language. Competency in these skills can only be developed over time and with exposure to the language in its common usage. Psychologists who have only had exposure to a language in a classroom should be extremely careful if they plan to practise in that language. A limited understanding of any language can lead to misunderstandings and client frustration when it is used poorly in the provision of psychological services.

Interpreters If a psychologist cannot speak the language of the client, he will need to use an interpreter. The use of an interpreter presents a number of challenges. First there is the question of confidentiality: when using an interpreter there is another party who is aware of the confidential information. The Code states that interpreters must be competent and must commit to keeping all information that is covered in the session confidential and that psychologists must ensure that interpreters are aware of the Code (B.7.a, c, d) and do not breach it. Psychologists should always use trained and accredited interpreters where possible and be cautious of cultural differences between groups that speak the same language. Psychologists should meet the interpreter before working with the specific client and discuss the issues relevant to interpreting that session (Khawaja 2011).

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APS Code B.7 B.7. Use of interpreters Psychologists who use interpreters: (a) take reasonable steps to ensure that the interpreters are competent to work as interpreters in the relevant context; (b) take reasonable steps to ensure that the interpreter is not in a multiple relationship with the client that may impair the interpreter’s judgement; (c) take reasonable steps to ensure that the interpreter will keep confidential the existence and content of the psychological service; (d) take reasonable steps to ensure that the interpreter is aware of any other relevant provisions of this Code; and (e) obtain informed consent from the client to use the selected interpreter.

When interpreters are present, psychologists also need to consider the impact they will have on the therapeutic relationship. The psychologist must ensure that the interpreter does not act as a filter, but rather translates verbatim and then assists in any clarification required. For this reason it is important that the interpreter is not in a dual relationship with the client that may impair his, or the client’s, judgment (B.7.b). It is not ideal for the interpreter to be a family member as he may have difficulties being objective in his translations, though in emergency situations this may be difficult to accomplish. The client must give informed consent if a translator is to be used (B.7.e), but this can be difficult as, often, a translator will be needed to communicate the information required to give consent. It is sometimes possible for the consent information to be translated and presented in a written form in a language the client is comfortable with. Whichever method is used, the psychologist should to the greatest extent possible ensure that the client is comfortable with using the particular translator. At the completion of a session the psychologist should debrief the interpreter (Khawaja 2011). In this debriefi ng the psychologist can reinforce the question of confidentiality and ensure that the interpreter is comfortable with the process.

Questions and body language While questioning and body language are matters of applied practice Body language: Nonverbal rather than ethics, they will be covered briefly here because to ignore them communication where signals are sent without the in practice is likely to lead to ethical violations. The APS (2008) has pointed use of words; e.g. in most out some problems in communicating with Indigenous clients. Many of these Western cultures making problems are equally relevant to other groups even if the required precautions eye contact is regarded as sincere and polite, but in or adjustment to the professional service will be different for each group. some indigenous cultures Psychologists need to consider their client’s cultural views on interactions it may imply dominance or with the psychologist (APS 2008). For example, does the client feel that it is disrespect. culturally appropriate for him, a male client, to look into the eyes of his female psychologist while he is discussing his anxiety? If it is not and the psychologist is unaware of this cultural norm, she may draw a different conclusion from the client’s behaviour.

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Alternatively, some groups may have difficulty with direct questions, instead preferring a more gradual or indirect path to the discussion of certain issues. Khawaja (2011) suggests that psychologists should avoid shaking hands with clients of the opposite sex, as this is a common area of cultural sensitivity. This is an example of a practice that psychologists can use more broadly with all clients. Psychologists could avoid initiating handshakes with any client, but accept a handshake when offered. However, psychologists still need to be aware of issues such as physical contact between client and psychologist and the potential for dual relationships (see Chapter 4). The overwhelming ethical principle is that psychologists need to raise their awareness of group norms to a very high level with the groups they regularly work with in relation to their communication and interaction expectations.

Groups in the community Respect: The due regard expected of psychologists for people of different belief systems or background, and whose opinions may differ from their own.

The APS (2008) states that psychologists need to be aware of cultural norms because they apply to the service provision and the interaction between the psychologist and the client. Further, Lee and Khawaja (2013) point out that psychologists must be aware of their own group membership and its impact on their practice. The key ethical aspect that reflects these concepts is respect .

APS Code A.2 A.2. Respect A.2.1. In the course of their conduct, psychologists: (a) communicate respect for other people through their actions and language; (b) do not behave in a manner that, having regard to the context, may reasonably be perceived as coercive or demeaning; (c) respect the legal rights and moral rights of others; and (d) do not denigrate the character of people by engaging in conduct that demeans them as persons, or defames, or harasses them.

As was pointed out previously, there are numerous groups in the community who are often treated without respect. Some groups have been subjected to a large amount of psychological research (e.g. children with autism spectrum disorders), and psychologists and the general public have a good understanding of these groups’ typical characteristics. Other groups in the community, such as university students, have been researched extensively, but public perceptions and psychological perceptions can vary greatly. There are also small groups such as asylum-seekers from specific regions that have received very little research in Australia and very little is known about them from a scientific perspective, yet there are constant media reports about them. The key ethical issue in working with any such group is that the psychologist should not make concrete generalisations about individuals from that group. Group membership does not mean that the client is going to exhibit the behaviours or characteristics that have statistically been found to be common in that group. Group membership simply suggests that there is a greater likelihood that they

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exhibit the group behaviour/characteristics. For example, consider university students as a group. Hypothetically, there is a general perception that they are typically working part-time, under 24 years of age, more likely to vote for the Greens, and more likely than others in the community to have consumed an alcoholic beverage in the past 24 hours. However, even if there was empirical evidence to support this characterisation, that does not mean that every client who is a university student is going to fit that description. They may be significantly more likely to meet that description than others in the community, but there is no perfect correlation for students or any other group. The key aspect for psychologists to remember is that each client is unique but will share commonalities with their own group as well as others. It is unethical to assume that just because your client is a member of a certain group he will automatically conform to the group norms. That said, it is vital that psychologists explore, through their interaction with clients, the aspects of the client’s identity, worldview and culture that are potentially going to influence the service provision. The psychologist then needs to consider how these characteristics can be catered for in order to respect the individual differences of the client and ensure that he receives the best possible service. It is vital that psychologists do not prejudge their client’s views on their group membership. As the APS (2008, 2010, 2012) Guidelines state, there can still be a strong negative stigma and discrimination (and related negative health outcomes) attached to some group membership. Clients can suffer from widespread (e.g. governmental), or very specific (e.g. their parents), negative experiences and/or treatment due to their group membership. It is vital that psychologists are aware of these matters and do not underestimate their potential impact. However, it should also be noted that for many people group membership is a source of pride and satisfaction, and provides a sense of belonging. Psychologists should allow their clients to clarify both the positive and negative aspects of their group membership. They should also be aware that negative or positive aspects of group membership can fluctuate over time. Psychologists should not assume that clients’ group membership is the reason they are seeking psychological assistance. The following sections will consider some of the client groups that the APS has highlighted as potentially requiring extra ethical consideration. While this is a very small subset of the groups that psychologists will work with in the community, many of the issues raised will be relevant to other groups.

Indigenous clients The APS’s (2008) Guidelines for the Provision of Psychological Services for, and the Conduct of Psychological Research with, Aboriginal and Torres Strait Islander People of Australia is a vital resource for all psychologists and covers the specific ethical consideration of working with Indigenous populations in more detail than this chapter can provide. Those Guidelines should be the starting point for all psychologists to build their ethical and applied knowledge in working with this group. The February 2007 issue of the APS’s InPsych publication is also an excellent resource for psychologists working with Indigenous clients. Such psychologists should be aware of the latest research on working with this client group and the research into

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Indigenous people’s experience of receiving psychological services. This special issue will give details of the latest clinical information for working with Indigenous clients. For much of Australia’s history the Indigenous population has been substantially affected by a lack of recognition and support from the non-indigenous organisations and groups. Further, much of the early psychological research and practice with Indigenous populations suffered from a lack of cultural sensitivity and understanding (APS 2008). Therefore it is vital that current psychological services do not continue with these aberrations. The APS (2008) put forward the following list of issues that should be considered when working with Indigenous clients. Psychologists: •

are aware of any relevant research pertaining to the provision of psychological services for indigenous people;

•

take into account ethnicity and culture when making professional judgements about, and dealing directly with, indigenous clients;

•

are aware of, and show due acknowledgment of and respect for, the value systems and authority structures operating in the indigenous communities for whom they provide psychological services;

•

where possible, consult Aboriginal Liaison Officers and District Education Officers when issues arise;

•

conduct their practice in a manner and, where possible, in an appropriate language medium with which indigenous clients feel comfortable;

•

have an awareness of the socio-political issues that might adversely affect the wellbeing of indigenous clients and the effectiveness of the services provided;

•

are aware of the impact of their own beliefs, stereotypes and communication rules on their interpretation of the behaviour of indigenous clients;

•

document in their records and reports those cultural, linguistic and other social factors that might be relevant to the provision of psychological services to an indigenous client;

•

clearly inform indigenous clients of their client rights, and the means by which those rights might be safeguarded; and

•

react in an appropriate manner against any prejudice or discrimination by other persons that is directed at an indigenous client. (APS 2008, p. 9)

Adhering to these guidelines will allow a psychologist to work in a competent manner with an Indigenous client. Many of the guidelines are also highly relevant to working with other groups in the community. In addition, there are several considerations when assessing or developing an intervention with any individual that will need to be tailored to the specific needs of a client. For example, has the test been developed for use with a client of Indigenous heritage? These matters are covered in more detail in Chapter 10, but it must be reiterated that the psychologist will need to determine which aspects of cultural norms of the Indigenous population any specific client relates to.

Working with female clients The APS (2012) Guidelines for Psychological Practice with Women and Girls states that women and girls should be considered in the full complexity encompassing the diversity in their

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identities and experiences. While the development of ethical guidelines for practice with women and girls may seem in itself sexist (there are no guidelines for the practice with men and boys), they do serve an important function. For too long psychology focused on narrow defi nitions and stereotypes of females, failing to consider the full complexity and diversity of female identities and experiences. In part, the APS guidelines do clarify the current position and emphasise the poor past practices in psychology in relation to women. Further, prevalence rates do significantly differ between men and women in a range of disorders (Freeman & Freeman 2013). Therefore the guidelines serve a useful function in providing ethical psychological services to women and girls. The APS (2012) also notes the differing role of males and females across cultures. This is important to note, both from the perspective of the psychologist’s value-based judgment but also in the way in which the client may feel that it is appropriate to interact with the psychologist. This can be relevant not only in the interactions between client and psychologist during the service provision, but also in the interactions the client has with others from within their group. For example, if the psychologist was working with a client who was a member of a group that viewed female psychological disorders as a punishment from a god/deity, it would be difficult to implement an intervention that required broad social support from the community. In this situation the psychologist would point out to the client the underlying biosocial basis for the disorder and help her understand this within her own cultural worldview. However, the focus would be on ensuring that the client received a service that assisted with her presenting condition within her broader cultural perspective.

Clients who are sex and/or gender-diverse The APS’s (2013) Guidelines on Working with Sex and/or Gender Diverse Clients gives an overview of working with clients who are sex and/or gender-diverse. The scientific debate regarding the point at which sex and/or gender is defi ned is beyond the scope of this book. However, psychologists should be extremely careful with terms such as male, female, intersex, transgender or transsexual when working with clients who Sex and/or gender diversity: Refers to persons feel that their gender/sex is different from that assigned at birth (APS 2013). who may be classified as When working with clients who view themselves in this way, the psychologist male or female at birth, should use the terms that the client is comfortable with. From this point a sound but may not consider themselves in those terms. initial professional relationship can be developed from a basis of respect. As with all service provision, psychologists should be competent to provide that service. Psychologists working with sex and/or gender-diverse clients should be aware of the latest research on working with these groups and the research into their experiences. When working with clients who are sex and/or gender-diverse is it important that psychologists consider the negative social response that these clients may experience in their daily lives. The APS recommends that psychologists are active in working towards overcoming these negative social responses. In a service provision setting it is vital that psychologists consider these negative responses when providing any psychological service.

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The APS (2013) also points out the additional ethical pressures that may be presented when working with children, young and older people who are sex and/or genderdiverse. Psychologists should always focus on the well-being of the client and only breach confidentiality, in relation to a young person’s sexual and/or gender diversity, in accordance with the Code. Psychologists need to ensure that their personal values and views on younger or older clients do not negatively impact on the ability to provide ethical psychological services to sex and/or gender-diverse clients (APS 2013).

Clients who are lesbian, gay or bisexual The fi nal group that will be considered in terms of ethical practice are clients who are lesbian, gay or bisexual. The APS’s (2010) Guidelines for Psychological Practice with Lesbian, Gay and Bisexual Clients should be the primary resource for all psychologists working with these clients. In these Guidelines the APS has once again highlighted the research confi rming that a client’s lesbian, gay or bisexual thoughts, feelings or behaviours are not indicative of a psychological disorder. While, for many students undergoing their psychological training, this may seem like a standard concept, psychology has had a long history of treating these sexual orientations as disorders. Hence the inclusion of the clear and emphatic statement in the Guidelines. It is important that while psychologists are mindful of the unique and difficult experiences that many lesbian, gay or bisexual individuals experience, they do not assume that all clients who are lesbian, gay or bisexual will experience these or see their sexual orientation as relevant to the psychological service they are seeking. However, because of the negative social experience many individuals who are lesbian, gay or bisexual experience in the community, they are at higher risk for a range of psychological disorders and psychologists should be aware of this (APS 2010). With the increase in social acceptance and media interest in topics such as same-sex marriages, psychologists need to be aware of the wide range of specific issues that lesbian, gay or bisexual individuals may need assistance with in a psychological context, and ensure that they maintain the appropriate skills and competence to assist these clients.

CHAPTER SUMMARY As has been shown above, individuals from various groups in the community may face increased risk of difficulties from issues that require psychological assistance. The key ethical issues that psychologists need to consider are competence and respect. Psychologists need to understand the unique difficulties that individuals in any specific groups may face and any group characteristics that affect the professional relationship. They also need to use their experience and training to determine how closely each individual client represents those group norms that have been scientifically developed. Psychologists must ensure that they do not overgeneralise or stereotype their clients based on their group membership. Further, they must remain mindful that group membership also has a range of benefits that can promote psychological well-being, and group membership should not be viewed as being only a negative aspect of an individual’s identity.

Chapter 6: Diverse Clients

QUESTIONS TO CONSIDER 1 2 3 4

How can psychologists work to reduce the negative experiences that many lesbian, gay or bisexual individuals experience in the community? If you were a psychologist working with a client from a group that you were not familiar with, what are five ways in which you could increase your knowledge about them? How could you adjust your informed consent procedure to meet the needs of more diverse clients? Are there any other groups in the community that need specific guidelines developed to improve the quality of psychological service provided to them?

REFERENCES APS (2008). Guidelines for the Provision of Psychological Services for, and the Conduct of Psychological Research with, Aboriginal and Torres Strait Islander People of Australia. Melbourne: APS. APS (2010). Guidelines for Psychological Practice with Lesbian, Gay and Bisexual Clients. Melbourne: APS. APS (2012). Guidelines for Psychological Practice with Women and Girls. Melbourne: APS. APS (2013). Guidelines on Working with Sex and/or Gender Diverse Clients. Melbourne: APS. Freeman, D. & Freeman, J. (2013). The Stressed Sex: Uncovering the truth about men, women and mental health. Oxford: Oxford University Press. Khawaja, N.G. (2011). Effective interviewing of culturally and linguistically diverse clients. InPsych 33(3), 20. Lee, A. & Khawaja, N.G. (2013). Multicultural training experiences as predictors of psychology student’s cultural competence. Australian Psychologist 48(3), 209–16.

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CHAPTER OBJECTIVES • • • • •

To understand the ethical requirements of treating clients who pose a risk of harming themselves To understand the importance of protecting the physical welfare of a client who is at risk of suicide even at the expense of his autonomy To ensure that all psychologists are proficient in planning for and assessing clients who present with potential suicidal ideation To guide psychologists in their ethical requirements when providing ongoing care for clients at risk of taking their own life To help psychologists understand the ethical issues involved in working with clients engaging in self-harm or dangerous/risky behaviours

KEY TERMS Autonomy Competence Deliberate self-injurious behaviour

Protection, care and support plan Self-harm Suicidal ideation

Suicide Suicide risk assessment

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Introduction

CASE STUDY 7.1

This chapter will discuss the ethical and professional issues of working with clients who pose a risk to themselves. This harm could be in the form of suicide, attempted suicide, self-harm or risky/dangerous behaviour. Psychologists, regardless of their work setting, Suicide: The deliberate may encounter clients who are at risk of harming themselves. Consider the act of a person taking his own life. case study below.

Javid is the only psychologist working as a human resource manager in a large accounting firm. Javid gained a master’s degree in organisational psychology ten years ago and now uses his knowledge of individuals and groups in the workplace to improve efficiency and satisfaction in the workplace. His main role is to assess staff and create groups that will work effectively together to maximise the output of the group. As part of this role Javid may have to reorganise groups when they are not meeting their goals. This may result in staff having to change their worksite within the organisation when they change groups. The performance of Scott, a junior accountant, has been flagged by the productivity department as being below the expected level. Javid has been asked by the department manager of Scott’s group to evaluate him and reassign him if necessary. As part of the evaluation Javid mentions that Scott might be transferred to another worksite, at which point Scott becomes upset and replies that he could not face making another move as he has only just made friends at this site and would end it all right now rather than have to move somewhere new. Upon further prompting from Javid to discuss what he meant by ‘end it all right now’, Scott becomes defensive and will not interact meaningfully with Javid.

As this case study suggests, psychologists working in all fields of psychology could interact with clients who are potentially at risk of harming themselves. While the fields of counselling, educational and developmental, clinical and forensic psychology are more likely to encounter clients who pose a risk of harming themselves, all fields and all psychologists owe the same ethical responsibilities to their clients. This chapter will discuss the ethical issues involved in working with clients who may be considering or attempting Suicidal ideation: The idea to take their own life (suicidal ideation). It will also cover clients who engage that a client entertains of in self-injurious behaviours (self-harm) or in dangerous/risky behaviour, but taking his own life. who are not attempting to end their own life. The following chapter will focus on clients who pose a threat to others. However, psychologists should always consider the risk to others (e.g. murder/suicide) when working with a client displaying suicidal ideation.

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Clients with suicidal ideation In discussing the responsibilities of psychologists working with clients at risk of taking their own life, we focus on the ethical aspects of their work rather than any specific therapeutic techniques. Empirically supported treatment methods to work with these clients may vary according to membership of age, cultural, gender, demographic and geographical groups. However, the overriding responsibility of the psychologist is to stop the client from taking his or her own life. The APS’s (2008) Guidelines Relating to Suicidal Clients points Autonomy: The client’s out that psychologists need to be mindful of a client’s autonomy. The right to make decisions psychologist’s fi rst priority, however, is the client’s immediate safety. The for himself; psychologists research evidence suggests that many clients who take their own life are should be mindful of a client’s autonomy vis-à-vis experiencing a potentially treatable psychological disorder. Therefore, a any discussions on any psychologist’s fi rst priority is to protect the client rather than granting him the service provided. autonomy to end his own life. According to data from the Australian Bureau of Statistics (ABS 2012), there were 2361 deaths from suicide in Australia in 2010, approximately six a day. These figures potentially underrepresent the number of deaths due to suicide because the true nature of some accidental deaths cannot be clarified. However, the ABS data from 2010 indicates that suicide is the leading cause of death for all Australians aged between 15 and 34, is almost twice as high in Australian Indigenous populations, and accounts for over 1.5 per cent of all deaths in Australia. This data does not include individuals whose attempts to take their own life do not result in death. These figures suggest that suicide is common in Australia and show that all psychologists need to be aware of their ethical and clinical obligations in relation to suicide. Further research has suggested that up to 66 per cent of individuals who die as a result of suicide had recently been in contact with a healthcare professional (Andersen et al. 2000; O’Connor et al. 2004; Pirkis & Burgess 1998; Stark et al. 2012). There is also research to suggest that up to 90 per cent of people who take their own life had a diagnosable psychological disorder (Conwell et al. 1996). This information indicates that many individuals who commit suicide do have a psychological condition and are in contact with healthcare professionals, which in turn suggests that with the highest level of care and ethically sound treatment principles, psychologists could help to reduce the prevalence of deaths by suicide in Australia. When a psychologist, such as Javid in the case study, works with a client who may potentially take his own life, the core ethical issue he will need to consider is the client’s right to autonomy (i.e. to make his own decision) conflicting with the psychologist’s obligation to do no harm and protect his client. Assuming that Scott, in the case study, was planning to take his own life, Javid has the conflicting obligation under the Code of either allowing Scott to make his own decision and take his own life (General Principle A) or to intervene in some way and protect him from harm (General Principle B). According to section 4 of the APS’s 2008 Guidelines, psychologists must fi rst ensure the immediate safety of the client, conduct a thorough suicide assessment to assess the risk of harm, and arrange an appropriate response to the level of risk indicated in the assessment. These are the immediate steps that a psychologist should engage in when working with a client who has indicated that he is at

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Competence: Having and maintaining the skills needed to practise in a field; psychologists only provide psychological services in which they are competent.

risk of taking his own life. Psychologists should also be aware of their competence to deal with clients with suicidal ideation and the risk to any third parties. Psychologists must keep detailed client records in all situations. When clients are presenting with suicidal ideation, however, it is vital that detailed records are kept on all phases of the assessment and treatment process. The next sections will cover these matters in more depth.

Ensure the client’s immediate safety and the safety of those around him or her Section 4 of the APS’s (2008) Guidelines Relating to Suicidal Clients lays down that psychologists are ethically required to protect a client from harm when it is in the form of a suicide attempt. Depending on the work setting, location and support services on hand, this intervention to ensure the client’s safety may vary. In workplaces where it is common for clients to have suicidal ideation (e.g. crisis support, inpatient facilities) there should be policies that facilitate immediate and coordinated responses to these clients. For example, in an outpatient clinic that specialises in treating clients with severe depression, a system could be adopted that allows the treating clinician to stay with the client while additional staff collect assessment tools or other resources. Also, experienced staff with advanced training in working with clients with suicidal ideation may be on call to assist early-career psychologists with difficult cases. Further, additional staff members could take the treating psychologist’s next appointments to allow for the continuation of care. Using this team approach, the treating psychologist can stay with the client and the supporting team can prepare the risk assessment and take over the treating psychologist’s caseload. In the case of Javid and Scott above, the psychologist would need to ensure the client’s immediate safety while preparing for the risk assessment. In a single-psychologist situation such as this, Javid should have a formal plan for working with a client displaying suicidal ideation in the initial stages of the client’s treatment and assessment. This may involve contacting an administrative staff member to gather any assessment materials that are not in the office. However, this must be done in a way that maintains client confidentiality. Alternatively, it may involve leaving the client in the office with the receptionist while the other materials are collected and the psychologist’s next appointment is cancelled. Each work setting will have unique issues and resources. However, psychologists need to ensure the client is not left on his own and they should contact the authorities if the client leaves the psychologist and the psychologist is concerned about the risk of harm to the client or a third party. The focus of this section is that all psychologists are aware that clients presenting with suicidal ideation are common and they should be prepared. In the above scenario, careful consideration should also be given to the psychologist, his staff and any other clients/individuals on the premises. Their safety is of the utmost importance. All psychologists should develop a plan that maximises the safety not only of the client with suicidal ideation but also the people in the immediate vicinity. There will be a large number of variables specific to each work setting that should be incorporated into such a plan (e.g. location, number of other people likely to be present, layout of the waiting room). All psychologists should endeavour to develop a broad plan to deal with the immediate

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safety of clients and third parties. They should pay particular attention to any vulnerable parties such as children or the elderly who may be at risk. This plan can then be adapted and implemented for any client who displays suicidal ideation, given their specific circumstances. When psychologists are working with clients through technology (phone counselling, email counselling or other online/telephonic service provision), extra precautions need to be taken for the client’s immediate safety. Psychologists are under the same obligation to protect clients with suicidal ideation in the online environment as they are in person (APS 2011). They need to be aware of the client’s physical location at the time of the service provision and be aware of the types of resources available. Section 2.3 of the APS’s (2011) Guidelines for Providing Psychological Services and Products Using the Internet and Telecommunications Technologies and a recent coronial fi nding advised that psychologists obtain and store the contact details of the next of kin or another person who can be contacted in the case of an emergency (Coroner’s Court of NSW 2009). If the psychologist is aware of her client’s physical location, has the emergency contact person’s details and knows what resources are available in the client’s location (e.g. hospitals, local GP), she will be able to develop a plan to protect the client in an emergency. The key feature of electronic communications is their portability; clients may specifically choose electronic counselling because it allows flexible delivery of service at multiple locations. Therefore it may be difficult for a psychologist to be aware of the client’s location during all sessions. So before considering electronic service provision, psychologists need to consider how they will locate their clients if suicidal ideation is present and the client needs to be protected. For many psychologists emergency services and psychiatric crisis teams may form part of their reaction plan to clients whose risk of harm is immediate. If it is not safe or possible to contain a client who is about to critically or fatally harm herself and who leaves the treatment setting, emergency services may need to be contacted. This might be particularly pertinent if there is a third party (e.g. client’s spouse, children, workmate) at risk in addition to the client or if the intended method of suicide may injure others (these contingencies will be discussed in the next chapter). In these situations it will be highly likely that confidentiality will need to be breached to protect the client and/or third parties. This falls under standard A.5.2.c of the Code, which permits the psychologist to breach client confidentiality in order to protect the client or a third party.

APS Code A.5.2 Psychologists disclose confidential information obtained in the course of their provision of psychological services only under any one or more of the following circumstances: (c) if there is an immediate and specified risk of harm to an identifiable person or persons that can be averted only by disclosing information;

However, as standard A.5.4 dictates, only the information required to protect the client and any identifiable third parties can be disclosed and only to those individuals who need the information.

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APS Code A.5.4 When a standard of this Code allows psychologists to disclose information obtained in the course of the provision of psychological services, they disclose only that information which is necessary to achieve the purpose of the disclosure, and then only to people required to have that information.

This standard of the Code states that when breaching confidentiality psychologists should only disclose information that is absolutely necessary. For example, if the client had said he was returning home to end his life, the only information that would need to be disclosed to the authorities would be the client’s name, address and the fact that the psychologist believed that he was about to take his own life. This needs to be taken into account when a psychologist is planning her response to ensure the immediate safety of the client. This decision-making process (see Chapter 3) should be clearly detailed in the client’s record along with any other relevant information. In protecting the client’s immediate safety a psychologist may need to disregard her client’s autonomy (i.e. his desire to take his own life). However, as detailed above, many clients are suffering from a diagnosable psychological disorder and may not be thinking in a logical or rational way, although this is not always the case. Therefore while a psychologist may need to set client autonomy aside, many clients have impaired emotions or cognitions at the time they try to take their own life. One potential exception to this is terminally ill clients wishing to end their own life. Assisted suicide, however, is currently illegal in all states and territories in Australia. From a purely ethical perspective a psychologist must focus on protecting the physical well-being of the client while providing any psychological assistance possible. As indicated by the APS (1996/2008), psychologists have a role in the discussion on assisted end of life for clients with a terminal illness. However, a psychologist would currently face the possibility of prosecution if she was involved in assisting in the death of a terminally ill client.

Suicide risk assessment Once a psychologist has ensured the immediate safety of a client who has displayed suicidal ideation, the APS’s 2008 Guidelines require the psychologist to undertake a thorough and Suicide risk assessment: specific suicide risk assessment. It is beyond the scope of this book to Considers the client’s cover the specific contents of such an assessment, but ethically they need age, gender, cultural and to be comprehensive. This may mean that the assessment considers the physical environment and demographic and personal risk and resilience factors of the client. These may the supports and risks these present, previous include age, gender, the cultural, geographic and physical environment and the suicide attempts, drug and supports and risks present within them, previous suicide attempts, drug and alcohol issues, and any alcohol issues, and any recent interpersonal issues in the home or workplace recent interpersonal issues (O’Connor et al. 2004). Psychologists also need to consider the link between in the home or workplace. a client’s thoughts of suicide and any plan or preparations. Psychologists should be cognisant of their personal values in relation to suicide broadly and in relation to the particular client and situation and ensure that they are not adversely affecting the service

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to the client (APS 2008). In settings where clients with suicidal ideation are commonly seen, a specialist psychologist or supervisor may conduct these assessments, but in small practices the treating psychologist is likely to be responsible for completing assessments. This can raise the question of competence. In emergency situations, such as a client with suddenly developing suicidal ideation, psychologists may fi nd themselves in a position where they are not competent to practise. As the Code clearly indicates (standard B.1), in these situations psychologists should refer to a more appropriate psychologist or service. However, in the case of a client who displays behaviour or thoughts that suggest an immediate risk of taking his own life, psychologists will need to take the initial steps to protect the client’s welfare under standard B.11.5.b of the Code.

APS Code B.11.5 When confronted with evidence of a problem or a situation with which they are not competent to deal, or when a client is not benefiting from their psychological services, psychologists: (b) take reasonable steps to safeguard the client’s ongoing welfare;

After rescheduling his next client’s appointment, Javid begins the assessment of Scott. Rather than discussing with Scott the news that he may have moved worksites and why this has resulted in such a strong reaction, Javid first discusses other areas of Scott’s life with him. They discuss Scott’s family situation, his living arrangements and his general and mental well-being before the meeting. They also cover his alcohol and drug use away from the workplace. Javid also discusses with Scott the type of activities he enjoys, how he responds to stressful situations and his general mood. He enquires about Scott’s family background and upbringing, and discusses Scott’s thoughts and behaviours from before his attendance at the psychologist’s office. Javid also specifically asks if Scott has attempted or considered taking his own life or self-harm before. He asks Scott if he has

CASE STUDY 7.1, CONT.

This standard indicates that psychologists need to take reasonable steps to safeguard the client’s well-being even when the psychologist would not be considered competent to do so under typical practice circumstances. In this situation a psychologist may have to undertake the initial service provision to ensure the client’s well-being before referring to an appropriate psychologist or service. Again, this process should be well documented in the client’s records. In relation to the suicide risk assessment, consider the extension of the case study of Javid and Scott.

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been abused in the past or if there are any major concerns in his life except the potential worksite. Javid also asks Scott to complete some carefully selected self-report measures. Finally they discuss Scott’s reaction to the news and his subsequent suggestion that he may take his own life.

After Scott’s initial negative reaction, Javid attempted to redevelop rapport with Scott. One way of doing this, while solidifying his ethical obligations, could be for Javid to emphasise that his main focus was Scott rather than the organisation they both worked for; that is, that Scott is now the client rather than the organisation. In situations such as these Javid’s direct responsibility to maintain Scott’s welfare would outweigh his obligations to the organisation he worked for, even if the organisation had been the client at the beginning of the process (see Chapter 2 on identifying the client). Through this transferring of client status, Javid would have explained the conditions of the therapeutic relationship as per a typical informed concept procedure (see Chapter 2). In this new relationship Scott would have been informed of the limits to confidentiality (Chapter 2; the Code A.5.2), including the potential for Javid to breach confidentiality to protect Scott. It would have been necessary to carry out a new informed consent procedure because the focus of the service provision has changed. With these new arrangements in place Javid could then begin the suicide risk assessment. However, it is important to note that this is a major change in the relationship between Javid and Scott. Javid is providing temporary emergency care to Scott in an area beyond his competence. This change in the relationship would dictate that Javid could not act in a human resources role with Scott in the future. The APS’s 2008 Guidelines emphasise that any suicide risk assessment must be thorough and must specifically address the suicidal ideation the client is displaying. O’Connor and colleagues (2004) say that any suicidal ideation assessment must draw together all available information to comprehensively assess the risk to the client. Further, the process should be well documented in the client’s records. While there are many risk assessment models, O’Connor and colleagues’ framework is particularly relevant because it is Australian and does not take into account the payment and regulatory issues of other locations. It is beyond the scope of this book to recommend or review individual risk assessment models, but all readers would benefit from the framework that O’Connor and colleagues have developed. It focuses not only on suicidal assessment but on changeability and reassessment. Their broad framework allows psychologists to utilise a range of assessment tools and techniques within the broad framework. Using a framework such as this allows psychologists to complete a thorough assessment in line with the APS requirements as laid out in the Code and the relevant Guidelines. This assessment takes into account the client’s specific situation in relation to his past and current mental state, his risk and resilience factors, his social connectivity, the cultural norms of his past and current community, the level of current risk and the interconnection of these aspects in his life. The assessments should consider the suicide plan and the availability of the method of suicide. It should also consider the investigation of broad psychological

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issues as there is often a high co-morbidity between suicidal ideation and psychological disorders (Nock et al. 2010). As can be seen in the case study above, Javid has completed an assessment that investigates Scott’s current and past situation and mental health to get the most accurate prediction of the risk to Scott’s well-being. O’Connor and colleagues (2004) also say that psychologists need to consider how confident they are about their assessments and the potential for changes. It is not ethically acceptable for a psychologist to complete a single assessment of suicidal ideation for a client if that client is at risk of taking his own life. Multiple assessments may take place over the following treatment session to maintain a current understanding of the client’s risk to himself. To meet his ethical obligations, at the conclusion of each assessment process Javid needs to establish a plan for the ongoing care and support of the client. The plans should be clearly detailed and documented in the client’s file.

Ongoing protection, care and support

Javid completes the suicide risk assessment using a range of assessment tools and interview techniques. He concludes that Scott is at a high risk of attempting suicide in the next 24 hours. Scott has a specific plan to take his own life with his mother’s prescription drugs. He has indicated that everything is getting to be too much trouble and that everyone would be better off if he wasn’t around. Since he has developed a good level of rapport with Scott, Javid informs Scott that he is going to need to get a third party involved. Javid informs Scott that he believes that Scott is suffering from depression and that this may be contributing to his negative feelings. He discusses with Scott the nature of depression and explains that with treatment the negative feeling that Scott is experiencing could be reduced or eliminated. Scott seems moderately receptive but unconvinced. Javid asks Scott if there is anyone he would like to have informed of his situation to help him. If there isn’t anyone he would feel comfortable involving, Javid feels that Scott may need to be hospitalised. Scott says that his sister, Liz, might be able to help him. After he contacts Liz she attends the office. The three of them then discuss the measures they are going to set up to ensure that Scott is safe for the next 24 hours until he has an appointment with a psychologist specialising in the treatment of depression and suicidal ideation. Javid has already arranged this appointment while waiting for Liz to arrive and has confirmed

CASE STUDY 7.1, CONT.

Based on the completed assessment process, the psychologist will have a prediction of the client’s suicide risk. Depending on the level of risk, she will need to develop a plan to support the client and protect his welfare. The outcome of the suicide risk assessments typically range from a very high or extreme level of risk, indicating that the client is at immediate risk of taking his own life, to a low or not-at-risk level indicating that there is no evidence that the client is planning to take his own life. For any outcome of a suicide risk assessment that indicates there is some risk of suicide the psychologist needs to put in place a response to protect the client (APS 2008 Guidelines 4.1.1.iii). See the continuation of the case study below.

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with the specialist that Javid will be responsible for Scott’s welfare until he attends the appointment with the specialist. Together Javid, Scott and Liz develop a management plan to ensure Scott’s safety for the next 24 hours. Scott is going to stay with Liz at her house to be away from their mother (and her medication). Liz and Scott are given emergency contact details for Javid and other 24-hour emergency services. They are also supplied with literature and websites that can provide more information on depression and suicide, and the contact details for support groups run by community organisations. If Scott’s condition deteriorates severely before the appointment the following day, Liz is to contact Javid and the emergency services for transport to hospital. Scott also gives consent for Javid to hand over the results of the suicide assessment to his GP and the specialist for his ongoing care.

As can be seen above, in this situation the psychologist takes comprehensive steps to protect the welfare of the client, at the same time providing opportunities for the client to be involved in the process. While, ethically, the psychologist must take steps to protect the client, he does not do so without allowing the client some input. While this is not always possible it is recommended. As part of a protection, care and support plan (PCSP) psychologists Protection, care and support plan: A plan to need to consider each individual’s situation, including their risk and supportive ensure that vulnerable factors, their underlying psychological issues and their social situation (APS clients have a clearly 2008). When clients are at high risk, as in the case above, immediate shortformulated strategy for treatment and support. term treatment and reassessment are necessary, often including hospitalisation. When there are lower levels of risk, the focus of treatment and reassessment can be on days and weeks. To maintain their ethical obligations, when developing a PCSP psychologists need to consider the time-frame between sessions so that appropriate supports can be set up. If the client is going to be seen again in 24 hours the resource and supports should reflect the time-frame between visits. If a low-risk client is not going to be seen for two weeks, community and long-term social supports are needed. Clients with thoughts of self-harm and suicide need to be provided with a broad array of social, community and medical supports, and a GP or psychologist should form only part of this support network. The main aim of the PCSP is to protect the client from harm by pulling resources together to systematically support the client and provide assistance for ongoing treatment. A recent NSW Coroner’s Court (2010) fi nding has supported the use of such plans. The use of a plan will assist psychologists to fulfil their obligation to protect the client. While there will be an initial PCSP, after each subsequent session/reassessment the PCSP must be reimplemented, adjusted or replaced. This process will continue until the client is not at risk of harming himself and a broad lifelong PCSP can be set up in case the client’s suicidal ideation re-emerges. Based on the suicide risk assessment, the psychologist will need to determine the duration between appointments with the psychologist (APS 1999). High-risk patients should be seen and reassessed within 24 hours, while clients with a low level of risk should been

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seen again within one month (O’Connor et al. 2004). However, clients need to be given additional resources, plans and contact information in case they need assistance or their situation changes between sessions. In emergency cases such as Scott’s, the psychologist needs to provide resources that will meet the potential needs of the client in the next 24 hours. In other cases, where the client is low risk and there is a longer duration between sessions, the client may need different resources. These may include tools and techniques to avoid situations that can lead to negative behaviours (e.g. alcohol and drug use), checklists or electronic reminders that stimulate positive cognitions, contact points for general support, and a step-by-step plan to seek assistance if the client’s condition deteriorates. For most clients, their PCSP will involve other people who can provide assistance in addition to the treating psychologist. As can be seen in the case study, this may include specialists in the field or family members. It can also include community support services, emergency services or other medical/healthcare professionals. However, the key ethical requirement is to ensure that unless the disclosure of confidential information is the only way to avert harm to the client (the Code A.5.2.c), the client has consented to it. It is also important that the psychologist helps the client to choose individuals who are capable of emotionally supporting him and are not going to be a negative influence in relation to his suicide ideation. For example, children, elderly parents, peers with drug or alcohol issues or individuals that the client does not know well can be uncomfortable, unsuitable or unable to assist him through this critical period. Since a person providing support may have to deliver a high level of care it is important for that person to have the requisite degree of maturity and responsibility in dealing with the issues. However, except in the case of clients who are minors, the psychologist is unlikely to have previously come into contact with the person the client suggests as someone who can support him. Therefore the psychologist will have to evaluate this support person and ensure that she is capable of fulfilling her role in the PCSP. If the psychologist does not believe that the support person can provide the level of care needed, the PCSP will need to be altered to reflect this. In relation to other professionals, either for referral to conduct further assessment or in the provision of ongoing care, client confidentiality (the Code, A.5), professional responsibility (B.3) and competence (B.1) are important ethical considerations. Where possible, clients should be allowed to choose which other healthcare professionals to involve. This may not be possible in emergency situations. When possible it is beneficial, as it helps to maintain the therapeutic relationship. When referring clients for ongoing care such as in the case study, it is important that the client is referred to an appropriate service or psychologist. Since the client will have developed some degree of relationship with the initial psychologist, it is important that the psychologist he is referred to does not need to refer him again, as multiple referrals may reduce a client’s commitment to the services being provided. As part of this process it is important to consider the competency of the psychologist to whom the referral is made. The treatment of clients with suicidal ideation needs to be coordinated and must not devolve into a case of continued referral to avoid service provision to a difficult client. When referrals are made it is vital that psychologists cooperate (the Code B.8) with the psychologist or services that are going to be providing the client with ongoing care, given other ethical considerations such as confidentiality (A.5).

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APS Code B.8 B.8. Collaborating with others for the benefit of clients B.8.1. To benefit, enhance and promote the interests of clients, and subject to standard A.5. (Confidentiality), psychologists cooperate with other professionals when it is professionally appropriate and necessary in order to provide effective and efficient psychological services for their clients. B.8.2. To benefit, enhance and promote the interests of clients, and subject to standard A.5. (Confidentiality), psychologists offer practical assistance to clients who would like a second opinion.

A recent fi nding by the NSW Coroner’s Court (2010) has stressed that all healthcare workers should ensure that referring professionals are aware of the management of the client. As part of this process for clients with suicidal ideation, the question of responsibility for the client’s welfare needs to be considered, agreed upon and documented. As could be seen in the case study above, Javid remained responsible for Scott’s well-being until he had seen the psychologist he had been referred to. Throughout this entire treatment and assessment process the psychologist should attempt to consider and maintain client independence and autonomy. During the emergency stage there may be a need to focus on well-being and safety rather than autonomy, but as the treatment progresses, or immediately for low-risk clients, there should be a return to a focus on client-driven practice. This could be, as in the case study, where giving the client options that equally maintain ethical practice allows him some autonomy. This section has covered the major ethical issues when working with clients with suicidal ideation. All psychologists should be aware of and comfortable with a number of empirically supported clinical tools and techniques that are suitable for working with such clients. It is important that psychologists remember that each client will have a unique presentation and will need individualised assessment and treatment, taking into account his demographic and personal risk and resilience factors. The entire progression of client presentation, assessment, reassessment and protection should be well documented. Psychologists should always seek supervision from experienced psychologists in the field and geographic location (though the authors acknowledge that rural psychologists may have to rely on technology to maintain supervision requirements) in which they operate, to ensure that they have developed and maintained the skills required to practise within the ethical obligations covered in this section. Psychologists should also seek supervision if they are aware of strong personal views on suicide or if working with clients with suicidal ideation is causing them discomfort.

Self-harm and behaviours that place the client at risk Self-harm, habitual self-harm or self-injurious behaviour (for an attempt to clarify the terminology and develop a consistent use of the terms see Silverman and associates 2007a,b)

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are not typically considered a suicide attempt, but the relationship between self-harm and suicide is complex and not yet fully understood in Australia (LIFE Communication 2008). Because of the incomplete understanding and problems with terms, psychologists must maintain ongoing education in this area to ensure that they are aware of the most current information available in the literature. For the purpose of this section and the discussion of the ethical issues involved, however, self-harm will refer broadly to all behaviour that a client undertakes that places him at risk of harm without the express desire to take his own life. These self-injurious behaviours could include deliberate cutting or burning of his own skin, risky behaviours such as excessive drug abuse or drink driving, and other behaviours that clients are involved in that could cause harm to themselves. It is important to note that from a treatment perspective each of these behaviours would require substantially different clinical tools and techniques, but from an ethical perspective there are many similarities between the requirements placed on a psychologist when clients are putting themselves in danger. It is important to note that psychologists should conduct a full suicide assessment if they believe that a client’s self-harming behaviour is in fact indicative of suicidal ideation. Many of the ethical issues apparent in working with clients with suicidal ideation are also present when working with clients who are placing their safety at risk in some other way (APS 1999). The problems in classification means that the exact number of individuals deliberately injuring themselves in Australia is unknown. De Looper and Bhatia (2001) report that there are up to ten times the number of hospitalisations for self-inflicted harm as there are deaths due to suicide. If this prevalence rate is still accurate and given the 2361 deaths by suicide (ABS 2012), this indicates that around 23 000 hospitalisations for self-harm occur in Australia each year. However, this figure focuses on deliberate self-harm (e.g. cutting and burning) rather than injuries and accidents that are caused by dangerous behaviour. There is little specific guidance on self-harm from the APS. Psychologists need to consider the overarching responsibility to protect a client’s welfare while maintaining their autonomy, to do no harm and also balance the competing harms that may be present in a situation. These overriding concepts will guide the following sections.

Deliberate self-injurious behaviour From an ethical perspective, deliberate self-injurious behaviour focuses on Deliberate self-injurious clients who are deliberately harming themselves. This form of behaviour can behaviour: This can include clients cutting, scratching include clients cutting, scratching or burning their body, but can also include or burning their body, but clients punching themselves or using objects to cause pain. Psychologists can also include clients should conduct a full suicide assessment if they believe that a client’s behaviour punching themselves or is in fact indicative of suicidal ideation rather than deliberate self-injurious using objects to cause pain. behaviour. Some deliberately self-injurious behaviours can harm others, such as deliberately provoking others. This type of behaviour and the ethical issues associated with harming others will be covered in the next chapter. For now, consider the case study of Billy.

CASE STUDY 7.2

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Billy is a 19-year-old female who has moved from Northern Queensland to attend a university on the Sunshine Coast. She has recently begun seeing Todd, one of the psychologists at the university welfare centre. Billy has been experiencing anxiety because of the relocation and the separation from her family and friends. After a few sessions Billy reveals that she has been cutting herself. Upon further discussion with Todd, Billy explains that she cuts herself when the anxiety gets to be too much for her to cope with. After further discussion and assessment Todd ascertains that Billy is not attempting to end her own life, is not cutting herself deeply, and is treating the wounds with antiseptic. It appears that the selfinjurious behaviour is a coping mechanism. Todd enquires if there are any family or friends in the area that Billy could contact and bring to a session to give her some ongoing social support. Billy says that all her family and friends are in northern Queensland and she does not want to worry them. Todd decides to continue with the treatment for the anxiety but increases the frequency of the treatment. He suggests some strategies to develop a social network at university and provides details of local community mental healthcare groups. He also helps Billy develop a plan to enact if she has a change in intensity of the self-injurious behaviour or develops thoughts of harming herself in different or more damaging ways.

Todd’s fi rst concern is the immediate welfare of Billy. As was shown in the section on suicidal ideation, there is a conflict between the client’s autonomy (General Principle A of the Code) and the psychologist’s primary responsibility to protect the client. From an ethical perspective, in the case of Billy the continued treatment of the anxiety without any specific treatment of the self-injurious behaviour may be the appropriate approach. If Todd was to breach confidentiality, with or without Billy’s consent (A.5.2.c), and contact emergency services or a next of kin, the therapeutic relationship might deteriorate. This might result in Billy no longer seeking assistance from Todd or any other service for the anxiety, and this might lead to an escalation in the self-injurious behaviour to a point that serious or life-threating harm is occurring. In this situation there is a need for the psychologist to consider which of the harms is potentially the worst for the client. With no suicidal ideation or risk of serious physical harm in the short term, it may be ethically sound not to interfere with a client’s harm to herself as long as there is ongoing monitoring and there is an improvement in the anxiety and subsequent self-injurious behaviour. However, consider the same case with some minor changes.

Billy is a 19-year-old female who has moved from Northern Queensland to attend a university on the Sunshine Cost. She has recently begun seeing Todd, one of the psychologists at the university welfare centre. Billy has been suffering anxiety and depression because of the relocation and the separation from her family and friends. She has also been hallucinating after taking various illicit drugs. After a few sessions Billy reveals that she has been cutting herself. Upon further discussion with Todd, Billy explains that she cuts herself at random times when things are too much for her to cope with. She started to cut herself on the thigh but now cuts her wrists and throat and does not treat the wounds in any way. Billy says that she does not want to end her life.

In this scenario Todd may be more concerned about Billy’s well-being than in Case Study 7.2, and may be ethically required to do more to protect her welfare. He may consider substantially increasing the frequency of appointments and helping Billy develop a more comprehensive plan to avoid situations that lead to her self-harm. He may also help her work towards reducing her drug-taking in an attempt to allow her to gain a better understanding of her moods and behaviour. Todd may also consider trying to refer Billy to a medical professional to help with her wound management. If the university welfare service that Todd works for does not have the necessary resources, or Todd lacks competence in cases of this kind, he may consider referring Billy to specialist services in the area. In this scenario there is probably no one that Todd could disclose this information to that would benefit Billy. However, if there was a family member or partner who could be contacted it could be ethically necessary to do so if Billy’s condition worsened. Todd may also provide details of community or government support services to provide assistance and services between appointments. If these initiatives are not successful Todd may consider hospitalisation in consultation with appropriate medical practitioners. As can be seen from these two scenarios, there is a need for substantial clinical judgment when working with clients who engage in deliberate self-injurious behaviour. This process should be fully documented and retained in the client file. The level of harm caused by the behaviour needs to be compared to the harm of directly treating the behaviour through hospital or other intervention. In some cases treating the underlying issues may remedy the situation. Psychologists should always seek the input of experienced psychologists and supervisors in their decision-making about clients who are injuring themselves. They should also continually educate themselves and receive professional development regarding self-injurious behaviours.

Dangerous or risky client behaviour that endangers the client Clients may seek the help of a psychologist to reduce their risky or dangerous behaviours. This may be to reduce or eliminate drugs, alcohol or other behaviours or thoughts. In most circumstances the main ethical issue, as long as no third party is at risk of harm,

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is competence. For example, if a client sought the assistance of a psychologist to reduce her problem drinking, the main ethical issue would be the psychologist’s knowledge and competence in selecting and implementing a treatment protocol. It is important to note that in a situation such as this there may be a third party at risk (e.g. the client regularly drives a car while intoxicated with her 3-year-old daughter as a passenger); these matters will be covered in the next chapter. When clients are seeking treatment for another problem and then raise instances of behaviour that the psychologist perceives to be risky or dangerous, the psychologist needs to consider client autonomy and the client’s right to live her life as she chooses. Psychologists need to be mindful of their own values and assumptions and ensure that they are not infringing client autonomy. For example, many people engage in extreme sports such as base jumping or white-water rafting. While these are inherently high-risk activities, many people consider them to be recreational activities. There are also certain cultural or tribal practices that may appear dangerous to outsiders. As long as the client is voluntarily involved, appears capable of understanding the risks of these pastimes and is not using them as a form of distraction from an underlying psychological disorder, these are not activities that a psychologist should discourage per se. Nor should the psychologist attempt to discuss these matters if they are not relevant to the client’s presenting issue. If the client appears to be unhealthily involved in risky or dangerous behaviours the psychologist will need to consider the ethical issues of autonomy and value judgment before intervening to protect the client. In this case the psychologist would need to proceed in that same way as if treating deliberate self-injurious behaviour, primarily considering the competing harms. Again, this is a highly complex area and psychologists should consult experienced colleagues to gain a deeper understanding of the issues given the field of psychology and the location in which they practise.

Illegal behaviour There can be situations where clients are seeking assistance for a behaviour that is illegal but not directly harming others (harm to others will be considered in Chapter 8). Psychologists in this situation need to consider the dilemma of reporting the criminal offence or continuing with the treatment. For example, a psychologist may work with a client who seeks assistance in eliminating her addiction to cocaine and the shoplifting she conducts to support the addiction. In this situation the client is committing criminal offences by possessing cocaine and thieving, but she is also seeking treatment. In this situation the psychologist needs to consider the impact of reporting a crime to the police (the cocaine possession and theft) and the client’s response to this breach of confidentiality. If the psychologist reports the crime it is unlikely that the client will continue with any form of psychological assistance. Therefore there is a chance that she will continue to use cocaine and may receive a criminal conviction. The psychologist may choose to point out that the behaviour is illegal but will not report it because the client is actively attempting to reduce and eliminate the cocaine use. In this situation the psychologist will be acting ethically as he is supporting the client in positively changing her situation. However, this is a very specific situation; more complex clinical presentations (especially those that place the client or others at risk of harm) will require different ethical responses from the psychologist. As always, psychologists should consult experienced practitioners in

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their field to develop their knowledge and understanding, but they should always be mindful of the negative impact on the therapeutic relationship of disclosing confidential information without the client’s consent.

CHAPTER SUMMARY This chapter has shown the importance of protecting clients from harm. In the case of clients who pose a risk of taking their own life, the protection of their physical welfare outweighs their right to autonomy. It is a psychologist’s ethical obligation to protect their client’s welfare in this situation. Psychologists are also ethically required to undertake comprehensive suicide assessment with clients when they appear to be at risk of taking their own life. Finally, psychologists must develop a plan, in conjunction with the client where possible, to protect, care for and support their clients. This entire process should be well documented. In relation to deliberate self-injurious, risky, dangerous or illegal behaviour psychologists must be aware of the sometimes competing ethical obligations of client confidentiality (the Code A.5), professional responsibility (B.3), competence (B.1) and client autonomy (General Principle A). Taking into account the complex presentation of each client, the psychologist must provide the psychological service in a competent manner that promotes client confidentiality and autonomy while focusing on protecting the welfare of the client. Psychologists should also be mindful that in many situations there will be the potential for multiple harms, and ethically they must attempt to balance these harms and assist the client to achieve the most beneficial outcome.

QUESTIONS TO CONSIDER 1 2 3 4

Could you objectively discuss issues such as suicide and/or euthanasia with clients? If not, what steps could you take to increase your competence in this area? Who should or should not be considered when attempting to find a person to support a client with suicidal ideation? Considering the field of psychology you do or would like to work in, what are the key steps you could take to ensure the client’s immediate safety? What is the role for psychologists in the consideration of legalising euthanasia?

REFERENCES ABS (2012). Suicide in Australia. 3309.0 released 24/07/2012. Andersen, U.A., M. Andersen et al. (2000). Contacts to the health care system prior to suicide: A comprehensive analysis using registers for general and psychiatric hospital admissions, contacts to general practitioners and practising specialists and drug prescriptions. Acta Psychiatrica Scandinavica 102(2): 126–34.

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APS (1999). Suicide: An Australian Psychological Association Discussion Paper. Melbourne: APS. . APS (1996/2008). Psychological perspectives on euthanasia and the terminally ill: An APS Discussion Paper prepared by a Working Group of the Directorate of Social Issues. Melbourne: APS. APS (2008). Guidelines Relating to Suicidal Clients. . APS (2011). Guidelines for Providing Psychological Services and Products using the Internet and Telecommunications Technologies. . Conwell Y., Duberstien P.R., Cox C., Herrmann J.H., Forbes N.T. & Caine E.D. (1996). Relationships of age and axis I diagnosis in victims of completed suicide: A psychological autopsy study. American Journal of Psychiatry 153, 2002–8. Coroner’s Court NSW (2009). Inquest into the death of AB, a police officer. . Coroner’s Court NSW (2010). Inquest into the death of Charmaine Margaret Dragun. . de Looper, M. & Bhatia, K. (2001). Australian Health Trends 2001 (AIHW Cat. No. PHE 24). Canberra: Australian Institute of Health and Welfare. Government Department of Health and Ageing. . LIFE Communication (2008). Living Is for Everyone (LIFE) Framework. . Nock, M.K., Hwang, I., Sampson, N.A., & Kessler, R.C. (2010). Mental disorders, comorbidity and suicidal behavior: Results from the National Comorbidity Survey Replication. Molecular Psychiatry 15(8): 868–76. O’Connor, N., Warby, M., Raphael, B., & Vassallo, T. (2004). Changeability, confidence, common sense and corroboration: Comprehensive suicide risk assessment. Australasian Psychiatry 12, 352–60. Pirkis J., & Burgess P. (1998). Suicide and recency of health care contacts: A systematic review. British Journal of Psychiatry 173, 462–74. Silverman, M.M., Berman, A.L., Sanddal, N.D., O’Carroll, P.W. & Joiner, T.E. (2007a). Rebuilding the Tower of Babel: A revised nomenclature for the study of suicide and suicide-related behaviours, Part 1: Background, Rationale, and Methodology. Suicide and Life Threatening Behaviour 37, 248–63. Silverman, M.M., Berman, A.L., Sanddal, N.D., O’Carroll, P.W., & Joiner, T.E. (2007b). Rebuilding the Tower of Babel: A revised nomenclature for the study of suicide and suicide-related behaviours Part 2 : Suicide-Related Ideations, Communications, and Behaviors. Suicide and Life Threatening Behaviour 37, 264–77. Stark, C.R., Vaughan, S., Huc, S. & O’Neill, N. (2012). Service contacts prior to death in people dying by suicide in the Scottish Highlands. Rural and Remote Health 12, 1876. .

8 Working with Clients who Pose a Risk to Others

CHAPTER OBJECTIVES • • • •

To understand the legal and ethical issues of working with clients who pose a risk of harm to third parties To understand the issues related to client criminal activity To understand a psychologist’s legal and ethical obligations in relation to suspected child abuse or abuse of other vulnerable groups To be aware of the potential risk of harm to psychologists from clients and measures to reduce the risk

KEY TERMS Autonomy Breach of confidentiality Child abuse

Confidentiality Decision assistance model Identifiable third parties

Mandatory reporting of child abuse Neglect

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Introduction In the course of their professional lives psychologists will work with clients who pose a risk of harm to people other than themselves. This could be a family member, a workmate, a random stranger or even their psychologist. In these situations psychologists need to consider if there is a risk of harm to an identifiable third party. If there is, the psychologist is ethically able to breach confidentiality to inform the authorities or other parties, in some situations. This chapter will consider a number of legal and ethical issues that need to be evaluated in this situation, such as the level, the type of harm and what other courses of action may be possible. T he  chapter will also consider the issues of child abuse and criminal acts committed by clients.

CASE STUDY 8.1

Identifiable third parties: A person or persons discussed and identified by the client who may be at risk of harm based on information provided by the client.

Clients who pose a risk to others There is currently no legal duty for psychologists to disclose confidential client information when they present a risk of harm to identifiable third parties (Kämpf et al. 2008). While there is no legal obligation to do so, psychologists are permitted to disclose confidential client information to protect an identifiable third party (McSherry 2008). Consider the case of Terry below.

Terry is a 35-year-old male who is seeing a psychologist, Richard, to assist with aggression and volatility. Terry was initially uninterested in the treatment and it was only with the encouragement of his wife, Pam, that he attended the first session. Now he has attended 12 sessions and seems genuinely committed to reducing his anger and aggression. In his twelfth session Terry made a vague suggestion to Richard about his involvement in a criminal gang. Terry says that with his new perspective on his behaviour and aggression and with his wife expecting their first child he is trying to leave the gang and spend more time with his family. However, he says that he has to do one more ‘job’ to do before leaving the group. When pressed further, Terry reveals that the ‘job’ involves acts of physical aggression towards a member of another gang. When Richard points out that, as discussed in the informed consent procedure, he may have to breach confidentiality to protect third parties, Terry becomes verbally aggressive towards Richard.

This case highlights some of the key concerns that will be covered in this chapter. The primary concern, as it was in the previous chapter on clients who pose a risk of harm to

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themselves, is the conflict between client autonomy and the potential action a psychologist may take to protect a third party that breaches confidentiality. In this case does Richard breach confidentiality to protect a third party or does he maintain Terry’s confidentiality? There is also the question of the identity of the third party. As can be seen later in the chapter, the ability to identify the third party can be complex. Psychologists need to consider if there is any other way that the harm could be averted. They also need to consider the vulnerability of the third party in weighing up the confidentiality versus disclose dilemma. If the party at risk of harm is a child, mandatory reporting of child abuse legislation may be relevant. While there is no specific legislation on mandatory reporting for other vulnerable groups (e.g. the elderly or cognitively impaired), the level of vulnerability may influence a psychologist’s decision-making in favour of disclosing. Psychologists also need to be aware of their own safety and the safety of other staff and clients. It is important to note that international legal cases such as Tarasoff in the USA (see Chapter 1) and Smith v Jones in Canada are not directly relevant to Australia in a legal context (Kämpf et al. 2008). There is debate in the Australian ethics literature (e.g. McMahon 2006; Kämpf et al. 2008) regarding what, if any, influence cases such as these would have in the Australian legal system should it be tested. While these cases have no direct effect on current Australian laws, they do make for interesting discussion and can provide some further insights into the topic for psychologists and students who desire a deeper understanding of the issues involved. They  a re not covered in this book but are widely available for those who are interested in the topic.

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Autonomy: The client’s right to make decisions for herself; psychologists should be mindful of a client’s autonomy vis-à-vis any discussions on any service provided.

Breach of confidentiality: It may be necessary to breach confidentiality if the psychologist is ordered to do so by a court or if the client or another identifiable person is in danger.

Mandatory reporting of child abuse: The legal requirement in some Australian states for psychologists to report actual or suspected child abuse to the appropriate authorities; not to be confused with mandatory notifications.

Legal and ethical issues when working with a client who poses a risk of harm to third parties As mentioned above, there is no legal obligation on psychologists in Australia to disclose confidential information to protect third parties. As Kämpf and colleagues point out, neither the Code of Ethics nor the APS (2005) Guidelines for Working with People who Pose a High Risk of Harm to Others explicitly states that psychologists must disclose instances of potential harm to third parties. This would indicate that the APS and the Psychology Board of Australia, the national registration body that has endorsed the Code of Ethics, support the notion that psychologists may, where appropriate, disclose confidential information to protect third parties. However, that decision is to be made for each case by the expert with the best knowledge of the facts, the psychologist who is working with the client. Using a decision assistance model (see Chapter 3), psychologists should, in consultation with experienced colleagues and/or legal experts where possible, attempt to evaluate the risk of harm. If there is a serious risk of harm and there is an identifiable third party, only then should a psychologist consider breaching confidentiality under A.5.2.c of the Code (Davidson et al. 2010).

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APS Code A.5.2 Psychologists disclose confidential information obtained in the course of their provision of psychological services only under any one or more of the following circumstances: (c) if there is an immediate and specified risk of harm to an identifiable person or persons that can be averted only by disclosing information;

The only exception to this is when a child is involved and mandatory reporting requirements exist (see below). It is important to note that the criminality or non-criminality of a threat of harm is not a guiding factor. Psychologists should evaluate the risk of harm to the third party independently of the legality/illegality of the client’s behaviour.

Risk of harm As was discussed in the previous chapter on harm to self, psychologists should conduct a thorough risk assessment if they believe that a client is likely to cause harm to a third party. As is detailed in standard A.5.2 of the Code, the risk would need to be immediate and specific, and to concern an identifiable third party. Standard A.5.2 also states that disclosure is only permissible when the only way to avert the risk of harm is the disclosure of confidential information. This highlights three key issues: who is at risk; what is the level of risk and the type of harm; and are there any other ways of averting the harm? This will be discussed in the next section. While the following sections provide hurdles to breaching confidentially, we are not trying to convince psychologists not to breach confidentiality. When it is the only way to protect a third party, or the treating psychologist, from substantial harm psychologists may ethically disclose the relevant information to the relevant authorities or the third party. However, this should not be done without due consideration and should not be a common occurrence for most psychologists. Confidentiality is a core aspect of Confidentiality: In a the client–psychologist relationship. Breaching it will have an impact on that therapeutic relationship between psychologist relationship and needs to be a last option. In many situations discussing the and client, certain details issue or threat with a client may clarify a misunderstanding; it may also help are protected and should a client realise that an aggressive threat is inappropriate. When it is remain confidential between necessary, however, psychologists should take the appropriate steps to the parties. protect third parties from serious harm.

Who is at risk? Standard A.5.2.c states that psychologists need to consider if there is an identifiable third party before they can ethically disclose confidential client information to avert harm to third parties. While this can seem straightforward, it can be more complex. If a client makes a threat against a group or an individual these people may or may not be specifically identifiable. For example, the following groups cannot be individually named but are identifiable: all the diners

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in a restaurant, the kid in my class that always steals my lunch, the crowd at the next Sydney Swans game, my neighbour who does not mow his lawn, and so on. In these examples, while the client has not specifically named anyone, the broad group or specific individual could be identified through the information provided. However, if a client says that he is going to hit the next person that cuts him off on the roundabout, that person is not identifiable. Similarly, when a client makes sweeping statements such as ‘I’m going to kill everyone…’, it needs to be considered within the psychologist’s training and her knowledge of the client. She needs to evaluate whether this is a genuine threat or simply a throwaway comment. Psychologists also need to be aware that in some cases the client may also be at risk. This may be intentional, as in a murder-suicide event. It could also be that in carrying out a particular act of harm the client will fi nd himself in a highly dangerous situation. In these situations psychologists need to consider the welfare of both the client and the third parties and if necessary take steps to protect all parties.

What is the risk and type of harm? When considering whether to breach confidentiality, psychologists need to evaluate the interplay between the level of risk and the type of harm. Consider the figure below. High

Level of harm

Carefully monitor the situation and discuss the threat with the client to determine intent

Considering breaching confidentiality

Be aware of the threat and monitor the situation

Low level of harm, breaching confidentiality would not typically be ethical

Low

Low

High Risk level

Figure 8.1

Client harm–risk determination

There are some threats of harm from clients that would not necessitate a breach of confidentiality: the bottom level of the figure (Note: please see the section below on mandatory reporting of child abuse and other considerations for vulnerable populations). For example, McSherry (2008) limits her discussion of disclosure to threats to kill or serious injury; the APS in its 2005 Guidelines focuses on sexual harm, violent acts and threats. This tells us that there are some behaviours that psychologists consider harmful enough to potentially breach confidentiality. Even when working with adolescents, however, practising psychologists consider some potentially harmful behaviours not harmful enough to warrant disclosure to parents or the authorities (Duncan et al. 2012). Australian psychologists will therefore have a hierarchy of harm that they will consider when deciding whether to breach confidentiality. Since A.5.2.c only describes harm, psychologists will need to consider the type of harm that

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is potentially going to be directed at a third party. For example, if a client resolves to verbally confront her partner about their inability to communicate, this could realistically lead to harm to the partner in the form of emotional distress. However, a psychologist would not consider breaching confidentially to warn the partner about this kind of harm. Equally, a client may categorically state that she is going to kill her boss the next day, which would likely result in a psychologist breaching confidentiality to protect the boss. These are the two Decision assistance model: extremes of potential harm. Each psychologist would need to consider at A model whose purpose what point along the continuum she would consider serious harm beginning is to help a psychologist systematically consider all and would therefore use a decision assistance model (see Chapter 3) to aspects of an issue before determine if she would breach confidentiality. It is also important for deciding on an outcome psychologists to focus on harm rather than if a crime is being committed. which is both ethical and While they will often occur together, psychologists need to focus on the focused on client welfare. potential for harm to occur. Psychologists also need to consider the level of risk when a client makes a threat. As was discussed in Chapter 7, risk assessment tools, while not without faults, can provide psychologists with information to support or supplement their clinical judgment. A risk assessment model might include client personality and aggression characteristics, previous behaviour, level of empathy, and so on. Psychologists need to consider the risk of clients carrying out their threats or if a comment that suggests harm to a third party is a genuine risk of harm or a harmless throwaway line. Psychologists should then evaluate the risk of a client carrying out the threat of harm together with the level of harm. In the top section of Figure 8.1 might be acts such as threats to kill, sexual violence or acts that are likely to result in death even if that is not the intention. Except in the lowest levels of risk (idle comments or throwaway lines), for these most harmful of acts the psychologist would consider breaching confidentiality. She would therefore consult colleagues and use an ethical decision assistance model (see Chapter 3) in deciding whether to breach confidentiality. Combinations of risk and harm that fall in the middle sections would require further clarification and/or ongoing monitoring before deciding if the potential for a confidentiality breach should occur. Using Figure 8.1, psychologists would also need to be aware of the identity of the third parties that may be at risk of harm. The fi nal point in standard A.5.2.c that psychologists need to consider is if there are alternatives to disclosing confidential information.

Alternatives to disclosing confidential information When considering disclosing confidential information to protect third parties, psychologists need to consider if there are any alternatives. Given the typical work situations of psychologists, there may be other, limited options to disclosure if the third party is identifiable and the level of risk and harm warrants action. Psychologists could potentially discuss the matter with the client and agree to take further action to avert the harm, such as hospitalisation. However, the instances of conditions that would necessitate hospitalisation and the client having the capability to make such voluntary informed decisions would be limited. There may be cases where the psychologist can convince the client not to take the action. This should only be done if it does not put the psychologist’s safety in jeopardy. While there are limited situations in which there are viable alternatives to disclosing confidential information, if a psychologist does decide to act she should always consider any possible alternatives in her decision-making.

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Other issues in disclosing confidential client information to protect third parties

Stephanie is a 65-year-old woman who is seeing Charles, the psychologist, to help her make decisions about planning for the rest of her life. Currently, Stephanie is in good health and is not experiencing any debilitating cognitive decline. She decided to see a psychologist to ensure that she was considering all the options and did not have any underlying conditions that might be making her irrational. Stephanie is a widow and quite wealthy. Her current will leaves her large share portfolio to one of her children, the family home to another and her extensive art and jewellery collection and a small holiday house to the youngest child. Recently, however, she is considering going on an extensive world trip and donating heavily to her favourite charities. She suggests that her children need to learn to fend for themselves and that her money could be better spent enjoying her life and helping the less fortunate. After a full cross battery cognitive assessment, executive functioning assessment and personality assessment, Charles cannot find any evidence to suggest a psychological impairment, cognitive decline or psychological condition that might be influencing her decision-making. Stephanie thanks him and says that she has an appointment with her stockbroker and real estate agent later in the week to begin liquidating some of her assets.

In this situation there is a clearly identifi able individual (the eldest child who is listed as Stephanie’s next of kin in her consent paperwork), who is going to be fi nancially harmed as a result of Stephanie’s actions. However, it is the psychologist’s role to assist the client. The psychologist would need to focus on Stephanie’s needs and assist her, given the nonphysical risks that are involved. The psychologist might help Stephanie explore her options

CASE STUDY 8.2

While the decision to disclose confidential information is a conflict between a client’s autonomy and protecting the welfare of a third party, it is also relevant to consider the client’s best interests. There may be many situations where intervening early, before a client harms a third party, can be in the client’s best interest. Taking steps to prevent the client’s action may have fewer long-term negative outcomes for the client than allowing him to commit a harmful act. This again is something that psychologists will need to consider in cases where it is relevant. Psychologists should always try to work with clients in dealing with the direct or underlying issues that may be contributing to their deliberately harmful actions. As mentioned previously, this may not be the case if the client is confronting somebody in a therapeutic manner that has the potential for long-term positive outcomes for the client with short-term emotional harm to the third party. While psychologists must be mindful of substantial harm to third parties, in low-level harm situations they should focus on the welfare and well-being of the client. They should assist clients to achieve their goals even if these goals may not lead to positive outcomes for third parties. Consider the example below.

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and help her to work through the outcome of her actions to ensure that she was aware of the consequences. In this situation it is Stephanie, the client, that the psychologist is focused on, not the family as a whole. Breaching confidentiality is likely to have a profoundly negative impact on the relationship between the client and the psychologist (and potentially all future psychologists), so the decision to breach should not be taken lightly. However, if it is the only path to protect an identifi able third party and the level of harm and risk warrant it, a psychologist can ethically disclose confidential client information. Using a decision assistance model, being aware of his client’s characteristics and in consultation with supervisors or workplace managers, each psychologist would need to use his clinical judgment to determine what level of risk and harm would warrant disclosing confidential client information.

Client criminal activity Criminal activity can be a value-laden topic for many in the community, including psychologists. When working with clients involved in criminal activity, psychologists need to ensure that, as long as there is no risk of serious harm to an identifiable third party, their focus is on the well-being of the client. According to the Code of Ethics, psychologists can only disclose confidential client information if clients request it, if the psychologist is legally obliged to disclose it, if there is a risk of serious harm to a third party, or when consulting colleagues; psychologists cannot disclose information because a client’s crimes are considered morally objectionable by the psychologist. Psychologists need to consider the best interests of the client and damage to the therapeutic relationship that any disclosure may cause (Jifkins 2010). The awareness of the negative impact of disclosure should dissuade psychologists from making unethical disclosures based on moral or values judgments. They can only disclose information to the authorities about criminal activity without the client’s consent if they are legally required to do so or if an identifiable third party is at risk. There will be some situations where the psychologist is aware that there is a risk of serious harm to an identifiable third party. If there is no alternative, the psychologist should consider breaching confidentiality to protect the third party as he would in any non-criminal situation (as was covered above). The next section will consider the legal requirements in relation to reporting past, current and future crimes. According to the APS (2010), there are very limited circumstances that legally require a psychologist to breach confidentiality and report a client’s past or planned criminal behaviour. There are offences that relate to treason and related areas that are mandated in some regions. In New South Wales there is the theoretical possibility for anyone to be charged if he does not disclose information on serious crimes; but legal opinion suggests that it is extremely unlikely for psychologists to be charged under this legislation if they are acting in accordance with the APS Code (APS 2010; Jifkins 2010). The APS also highlights that if psychologists are receiving specific payment for not revealing information related to a criminal act—something that can happen—they are likely to be breaking the law. When faced with legal contexts as specific as these, psychologists should obtain independent legal information specific to their situation.

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Psychologists are also unlikely to be charged under criminal law for not reporting a client’s past crimes or intent to commit a crime in the future, although there is the potential for a civil case if the third party can show that they were owed a duty of care (APS 2010). Therefore, in working with clients, it is important for psychologists to consider to whom they owe a duty of care. When facing this situation psychologists should always consult experienced colleagues and obtain legal advice specific to their situation. Whenever psychologists are faced with decisions about the criminal activity or future activity of a client they should make use of a decision assistance model (see Chapter 3). This model should include references to the legal and ethical requirements and to discussing complex matters with colleagues.

Legal and ethical obligations in relation to suspected child abuse or abuse of other vulnerable groups Mandatory reporting of child abuse is government legislation that requires certain groups within the community to report suspected abuse or neglect of children. In some states psychologists are mandated to report as part of their registration as a psychologist; in other states it is through the work location or employer (APS 2010). It is vital to note that the legislation, and the requirements within it, are different in each state and Child abuse: The territory of Australia and are updated occasionally. It is crucial that maltreatment of children psychologists are aware of the current legal requirements on mandatory by adults or other children significantly older than the reporting of child abuse in their practice location and are also aware of any child victims, e.g. physical employer requirements. Even the method of reporting differs between or sexual abuse. locations. Some employers, such as government departments, may require their employees to report suspected abuse or neglect. While this is not legally Neglect: The failure to mandated, psychologists may be contractually obliged to do so. As with any provide a reasonable level workplace condition, psychologists should inform all parties of this disclosure of care by the person responsible for providing requirement and gain consent before commencing service provision. This support. form of disclosure is ethically permissible under standard A.5.2.c of the Code relating to harm to a third party. When there is a legal obligation to report abuse and/or neglect, psychologists are not required to carry out a decision-making process, as discussed in Chapter 3. They are required to make the report regardless of the situational variables. However, psychologists do need to consider what constitutes a genuine suspicion of abuse and some level of decision-making will be required in this regard. Most of the mandatory reporting legislation uses terms such as ‘awareness’ or ‘reasonable suspicion of child abuse’ (Australian Institute of Family Studies 2012). Psychologists should note that legislation varies in the level of suspicion and types of abuse, and that they must be aware of the specific requirements in their location and employment situation. Psychologists need to use their professional training and skills to consider not only the physical signs of abuse but the psychological indicators of children being abused. It is in this area that they will need to employ their professional skills to differentiate behaviours and psychological symptoms that indicate

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abuse from other causes. According to the APS (2010), direct observation of abuse, a child or individual familiar with the child reporting the abuse, or professional observations indicating abuse or neglect, are enough to form a reasonable suspicion. If a psychologist suspects that there is abuse occurring and he is in a location that mandates him to report, he should do so. From an ethical perspective, however, even a psychologist in a non-mandatory environment would likely be ethically obliged to report, given the suspected harm to a third party and the vulnerability of the victim. When considering breaching confidentiality to protect third parties from harm (e.g. using Figure 8.1 above), psychologists also need to consider the vulnerability of the third party. There are currently no mandatory reporting requirements for older or vulnerable people in Australia (Jenkins 2010). However, psychologists should be aware of new legislation in this area or workplace policies that may require psychologists to report this form of abuse or neglect. These considerations would then need to be included in any informed consent procedure. When considering whether to breach confidentiality, the capacity of the third party should be considered. For example, older people who have a significant level of impairment, people with significant cognitive, psychological or emotional impairment, and children (unless in a mandatory reporting environment that requires immediate report) can be very vulnerable, and this would influence a psychologist’s decision to breach confidentiality to protect them. The structure in Figure 8.1 can still be used for vulnerable individuals, but the level of harm is increased for those who have increased vulnerability. For example, if a psychologist became concerned that a client was about to commit an assault, but was not certain, she might be more likely to breach confidentiality if the victim was a man in his eighties with a substantial cognitive impairment rather than a man in his twenties without any cognitive impairment; the older man is potentially more vulnerable.

Potential risk of harm to psychologists from clients Psychologists, their staff and other clients may face a risk of harm from clients displaying violent or aggressive behaviours. Regardless of the practice location or the types of clients they typically work with, all psychologists should consider assessing and managing risk as part of their regular practice. Those psychologists who typically work with client groups that the literature indicates are at a higher risk of violent or aggressive behaviour should undertake extensive planning and risk-minimisation procedures. These procedures would be entirely different for a psychologist working in a psychiatric hospital as compared to one working in a university research setting. However, all psychologists should take precautions to protect themselves and others in the workplace from potentially dangerous clients. While a psychologist’s working environment should be warm and professional, she should also consider safety in the design of her workplace. For example, she should have a seating arrangement that allows her direct access to the door, rather than having to get past a potentially aggressive client. She may also consider the placement of windows (or glass panels in doors) that allows a view of the psychologist from outside the office, while carefully ensuring that clients cannot be seen. This not only offers protection from dangerous clients

Chapter 8: Working with Clients who Pose a Risk to Others

but may also provide some protection against suggestions of sexual impropriety that may be difficult to disprove if the workplace is completely enclosed. Psychologists may also consider the installation of emergency alarms if they regularly work in the same workplace; alternatively, portable personal alarms or smart phone apps that alert support staff or the police in case of emergency could be useful. While these may lead to a breach of client confidentiality, this is ethical if a psychologist feels that she is in significant danger. In some practice settings psychologists may also consider procedures to evacuate the workplace or areas of the workplace (e.g. waiting rooms) to a safe location if a client is at risk of harming or causing serious offence to other clients. Psychologists also need to give serious consideration to the risks of home visits or providing services from a dual-purpose venue (e.g. a home office/practice). These workplace settings may put psychologists at increased risk of harm as there may be no support staff or services present. In this situation, it is not until after the initial visit that the psychologist will be aware of the potential dangers. Potentially, there could also be workplace health and safely issues if staff or students on placement are working in non-compliant workplaces. Psychologists also need to consider the ethical issues of dual relationships and the suitability of the location (e.g. children/spouse/neighbours interrupting) for service provision. If the psychologist is working from home or in a client’s home, the potential for non-professional interactions may be increased. Clients may also become aware of the living arrangements or the transportation methods of the psychologist, which may place her at additional risk of harm. Psychologists need to systematically evaluate all aspects of their practice in relation to their safety. These considerations should also cover their staff and other clients and family in the practice area. While some working environments may have physical limitation as to the measures psychologists can take, they should always have in place all possible solutions to protect themselves.

CHAPTER SUMMARY This chapter has discussed the ethical issues related to clients who pose a threat to others, including their psychologist. It emphasises that it is ethical to breach confidentiality to protect third parties in some situations. However, the type of harm and the vulnerability of the potential victim needs to be considered in any decision. Psychologists need to consider the client’s well-being and autonomy as against any obligation to protect an identifiable third party from serious harm. The chapter has also shown that only in exceptional circumstances, or in some states when children are involved, are psychologists required to report criminal activity. It will be the level of harm and the vulnerability of the potential victim that will contribute to any breach of confidentiality. Psychologists should focus on harm rather than crime in making decisions about breaching confidentiality. Psychologists need to consider the potential for clients to harm the psychologist or other clients. Precautions should be taken to provide a safe working environment. Psychologists should also be cautious about working with clients in their own home or the client’s home.

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QUESTIONS TO CONSIDER 1 2 3 4 5

Why is there the need to consider only the harm, and not the criminality, of a behaviour when breaching confidentiality? What is an identifiable third party? Would you breach confidentiality if a client reported that he was going to stand up to a bully in his workplace? What skills/techniques would you employ in ethically assessing if a child was suffering from abuse? How can psychologists increase their safely and/or ethical behaviour when they see clients in the client’s home or their own home?

REFERENCES APS (2005). Guidelines for Working with People who Pose a High Risk of Harm to Others. . APS (2010). Guidelines on Reporting Abuse and Neglect, and Criminal Activity. . Australian Institute of Family Studies (2012). Mandatory Reporting of Child Abuse and Neglect. . Davidson, G.R., Allan, A. & Love, A. (2010). Consent, privacy and confidentiality. In A. Allan & A. Love (eds), Ethical Practice in Psychology: Reflections from the creators of the APS Code of Ethics. West Sussex: Wiley-Blackwell, pp. 77–92. Duncan, R.E., Williams, B.J. & Knowles, A. (2012). Adolescents, risk behaviours and confidentiality: When would Australian psychologists breach confidentiality to disclose information to parents? Australian Psychologist. Early online publication. . Jifkins, J. (2010). Reporting abuse, neglect and criminal activity. InPsych 32(2), 32–33. Kämpf, A., McSherry, B., Thomas, S. & Abrahams, H. (2008). Psychologists’ perceptions of legal and ethical requirements for breaching confidentiality. Australian Psychologist 43(3), 194–204. McSherry, B. (2008). Health professional–patient confidentiality: Does the law really matter? Journal of Law and Medicine 15(4), 489–93. Smith v. Jones (1999) 169 D.L.R. (4th) 385 (Supreme Court of Canada)

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9 Ethical Issues in Research

CHAPTER OBJECTIVES • • • •

To understand the key ethical issues associated with undertaking research (as per the APS Code and the NHMRC National Statement) To evaluate the ethical risk associated with research projects, especially with regard to vulnerable groups To consider a famous historical experiment in light of ethical considerations at that time To be aware of the necessity to always consider client welfare both during and after the experiment has been completed

KEY TERMS Conflict of interest Duty of care Ethical conduct Evidence-based practice

Learning experiment Non-maleficence Psychological harm Research participant

Suicidal ideation Voluntary consent

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Introduction In this chapter we will consider the issues that pertain to psychologists and their research. Many psychologists will not do research in their applied clinical setting, but there are many involved in practitioner research, and in university research and teaching roles. However, all psychologists will need to read research fi ndings to develop and maintain their competence. As has been discussed in other chapters, the position of the psychologist is one of trust and integrity. It follows that participants taking part in research conducted by psychologists are afforded the same level of professional and ethical standards as the clients of psychologists. The general principles contained in the Code should also be considered in Research participant: A person (subject) association with the National Health and Medical Research Council (NHMRC) who is taking part in a National Statement, which is discussed later in this chapter. Research project involving some participants should not be subjected to anything that might affect their form of experimental design, for example a well-being. There are, obviously, many different types of research, but from standard experiment or the perspective of the psychologist in acting ethically the main premise is survey which in this case doing no harm, and in many ways this is no different from direct therapeutic would be conducted by a work. In considering ethical issues in research all the general principles (GPs) psychologist. of the Code have some relevance in this chapter but particularly B.14. Research.

The APS General Principles In order to refresh your memory and to make sure that that you have not blanked out at this stage, the General Principles are reproduced below.

The APS General Principles •

General Principle A: Respect for the rights and dignity of people and peoples. According to the APS Code (2007) this ‘combines the principles of respect for the dignity and respect for the rights of people and peoples, including the right to autonomy and justice’ (p. 6).

•

General Principle B: Propriety. This ‘incorporates the principles of beneficence, non-maleficence (including competence) and responsibilities to clients, the profession and society’ (p. 6). General Principle C: Integrity. This principle ‘reflects the need for psychologists to have good character and acknowledges the high level of trust intrinsic to their professional relationships, and impact of their conduct on the reputation of the profession’ (p. 7).

•

As we go through this chapter we will refer back to this case study and discuss how the different situations evolve and the implications for the psychologist in relation to the Code. See below for details of standard B.14 of the Code, which is the specifically important part that we need to be aware of.

Provisional psychologist Savannah Parkins was on a supervised placement at a local high school in Brisbane while studying for her MPsych in Educational Psychology at the University of the Eastern States. Savannah had to complete a research project as part of her degree and she used the opportunity in school to recruit students between the ages of 14 and 18. The students were asked to complete a questionnaire about bereavement, especially related to the death of close relatives. Savannah did not seek approval from the university’s Human Research Ethics Committee (all universities have this type of committee, which all correspond to the same principles of the NHMRC), as she already had permission from the school. The parents were not asked for permission but the students were each told that they did not have to participate if they did not want to. Savannah recruited 20 students to complete the questionnaire; ten of these were students that she had been counselling and they completed the survey at the end of the session. Savannah believed that being a psychologist to some of the students helped them feel at ease with completing the survey.

APS Code B.14 B.14. Research B.14.1. Psychologists comply with codes, statements, guidelines and other directives developed either jointly or independently by the National Health and Medical Research Council (NHMRC), the Australian Research Council, or Universities Australia regarding research with humans and animals applicable at the time psychologists conduct research. B.14.2. After research results are published or become publicly available, psychologists make the data on which their conclusions are based available to other competent professionals who seek to verify the substantive claims through reanalysis, provided that: (a) the data will be used only for the purpose stated in the approved research proposal; and (b) the identity of the participants is removed B.14.3. Psychologists accurately report the data they have gathered and the results of their research, and state clearly if any data on which the publication is based have been published previously.

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Shock at La Trobe University, 1973 As budding psychologists you should all be aware of the famous (or possibly infamous) Milgram obedience experiments that took place at Yale University in the early 1960s. We will come back to this experiment in more detail later, but as a brief summary the American psychologist Stanley Milgram asked unsuspecting volunteers to participate in a learning experiment. The volunteers were asked to administer electrical shocks in increasing intensity as the learner (an actor) continued to fail to get the answers correct Learning experiment: An experiment where the ability (Milgram 1964). The experiment was designed at a time when the Nazi war of the subject to do learning crime trials had a prominent focus in that for many former Nazis the defence tasks is investigated, such of ‘I was only following orders’ was used to justify various atrocities. The as Milgram’s infamous ‘shocking’ aspect of Milgram’s experiment was that obedience and conformity obedience experiment from the 1960s. were so easily attained. A recent publication by Australian author Gina Perry (2012) considers many issues surrounding these experiments, including an account of a replicated study at La Trobe University in Melbourne. One of the main reasons for having an ethical code, as we know, is to protect the client or the research subject because they may be in a position of vulnerability. Perry (2012) details the replication study at La Trobe in 1973, and an interview on ABC radio and in print in the Sydney Morning Herald (Elliott 2012) indicated the serious nature of doing experiments of this kind without proper ethical control. Dianne Blackwell, who was an undergraduate student at La Trobe in 1973, took part in the La Trobe version of the obedience experiments; when interviewed in 2012 in the SMH she said that even now she has been left ‘utterly gutted’ by the experiment. Her fl atmate, who was the ‘learner’ in the La Trobe experiment, recruited Blackwell. Blackwell stated: ‘With each incorrect answer I gave her an increased shock. She began by making a low noise, just “ouch” and “ooh”, but it got louder and louder and more and more distressed.’ Blackwell said that she then heard a ‘distressingly loud scream, like she was in real pain’ and then there was nothing, not a sound. ‘I remember thinking “I killed her”. And then this ridiculous thought went through my head, that if I give her one more shock it won’t matter because she’s dead.’ At this point Blackwell recalls that her friend emerged from the other room with ‘a big grin’ and told her that it was just a test on obedience (based on Elliott 2012). If we consider that Blackwell was recalling this event over 40 years after it happened and the apparent distress that she still experiences, we have a clear Ethical conduct: Behaviour that could reasonably be indication why it is necessary to have codes of ethics. This particular example construed as being within illustrates the potential negative affects of involvement in ethically dubious the bounds of ethical research. For this reason, psychological research should be developed and norms, in the practising refi ned based on gauging the risks and potential long-term ramifications of situation or in other areas of life. such research, as a key aspect of ethical conduct as a psychologist. Consider whether the research described in the Savannah case study led to this sort of harm.

Chapter 9: Ethical Issues in Research

Gauging risk and the NHMRC National Statement When considering conducting research, psychologists are required to adhere to ethical codes developed alongside the National Health and Medical Research Council, as well as any other appropriate national bodies such as the Australian Research Council. The NHRMC’s National Statement is the set of ethical guidelines that all research bodies must follow when considering whether a project is ethical or not. The purpose of the National Statement is ‘to promote ethically good human research’ (NHMRC 2007, p. 12). It provides the institutional review bodies (such as the research committee at your university) and researchers with clarification as to the ‘ethical design, conduct, and dissemination of results of human research’ (p. 12). The minimising of risk to any participant, as well as to the psychologist, is paramount, which is why there are strict procedures to ensure that ethically appropriate research is carried out. If we go back to the case study for this chapter and consider the actions of provisional psychologist Savannah Parkins in relation to the National Statement, we can attempt to understand whether appropriate consideration of the risk to the participants has taken place. In our case study, Savannah Parkins has decided to carry out some research on students who are up to 18 years of age. They were asked a set of questions about bereavement which specifically asked about people close to them who had died. Even with that brief part of the case study, we are in a position to consider the potential levels of risk that may be involved in the research. In gauging risk, the NHRMC suggests that the following must be taken into account: •

the kinds of harm, discomfort or inconvenience that may occur;

•

the likelihood of these occurring; and

•

the severity of any harm that may occur. (NHMRC 2007, p. 16)

If we consider that Savannah had asked students who were under 18, and potentially unable to give consent, to complete a survey (we also know that Savannah did not seek approval from an ethics committee), then we can understand the potential harm that could be caused to those students. The proper ethical checks were not in place to ensure that their well-being was uppermost in the design and administration of the survey. The NHMRC categorises research in which there could be inconvenience, discomfort and, fi nally, harm to the participants involved. The levels of risk can be thought about in distinct sections as detailed below: •

•

Negligible risk : This is the lowest form of risk where it is envisaged that there will be no discomfort and no risk of harm. The highest level of risk expected to result from this type of research is no more than inconvenience, such as travelling to the place of research or completing an online survey. Low risk: The only type of risk that is envisaged by the researcher is that of discomfort. Of course, what is regarded as ‘discomfort’ can vary from person to person, but as a universal rule anything that may be stressful to the participant is not low risk. For example, asking an adult about their general experiences of school may be at most slightly uncomfortable but it is unlikely (or foreseeable) to be stressful since there has been a reasonable time between the questions and the experiences being asked about. However, if you were to ask a question to students in Grade 8 about bullying then there is

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•

a reasonable chance that this could be more than discomfort and could not be considered low risk. Generally, any research involving people under 18 would be classified as ‘not low risk’ because of the vulnerability inherent in that age group. Not low risk: This is the category of risk that is at the most serious end of the spectrum, and the NHMRC puts them in distinct categories to aid the researcher. These are as follows: • physical harms: including injury, illness, pain; • psychological harms: including feelings of worthlessness, distress, guilt, anger or fear related, for example, to disclosure of sensitive or embarrassing information, or learning about a genetic possibility of developing an untreatable disease; • devaluation of personal worth: including being humiliated, manipulated or in other ways treated disrespectfully or unjustly; • social harms: including damage to social networks or relationships with others; discrimination in access to benefits, services, employment or insurance; social stigmatisation; and fi ndings of previously unknown paternity status; • economic harms: including the imposition of direct or indirect costs on participants; • legal harms: including discovery and prosecution of criminal conduct. (NHMRC 2007,  p. 16)

Determining the level of risk is important, but a common complaint from researchers (especially in the university sector) is that human research ethics committees seem to be pernickety and unduly questioning of research methodologies. The implication is that a project’s methodology has nothing to do with its ethical considerations of the project. The NHMRC are clear on this, in that the methodology of the project must be robust and must protect the participant from harm, which is clearly an ethical issue. Following on from this, let us consider the following two questions that arise from Savannah’s project: Question 1: How many times a week would you say that you thought about a relative who had passed away? Question 2: Would you say that the relative who passed away was a good person? It should be clear that question 2 poses some issues, while question 1 seems reasonable enough. Even though we are not fully aware of the intricacies of Savannah’s project it would be fair to assume that there are no prima facie ethical problems with question 1 because it would be regarded as being within the bounds of a reasonable set of survey questions. While some overarching support might be offered (e.g. telephone counselling for any participant who became distressed responding to the death of a loved one), the question is respectful and reasonable. Conversely, question 2 would appear to be both ethically and Psychological harm: methodologically fl awed. From an ethical perspective, question 2 is Psychological treatment problematic because there is a distinct possibility that the participant may where the client is subjected to a situation experience psychological harm as a result of this insensitive and poorly where she becomes structured question. As with all research, the potential benefits must be clear uncomfortable (or and any level of harm must be proportionate. It would be fair to say that potentially more serious) question 2 would cause problems for an ethics committee as the harm caused, and is cognitively affected. which is unnecessary, would significantly outweigh any benefits from the

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project. Savannah’s question 2 is an example of the crossover between a methodological and an ethical issue. These two issues are not always mutually exclusive.

Duty of care and non-maleficence

Non-maleficence: It is one of the cornerstones of good ethical practice that whatever the intervention or service that is offered, no harm to the client should result from it. Psychologists have a duty to ensure that the minimisation of any risks in treatment is paramount in the psychologist’s approach to appropriate intervention.

Ensuring that no harm comes to your client through your practice and, by extension, involvement in a research project is fundamental to good ethical practice. Non-maleficence is defined by Corey and associates (2011, p. 20) as meaning ‘avoiding doing harm, which includes refraining from actions that risk hurting clients. Professionals have a responsibility to minimise risks for exploitation and practices that cause harm or have the potential to result in harm.’ The welfare of the participants (as with any client) must not be compromised just because of a research project. As we have emphasised in earlier sections of this chapter and elsewhere in the book, there is nothing more important than ensuring that your participants’ welfare is your overarching concern. In general psychological practice you must ensure that your therapeutic approach is reasonable, given the presenting conditions and evidence base. As the purpose of research is to create and contribute to evidence-based practice, formulating research on Evidence-based practice: an established evidence base is not always possible. For this reason research Practice in which there is ethics committees exist, and adhere to the guidelines set by the NHMRC. It evidence that a particular therapy or approach is follows that the researcher should not subject the participants to physical or effective with a certain group mental distress; in other words, care must be exercised to ensure that the of clients. Usually evidence well-being of participants is paramount. As per the APS Code (B.14), privacy would be in the form of peer-reviewed studies. must be maintained and the data must not be identifi able after publication. In our case study, Savannah may well have been attempting to ensure that the participating students’ welfare was of paramount importance. Unfortunately, the research project was not submitted for approval to a recognised ethics committee that adheres to the National Statement, and it is therefore not possible to state categorically that the students’ welfare was protected. To gain approval from such a committee certain procedures would have been required to ensure that participant well-being was properly considered. For example, if a student was distressed because of the questions (which was possible based on the two questions from the survey that we saw in the previous section) she should have been given immediate access to a separate psychologist or school counsellor, clearly not Savannah. Plainly this was not done, so would have been to the detriment of the participants. In research ethics applications, the researchers are asked to describe what will be implemented to cover these potential eventualities, that is, how risk will be managed. The possibility of psychological (or other) harm in research is sometimes unavoidable. That being said, different people fi nd different things distressing or uncomfortable, and Duty of care: Ensuring that support services may never be consulted in many research projects. The no harm comes to your important point here is that when you are ethically considering participant client through your practice as well as considering that welfare you are required to demonstrate that if something goes awry there is the client’s welfare is always a mechanism in place to support you or the client in that situation. In other of primary importance. words it is demonstrating your duty of care to research participants, an

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aspect of Savannah’s project which indicates it was not ethically sound—there was nothing in place to protect the participants’ psychological well-being.

Informed consent There is a good deal of overlap between the APS Code of Ethics (A.3. Informed Consent) and the NHMRC’s National Statement, in that both require the participant (or client in practice situations) to be made fully aware of the nature and purpose of the project. How a psychologist conducts himself in a research capacity comes under the NHMRC’s National Statement, as is stated in the Code. The most important aspect here is that prior to involvement participants ‘understand what they are being asked to agree to do, they must have the capacity to comprehend and evaluate the information that is offered to them prior to actual participation’ (Koocher & KeithSpiegel 2008, p. 531). Participants must be provided with a statement, which is normally in a written format, explaining the nature and purpose of the project (see Chapter  2). According to the National Statement, participation must always be voluntary and ‘the purpose, methods, demands, risks and potential benefits of the research’ (NHMRC 2007, p. 19) must be clearly articulated to prospective participants before the study begins. Consent can be obtained in various forms, as mentioned above, including oral, written, or by implied consent. The last is fairly common practice in survey-based research, where the completion and returning of a survey can be regarded as consent. This is presuming, of course, that a statement has been provided to the participants, thus enabling them to make an informed decision about participation in the research. According to the NHRMC, this is also dependent upon: 1)

the nature, complexity and level of risk of the research; and

2)

the participant’s personal and cultural circumstances. (NHMRC 2007, p. 19).

Consent can be waived if data is non-identifi able and this would be a decision made by the locally established ethics committee. If we consider point 2 here, there can be very particular circumstances that would affect your decisionmaking; if the research project was examining suicidal ideation , for example, you might wish to inform the participants deemed to be ‘at risk’ of this process. If we refer once more to Savannah’s project we can see that very little in the way of informed consent was obtained from the participants. It seems that only brief information (if any) was supplied to the students and therefore an informed decision-making process about whether to participate was not possible. It is reasonable to assume the students would also have felt under some pressure to participate, as the researcher was also their psychologist. As the situation involves participants under the age of 18 years, Savannah should have taken more care to ensure that the students were fully cognisant of the intricacies of the project. In this situation, as well as others where the participant cannot give full consent, due to either age or capacity to understand, an appropriate adult may give consent on their behalf. See Chapter 5 for a discussion of the ability of older and younger individuals to give consent.

Suicidal ideation: The idea that a client entertains of taking his own life.

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APS Code A.3 A.3. Informed consent A.3.1. Psychologists provide information using plain language A.3.2. Psychologists provide information using plain language A.3.3. Psychologists ensure consent is informed by: a) explaining the nature and purpose of the procedures they intend using; b) clarifying the reasonably foreseeable risks, adverse effects, and possible disadvantages of the procedures they intend using; c) explaining how information will be collected and recorded; d) explaining how, where and for how long, information will be stored, and who will have access to the stored information; e) advising clients that they may participate, may decline to participate, or withdraw from methods or procedures proposed to them; f) explaining to clients what the reasonably foreseeable consequences would be if they decline to participate or withdraw from the proposed procedures; g) clarifying the frequency, expected duration, financial and administrative basis of any psychological services that will be provided; h) explaining confidentiality and limits to confidentiality (see standard A.5.); i) making clear, where necessary, the conditions under which the psychological services may be terminated; and j) providing any other relevant information.

Coercion, inducement and deception At one level coercion, inducement and deception in research seem heinous and unethical. In some situations it could be argued, at least for the latter two, that these are perfectly acceptable methods used by researchers who have received ethical permission to do so. But it is not as simple as that. First, a person must give voluntary consent to participate in research. It is unacceptable to use coercion out of a position of authority, such as a lecturer asking his class to be involved in research, or a similar situation with a supervising psychologist getting her Voluntary consent: Refers trainee to complete a survey. This type of pressure is wholly unacceptable to a client being able to give and hence the reason why ethics committees fl ag issues of this nature and permission for a certain action to take place without often request that another person recruit participants, creating a separation any form of coercion. between the researcher and any other relationship he may have with the potential participants. An enthusiastic researcher stopping people in the corridor of his university and using his charm and wit to encourage students to participate may be a form of coercion. In that particular circumstance it is more likely that this would be considered encouragement. On the other hand, if the researcher is involved in marking the students’ assignments and this position is manipulated to gain participants, this is a clear breach of the

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Code and is obviously coercion, which is unethical practice. Consider Case Study 9.1 in this instance; it is quite possible that Savannah’s dual relationship (psychologist and researcher) would be considered to be a form of implicit coercion. Second, offering inducements is an acceptable practice in research, but it is strictly monitored, and inappropriate or excessive fi nancial rewards are not ethically acceptable. Fisher (2013, p. 245) sums it up thus: ‘Compensation for effort, time, and inconvenience of research is permitted if inducements do not encourage individuals to lie or conceal information that would disqualify them from the research or lure them into procedures they would otherwise choose to avoid.’ It is possible to compensate someone for his time or effort but this must be reasonable for the task required. The NHMRC (2007, p. 20) states that ‘payment that is disproportionate to the time involved, or any other inducement that is likely to encourage participants to take risks, is ethically unacceptable’. The third aspect of this section is that of deception in research, which is ethically acceptable only if the following points are fully adhered to: 1)

participants will not be exposed to an increased risk of harm as a result of the concealment or deception;

2)

a full explanation, both of the real aims and/or methods of the research, and also of why  the  concealment or deception was necessary, will subsequently be made available to participants;  and

3)

there is no known or likely reason for thinking that participants would not have consented if they had been fully aware of what the research involved. (NHMRC 2007, pp. 23–4)

Conflict of interest In order to ensure that a conflict of interest does not exist either in perception or in actuality, researchers are required to declare any vested interests that could be regarded as compromising the integrity of the researcher and thus the accuracy of the Conflict of interest: To results. In scientific drug research quite often large pharmaceutical companies avoid such a conflict, researchers are required to pay for research to be conducted for them at universities. The research is still declare any vested interests expected to be independent and unbiased but there is a potential for a conflict that could be regarded as of interest, which is why a declaration of funding sources should be made if compromising the integrity there is a connection of this sort. After this declaration has been announced of the researcher and thus the accuracy of the results. readers or participants are able to make a more informed decision on the authenticity of the project. As an example, in the APS journal The Australian Educational and Developmental Psychologist all authors of articles are required to follow the following guideline: Please provide details of all known financial, professional and personal relationships with the potential to bias the work. Where no known conflicts of interest exist, please include the following statement: ‘None’. (Source: http://assets.cambridge.org/EDP/EDP_ifc.pdf)

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Ensuring that authors are up front about their funding sources and any dual roles allows people to make their judgment about the fi ndings more informed.

Reporting and publication of results It goes without saying that reporting the results of research studies must be done honestly and accurately. There can be no excuse for fabricating or falsifying results. Over many decades there have been many examples of researchers having been found to falsify data and being caught many years later. The website Retraction Watch ( http://retractionwatch. wordpress.com) is an excellent resource for discovering problems in studies that hitherto had been regarded as sound or having used falsified data. Once uncovered, these studies are withdrawn from scientific literature. Some prove more interesting and elaborate examples of research fraud than others, and there are even a couple of withdrawn projects involving psychologists on the website. The fraud committed by Dutch social psychologist Diederik Stapel is a case in point. Stapel had built a very successful career as an eminent academic and well-known public figure because of his interesting research in how people interact with their environment. Unfortunately for him (and many of his students), he fabricated most of his results. In fact  it  seems the experiments he claimed to have conducted never took place (Bhattacharjee 2013). An excellent and humorous article entitled Great Moments in Academic Fraud (Ross 2012) is worth reading and gives an Australian slant on various cases of research misconduct perpetrated by academics. Psychologists found to be committing any form of research fraud, whether it be that of plagiarism or data falsification, will pay a huge penalty once caught. The penalty of losing one’s job and reputation, not to mention instances of jail in the USA for harming life, means that the ramifications of being caught are so huge it is difficult to understand why some people take this particularly self-destructive route. With so many publications being digitised, widely and easily available via the internet, it would be a foolish endeavour to undertake, as chances are the ‘errors’ will be discovered, even 20 years into the future. Finally, some simple ethical rules for reporting research fi ndings: •

• •

After results are published it is perfectly acceptable for any person to request access to the original raw data. Despite the need to protect the confidentiality of the research participants, researchers should not unduly refuse to provide this information upon request. Plagiarism should not be committed and any use of another person’s work must be appropriately referenced and acknowledged. Plagiarism is the cardinal sin of academia! Authorship of the paper should be appropriately and ethically acknowledged to anyone who has contributed a significant amount of work to it. In academia, a supervisor should not be the fi rst author of a paper where the student has done most of the work. There should be an honest acknowledgment of lead author status. Just to make sure you are still with me on this we have reproduced the part of the APS Code about authorship.

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APS Code C.5 C.5. Authorship C.5.1. Psychologists discuss ownership with research collaborators, RAs, and students as early as feasible and through the research and publication process as necessary. C.5.2. Psychologists assign authorship in a manner that reflects the work performed and that the contribution made is a fair reflection of the work people have actually performed or of what they have contributed. C.5.3. Psychologists usually list the students as principal author on any multipleauthored article that is substantially based on the student’s thesis. C.5.4. Psychologists obtain the consent of people before identifying them as contributors to the published or presented material.

Vulnerability The nature of conducting research in psychology means that we may be working with groups of people regarded as being more vulnerable than the general population. According to the NHMRC the main areas of concern are: •

their capacity to understand what the research entails, and therefore whether their consent to participate is sufficient for their participation;

•

their possible coercion by parents, peers, researchers or others to participate in research; and

•

conflicting values and interests of parents and children. (p. 55)

Researchers must note these points and ensure that participants are fully able to understand the nature of the research and what it will entail. It is not possible to put an age on whether or not consent can be given because of the different levels of cognitive maturity that children and young people will display. It is important that while a parent or guardian may give permission for involvement, the children or young people are willing to be involved and no coercion has taken place. The research should not harm the children or young people in any way and research committees usually take a lot of care to ensure that this is the case with this potentially vulnerable group. As with any group of potentially vulnerable people, consideration should be given to the type of research in which they are able to participate. Modifications should also be made to the methodology so that there is a reduced level of distress or discomfort. ‘People with a cognitive impairment, an intellectual disability, or a mental illness are entitled to participate in research. While research involving these people need not be limited to their particular impairment, disability or illness, their distinctive vulnerabilities as research participants should be taken into account’ (NHMRC 2007, p. 65).

Chapter 9: Ethical Issues in Research

Milgram’s experimental legacy At the beginning of this chapter we considered the Milgram experiment about obedience. This was used to give you an idea of what ethically questionable research can involve, especially when it is at the more high-risk end. In this section we revisit that experiment and consider it in more depth, especially now that you have a much greater understanding of the ‘dos and don’ts’ of ethical research. As we know, there has been much criticism of Milgrim’s study over the past 50 years and even at the time Milgram had to defend himself. In 1963, defending the obedience experiments in a reply to a critical editorial in the St. Louis Post-Dispatch, Milgram stated: ‘Relatively few subjects experienced greater tension than a nail-biting patron at a good Hitchcock thriller’ (Blass 2007). If we consider the fi ndings from a participant in the La Trobe University study in 1973, then we also know that there is a very real possibility that some participants experienced traumatic recall long after the experiments had ended (Perry 2012), more than any Hitchcock thriller would provoke. In fact, even by Milgram’s own reporting it could reasonably be argued that his comment was wholly contradictory to his writing in the actual article as published in the Journal of Abnormal and Social Psychology. In a section of that article entitled ‘Signs of extreme tension’ Milgram noted the following: In a large number of cases the degree of tension reached extremes that are rarely seen in sociopsychological laboratory studies. Subjects were observed to sweat, tremble, stutter, bite their lips, groan, and dig their fingernails into their flesh. These were characteristic rather than exceptional responses to the experiment. (Milgram 1963, p. 375)

In the same article Milgram also noted: •

Regular occurrence of nervous laughing fits;

•

14 of 40 subjects showed definite signs of nervous laughter and smiling (seemed bizarre);

•

Full-blown, uncontrollable seizures were observed for 3 subjects. On one occasion we observed a seizure so violently convulsive that it was necessary to call a halt to the experiment...; and

•

The subject, a 46 year old encyclopedia salesman, was seriously embarrassed by his untoward and uncontrollable behavior. (Milgram 1963, p. 377)

There were ethical matters considered in the experiment at the time and there was an ‘interview and de-hoax’ described by Milgram (1963, p. 374) as follows: ‘[P]rocedures were undertaken to ensure that the subject would leave the laboratory in a state of well-being. A friendly reconciliation was arranged between the subject and the victim, and an effort made to reduce any tension.’ Clearly an experiment can really only be judged on its ethical value at a particular time, the time of the actual experiment. Nowadays if an experiment involved deception there would, according to the NHMRC, be a debrief with the participant where the nature of the study would be fully explained and the well-being of the participant would be fully checked. Milgram stated that he had considered the well-being of his participants, but Baumrind’s Ethical Criticism of Milgram (1964, p. 422) questioned whether this was indeed possible and asked ‘what sort of procedures could dissipate the types of emotional disturbance described?’

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So even at the time there was criticism in various American psychology journals of Milgram’s ethical conduct in this experiment. Baumrind also quotes from the American Psychological Association’s ethical code at the time and suggests that Milgram did not meet the standards for debrief and looking after the welfare of the participants: ‘I would not like to see experiments such as Milgram’s proceed unless the subjects were fully informed of the dangers of serious after effects and his correctives were clearly shown to be effective in restoring their state of well being’ (p. 423). The concern is clearly the welfare of the participants, who, as we will remember, believed that they had actually caused serious harm to a ‘learner’. It would be difficult to imagine any ethics committee coming close to authorising this type of research, especially as we know that some participants of the La Trobe study have not fully recovered from their experience of this shocking set of experiments. One of us took the liberty of contacting Professor Alan Elms, who was Milgram’s fi rst Research Assistant on the original experiment, and he kindly provided answers to two questions regarding the project’s ethical integrity. This correspondence is reproduced below for your information.

Response from Alan C. Elms Q: At the time of the original experiments what was the procedure for getting a project ethically approved? Was there an Ethics Board at the university as we have in place now? Elms: At the time of the Milgram experiments, Yale University had no Institutional Review Board—nor did any other university in the USA, as far as I know. Decisions on whether a research study was ethical or not rested entirely with the faculty member who was in charge of the research—in this case, with Stanley Milgram himself, as he was then a full-time member of the Yale Psychology Faculty. When Milgram applied for funding from the National Science Foundation, he included in his application a discussion of ethical issues in terms of how he would protect the well-being of his subjects. As I recall, NSF asked for some further information on that aspect of his application before they decided to give him any money; at any rate the application (plus a subsequent request for additional funds) was then considered and approved by a committee of psychology faculty members from other universities and by NSF officials. The American Psychological Association had a set of ethical guidelines already in place at that time, though it was not nearly as extensive as the APA’s later ethical requirements for research on human subjects. Advance approval from the APA was not required or even sought for research projects, but complaints received by the APA were investigated after the fact. The APA received one such complaint about Milgram’s research (after the research was completed) and investigated the complaint. The APA’s investigative committee eventually rejected the complaint and issued a judgment in Milgram’s favor. Q: In your opinion, based on the rules of the time, do you think that the experiment was ethically conducted? Would you have changed anything at the time if you were in charge based on ethical issues at that time? Elms: I feel that Milgram’s experiments met and even exceeded ethical requirements in place at that time. If I had been in charge, I might have made additional efforts to encourage subjects

Chapter 9: Ethical Issues in Research

to consider their ethical obligations toward their fellow humans (such as the ‘learners’)—but in so doing I would have been going well beyond any ethical requirements in place then or now. (A.C. Elms, Personal Correspondence with the first author, 28 April 2012)

CHAPTER SUMMARY This chapter has covered ethical issues in research from the perspective of the researcher and that of the participant. The APS Code of Ethics has been discussed as well as the overarching NHMRC National Statement, which is the authoritative document on research ethics for anyone doing research in Australia. When conducting research consider the cost–benefit ratio in that the level of risk must be in keeping with the potential benefits of the study. It should be borne in mind that the levels of risk may be viewed differently by some participants; for example, someone with cancer may be willing to be involved in a higher risk project than would normally be the case, and the reviewing body should take this into account when deciding whether to approve a project or not (NHMRC 2007). Research projects have to be constructed and applied in an ethical manner and this has been illustrated by various examples including that of the chapter case study, Savannah Parkins, who did not follow the expected protocols and procedures to have an ethically sound project. The issues with experiments such as that of Milgram highlight the dangers of projects that may significantly harm participants, in that case psychologically, but in other cases there may be physical harm as well. Ethical standards are fluid and in the future scientists may laugh at what we think is ethically permissible in 2014, but participant well-being is paramount at the standards of the current APS Code of Ethics and the NHMRC National Statement.

QUESTIONS TO CONSIDER 1

2

3

4

Savannah Parkins has not followed the ethical codes particularly well. List and discuss the areas where the project she was working on cannot be considered ethical. What should she have done to ensure that the project was of a higher ethical standard? The Milgram experiment has been given much attention in this chapter. Imagine you are the psychology representative at your local university human research ethics committee. Would you be concerned about Milgram’s experiment if an application for the experiment was under consideration by your committee? What concerns do you think a committee should or would have? It is too difficult to get ethical approval these days for psychology research experiments. It seems that many of the considerations are weighted in favour of the participants and not those of the researchers. Do you agree or disagree with this statement? State your reasons. Is it ever ethical to offer incentives to potential participants in research? Give reasons for and/or against the use of financial or other incentives in research projects.

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REFERENCES APS (2007). Code of Ethics. Melbourne: APS. Baumrind, D. (1964). Some thoughts on ethics of research: After reading Milgram’s ‘Behavioral Study of Obedience.’ American Psychologist 19(6), 421–3. Bhattacharjee, Y. (2013). The mind of a con man. New York Times, 28 April. . Blass, T. (2007). Memorable Quotes. The Stanley Milgram Website. . Corey, G., Corey, M.S., & Callanan, P. (2011). Issues and Ethics in the Helping Professions (8th edn). Belmont, CA: Cengage Learning. Elliott, T. (2012). Dark legacy left by shock tactics. Sydney Morning Herald, 26 April . . Fisher, C.B. (2013). Decoding the Ethics Code. A practical guide for psychologists (3rd edn). Thousand Oaks, CA: Sage Publications. Koocher, K., & Keith-Spiegel, P. (2008). Ethics in Psychology and the Mental Health Professions: Standards and cases. New York: Oxford University Press. Milgram, S. (1963). Behavioral study of obedience. Journal of Abnormal and Social Psychology 67(4), 371–8. Milgram, S. (1964). Issues in the study of obedience: A reply to Baumrind. American Psychologist 19, 848–52. NHMRC (2007). National Statement on Ethical Conduct in Human Research. Canberra: Australian Government. Perry, G. (2012). Behind the Shock Machine: The untold story of the notorious Milgram psychology experiments. Melbourne: Scribe Publishers. Ross, J. (2012). Great moments in academic fraud. The Australian, 5 July. .

10 Ethical Assessment and Intervention ‘Intelligence is what is measured by intelligence tests.’ —Edwin Boring (1923)

CHAPTER OBJECTIVES • • • • • • •

To define the various forms of psychological assessment To become familiar with sections of the APS Code/Guidelines relevant to psychological assessment procedures To understand the implications of test results and labels To understand the limitations of testing (including online) To be aware of potentially controversial interventions To understand what evidence-based interventions mean To understand what makes an intervention problematic

KEY TERMS Group therapy Informed consent Multi-agency report

Non-maleficence Psychological assessment Psychological test

Psychometrics Self-reporting

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Introduction

CASE STUDY 10.1

Sam Adder (14) has had perennial learning difficulties since he was six. He has been seeing the same school psychologist, Bianca Baseline, since the early days and they have an excellent rapport. He was given a label of ‘special needs’ but does not qualify for extra school funding, as his IQ score is one point above the minimum of 69. If Bianca Baseline had scored him slightly lower on a couple of questions of the WISC-IV they would have received funding that would have helped with his schooling. Bianca’s boss, Dr Rosso Angère, has been leant on by the Principal of Sam’s school. Dr Angère becomes somewhat cross with Bianca because she will not revisit her score even though there was a semantic dispute over whether octopuses have legs or arms.

CASE STUDY 10.2

Assessment and intervention are areas in which most psychologists will fi nd themselves practising at some point in their career, irrespective of specialisation or area of endorsement (see Chapter 12). Often psychologists are asked to conduct assessments for various reasons and a range of tools are used, such as psychometrics or observation schedules. In this chapter we will discuss some of the different forms of assessment from an ethical perspective, but there is far more to consider about the ethics of assessment than we can ever cover in this chapter. There is a wide range of assessment types and formats, including many controversial therapies that have been in vogue for a time and then gradually faded away. This chapter will consider some of these therapy types and highlight the ethical guidelines for practice, once again to ensure that the psychologist causes no harm to the client and is able to protect herself from potential litigation and/or reports to the Psychology Board of Australia. As with all the components in this book, the emphasis is on the practitioner being able to justify her practice as appropriate to the specific client receiving the service, if called to do so by a discipline board. Two case studies will be used to emphasise some of the key issues in this chapter.

You are an eminent forensic psychologist and you are contacted by the Vienna Institute in Perth and asked to do a court report for an incarcerated client. Dr Freud, Chair of the Institute (and an old golfing buddy at the Sea View Golf Club in Cottlesloe), wants Anthony Monk kept locked up as he is a serious danger to the community. Nobody really disputes this—since he murdered several politicians in the late 1980s. Dr Freud is keen to go through the perfunctory formalities of the parole board and suggests that you could get the report done in time for port and cigars at the Club. As you have high ethical standards you tell Freud that you will have to meet the client and see the files in order to do a proper job. Monk has been sedated again because of

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unruly behaviour after watching the federal election results on television, so it would not be possible to meet him this time, but you know him from before and there is hardly a new perspective here. You decide to write the report, in the usual prose, without having seen the client, and are paid handsomely for your work.

Psychological assessment A psychological assessment can have many different properties and can be conducted for many different purposes. An assessment is usually designed to provide information to the psychologist, a third party, and of course the client, so that a particular course Psychological assessment: of action can be taken. A parole board may ask for a forensic psychologist to An assessment designed to provide information to the conduct a psychological assessment to determine whether a person is suitable psychologist, a third party for release. A teacher may ask an educational and developmental psychologist and the client, so that a for a psychological assessment of a student’s cognitive abilities, as there is a particular course of action problem with his literacy skills. A person has sustained a serious head injury can be taken. and a medical doctor has asked a clinical-neuro psychologist for a psychological assessment in order to investigate whether there may be some residual cognitive damage. As there are many different forms of assessment depending on the circumstances, the Code presents minimum ethical standards.

APS Code B.13 B.13. Psychological assessments B.13.1. Psychologists use established scientific procedures and observe relevant psychometric standards when they develop and standardise psychological tests and other assessment techniques. B.13.2. Psychologists specify the purposes and uses of their assessment techniques and clearly indicate the limits of assessment techniques’ applicability. B.13.3. Psychologists ensure that they choose, administer and interpret assessment procedures appropriately and accurately.

Psychological assessments must follow strict procedures that are appropriate for the task and are able to add value to the assessment in hand. As is stated in the Code, psychologists are expected to adhere to established procedures in the particular assessment that they undertaking. For example, in psychometric testing the manual for that particular instrument gives very detailed instructions on the procedure that should be conducted. It is only if the guidelines are followed accurately that meaningful interpretation can take place. It is expected that the psychologist fully explain the nature of the assessment she is using so that the client is able to understand the possible limitations of the instrument and if there are inherent dangers in the

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Informed consent: When the client knows the psychologist’s qualifications, what is being provided, that confidentiality will be maintained, what the service will cost and how it will end, she can make an informed decision about whether to receive the service.

procedure. Despite these negatives, the psychologist should also explain the potential positive outcomes, which must be realistic and achievable. The client is then able to give informed consent (see Chapter  2) and decide whether he accepts the particular assessment. Koocher and Keith-Spiegel (2008, p. 251) suggest that the question of consent and the client being fully informed about the reasons for the assessment is a serious issue: [C]lients have a right to know the purpose of the evaluation and the use that will be made of the results. They are also entitled to know who will likely have access to the information they provide to the evaluator. Such use and consent problems often arise when the individual who conducts the assessment does so as an agent of an institution or organization.

It is worth pondering how many psychologists give enough details to their clients of the psychometric properties in the test, and, in the case of psychologists working with children and adolescents, whether they fully detail the reasons for the testing to the students; for example, if you score particularly badly you may end up being given a label that may affect you (either positively or negatively) for the rest of your life (Boyle 2014). For psychologists, this is defi nitely worth reflecting on and asking yourself if you have been completely honest to the client about the nature of the particular assessment you were asked to complete. As we mentioned earlier, a psychological assessment can come in various guises and will be made up of different methods. We will give a brief description of a few methods here but the list is not exhaustive. Neither the Code nor the guidelines are an edict and therefore do not tell you specifically what to do in a given situation or which assessment tools to use. Of course, in some of the scenarios mentioned above it is not clear what method would or ought to be used. The report of a psychological assessment should usually form part of a larger multi-agency report. One assessment in one area cannot be regarded as complete, and as the Code states, the psychologist must interpret results accurately and Multi-agency report: information from different sources should always be part of the overall report. A report by various The types of methods that might be used include structured or semi-structured professionals who have collaborated in an interviewing, which will provide qualitative information on different assessment of a client, for situations; for example, the psychologist may be asking Sam Adder example a joint report by s (Case Study 10.1) to describe some of the difficulties he is experiencing in his psychologist, school teacher class. Some form of interviewing should have been conducted in Case Study and speech pathologist who have worked together to 10.2 in order to form an opinion of the level of psychosis still evident in the assess a child for autism client. Psychological testing receives special mention in the APS Guidelines spectrum disorder. (2009) because most psychologists use this tool in their practice; it is described in more detail in the next section. Self-reporting: An Other methods that may be used are those of self-reporting, and individual reporting on practitioners, especially in therapy, frequently use this. Corey and associates their own behaviours or (2011), however, suggest that it is one of the least useful methods because thoughts, typically as part of an assessment. There of the subjective nature of the client’s reporting. An essential method that are a range of assessment most psychologists use in various forms is that of observation. If a child is tools that use self-report presenting with behaviours suggesting ADHD in the home, for example, an questionnaires. observation would take place in the school to see if there is consistency in

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behaviours across environments. Other methods are mentioned in APS (2009) but we do not have enough space to list them here.

Psychological testing In some circles in psychology, and probably more so in areas where people use psychological assessments as part of a wider need, the terms ‘psychological assessment’ and ‘psychological testing’ are used synonymously and interchangeably. Maybe as psychologists we have to take some responsibility for this by not correcting this error, and in some cases perpetuating it. Chris Boyle previously worked as a school psychologist and saw many examples of psychologists producing reports for authorities based on one psychometric test and not much else. Of course, this is an anecdote but as the 2009 Guidelines quoted below indicate, there still seems to be reason to emphasise that standardised assessment is only one tool or method—it is not and should not be the only psychological assessment tool used to form a conclusion.

Definition of a psychological test •

•

•

Broadly, a psychological test is a set of items that have normalised scores whose properties meet the standards of reliability and validity. They are usually designed for testing on individuals, for example cognitive assessment, personality inventory, dyslexia screening (Shum et al. 2013). A psychological test is not the same as a psychological assessment. Usually the former forms part of the latter. It is not good practice to use psychology tests in isolation, unless it specifically states this in the test manual. ‘[T]hey are characterised by standard administration and scoring, the use of a manual and usually the availability of population norms to assist interpretation’ (APS 2009, p. 7).

Psychological test: Broadly, a psychological test is a set of items that have normed scores whose properties meet the standards of reliability and validity. They are usually designed for testing on individuals, for example cognitive assessment, personality inventory, dyslexia screening.

If a referral is made for a psychological assessment, it is the psychologist who is best placed to decide what exactly this would involve. In Case Study 10.1 Bianca Baseline should be taking information from various sources regarding her client’s functioning. It would seem that she is working from just the cognitive ability score, which we know from the manuals (certainly in the Wechsler scales) is not recommended, as any piece of information in isolation could lead to misinterpretation. In Figure 10.1, Shum and colleagues (2013) show the assessment process from the original reason for the referral to the referral in turn influencing how, where and what information is collected. Shum and colleagues give examples, but there are many different sources of this type of information. The important thing is that the reason for the original referral will heavily affect the data collection. The Code B.13 states: ‘Psychologists ensure that they choose, administer and interpret assessment procedures appropriately and accurately’. It is not ethical practice to use certain testing tools purely because one is comfortable with their use. As Figure 10.1 shows, the range of information gathered should be done in such a way that it accurately answers the questions (or hypotheses) behind the reason for the referral.

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Data Collection Observation

Interview

Psychological Testing

Checking Records

Answering Referral Problem

Figure 10.1

The relationship between psychological assessment and psychological testing Shum et al. 2013, p. 22

Psychological tests such as cognitive or personality assessments are usually in the form of psychometrics and need to be selected carefully and not based on their title alone. Other considerations include ensuring that the question of the test’s purpose is Psychometrics: The measurement of clearly answered. It cannot be overemphasised how important it is to ensure psychological properties, that the manual is consulted, as this will contain all the relevant information usually in the form of a test in order to ensure the appropriateness of the task in hand. Of course it should such as a personality test or cognitive test. also go without saying that the test norms must be appropriate for the population that the psychologist is working with. For example, a popular instrument for testing for ADHD in Australia is the Connors’ Rating Scales 3, but the norms for this test are based on a sample of the population of the USA. When the scores are being reported in Australia, therefore, they are fl awed if the psychologist is basing the fi ndings (the scores) on comparisons between his client and the norms used to standardise the test, as the sample population is from the USA, not Australia. This is why there are Australian versions of major psychological tests. Usually there are a few Australianisms added to the questions or Americanisms are removed; for example referral to baseball or American Football would be simply replaced with popular Australian sports such as cricket, AFL or rugby.

Cultural diversity and testing There are many issues of cultural bias of which the psychologist needs to be aware. Cultural diversity issues are dealt with extensively in Chapter 6 and here we will consider this issue directly in respect of psychological testing and assessment. As we have discussed, it is good practice to use test results as part of a wider assessment, and this is endorsed by Fisher (2013, p. 293), who says that ‘interpretations should never be based solely on test scores’. Other general points to consider are that the dichotomous situation where the test questions have to be administered directly according to the instructions can directly clash with any restrictions

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on the subject who is undertaking the test, for example if the client has difficulty with hearing, speech or dexterity. It should be remembered that, when considering the testing of diverse populations across a country as diverse as Australia, it is quite conceivable that the test results may be invalid with certain groups of people. The APS is quite categorical when it states in the Guidelines for working with diverse groups ‘there are currently no known formal psychological tests that have been developed specifically for use with indigenous people and that provide current-day norms and measurement statistics for indigenous test takers’ (APS 2008a, p. 4). More recently, very specific assessment tools, such as the Kimberley Indigenous Cognitive Assessment tool, have begun to be developed for Indigenous populations. However, it should be noted that this is a screening tool for assessing cognitive decline and dementia in older Indigenous individuals rather than a broad assessment tool (LoGiudice et al. 2006). For all the reasons we have given and because of the many psychometric tests that are still being conducted in Indigenous communities, we really have to query whether the guidelines on psychological testing are being followed (as set out in the quotation below). Informed consent is critical to good ethical practice, especially in the administration and reporting of psychological tests. The following is an extract from the APS Guidelines for Psychological Assessment and the Use of Psychological Tests : Psychologists undertake psychological assessment in diverse settings and are aware that clients’ language and cultural background are important factors influencing the assessment. This awareness influences psychologists’: a)

choice of assessment methods;

b)

interpretation of results;

c)

compilation of their reports; and

d)

communication to their clients regarding the assessment. (APS 2009, p. 2)

If any test-taker is unable to fully understand the procedures and reasons for the testing—a separate point to whether they can do the test or not—it renders the results invalid on two fronts. First, the Code is quite clear about the need to receive informed consent before administering any test. Second, the manuals will usually also have a clause which states that informed consent must be received before the test can be carried out. This clearly says that psychologists must do more to take into account a number of ethical principles before proceeding with any form of assessment.

Psychological assessment reporting Reporting fi ndings based on a psychological assessment has to be meaningful to various stakeholders. If we consider Figure 10.1, there must be a clear purpose to the assessments that are carried out and they must be directly relatable to the reasons for the original referral. Moreover, the fi ndings that are reported must answer the question that was the subject of the request for a psychologist to be involved. The Code sets out ethical considerations for reporting fi ndings and the relevant points are quoted below.

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APS Code B.13 B.13.3. Psychologists ensure that they choose, administer and interpret assessment procedures appropriately and accurately. B.13.4. Psychologists use valid procedures and research findings when scoring and interpreting psychological assessment data. B.13.5. Psychologists report assessments results appropriately and accurately in language that the recipient can understand B.13.6. Psychologists do not compromise the effective use of psychological assessment methods or techniques, nor render them open to misuse, by publishing or otherwise disclosing their contents to persons unauthorised or unqualified to receive such information

CASE STUDY 10.3

As is stated here, psychologists must report their fi ndings in a format that can be understood by the intended recipient (B.13.5.), whether that is the client or a third party. If we consider psychologist Bianca Baseline’s assessment of 14-year-old Sam Adder, Sam’s parents or guardians, his teacher and Sam himself should be able to understand the feedback or written report. Bianca may have to write more than one report based on the level of understanding that she would judge them to have. Psychologists and, I am sure, other professionals who have to interpret quite complicated results, can be prone to write in technical language that can be very difficult to understand for non-psychologists. It would be wise to avoid specific psychological language when attempting to give meaning to the fi ndings, for example avoiding ‘your son scored less than two standard deviations from the norm’ or ‘your daughter was on the 99th percentile’. If the report is filled with jargon then the dissemination and communication of meaning has not taken place, rendering the report useless to some interested parties. Caution should also be taken when using computer-generated reports which can contain much information that might not be particularly relevant to some people.

Heather’s verbal reasoning abilities as measured by the Verbal Comprehension Index are in the Borderline range and above those of only 3% of her peers (VCI = 71; 90% confidence interval = 67–78). The Verbal Comprehension Index is designed to measure verbal reasoning and concept formation. Heather’s performance on the verbal subtests presents a diverse set of verbal abilities, performing much better on some verbal skills than others. The degree of variability is unusual for a child her age and may be noticeable to adults who know her well. Heather performed much better on abstract categorical reasoning and concept formation tasks that did not require verbal expression (Picture Concepts = 7) than on abstract categorical reasoning and concept formation tasks that required verbal expression (Similarities = 2).

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For example, why provide the technical report to a social worker who is not conversant with the deeper nuances of psychometrics—and of course why should she be? Finally, Case Study 10.3 illustrates the point made in the Code under B.13.5, which urges appropriate language in the report so that it can be understood. This case study is meant to represent a section from a psychological report. Even in this brief segment we are able to see that to the uninitiated this report will not make a lot of sense. If a client, or the person who is a report recipient, is not familiar with the cognitive constructs and scaling of subtests, this is a very poor report. Using more descriptive language can have benefits; after all the process of a psychological assessment is meant to provide some sort of answer to the questions that were originally asked at the referral stage. If the client is unable to understand the psychological fi ndings in reasonably plain English then the question must be raised as to the purpose and use of the assessment.

Intervention The overriding imperative of any psychological intervention should be Primum non nocere (First, do no harm). The purpose of psychological intervention is to ameliorate a client’s difficulties in a particular domain, to make her feel better about herself, and optimally to improve her current situation so that she will need minimum or no ongoing support from a psychologist. Whatever therapeutic intervention the psychologist deems appropriate, it should result in the best possible outcome for the client. Of course, it might not work out exactly like that but this should be the standard that is aimed for, in that at least no harm comes to the client. For example, the psychologist decided that eye movement desensitisation reprogramming (EMDR) was the best option for a client who had posttraumatic stress, but this did not seem to have any benefit. After a couple of sessions of EMDR it was deemed appropriate to try another therapeutic approach, so cognitive behavioural therapy (CBT) was used. It is not unusual to try one approach and if unsuccessful consider another. The best outcome for the client is sought at all times based on appropriate clinical judgment and empirical support. As was mentioned earlier in the chapter, a psychologist should be willing to consider various tools for assessment, and similarly an intervention should consider wide possibilities, not just the treating psychologist’s favourite approach. According to the APS’s Evidence-Based Psychological Interventions in the Treatment of Mental Disorders, ‘Best practice is based on a thorough evaluation of evidence from published research studies that identifies interventions to maximise the chance of benefit, minimise the risk of harm and deliver treatment at an acceptable cost’ (APS 2010, p. 2). Psychologists are ethically obliged to use evidence-based practice. Standard B.1.2 of the Code states that psychologists should be ‘basing their service on the established knowledge of the discipline and profession of psychology’. Any intervention should be cost-effective to the client and/or any third party who is paying for the treatment, such as an employer or insurance company. You will recall from Chapter 4 the case of Dr Eugene Landy, who was charging the famous Beach Boy Brian Wilson US$35 000 a month (plus various exorbitant personal expenses); that is a considerable amount of money today but it was even more in the late 1970s and 1980s. In order to ensure that evidence-based interventions are exactly

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that, the main tools for ensuring that they are robustly evidenced is to consider studies that have meta-analyses, literature reviews (which should combine a historical with a contemporary outlook), and what is widely regarded as the gold standard of evidence, that of randomised controlled trials. The latter can be difficult to fi nd in mental health research that deals with the practical application of intervention to clients because of the question of nonmaleficence, which means that no harm should be done to the client. If a Non-maleficence: One of the cornerstones of good client needs a particular therapeutic intervention and it turns out that he is ethical practice, in that not responding because the experimental intervention is not having an effect, whatever the intervention then there are serious ethical concerns regarding an approach of this kind or service offered no harm (Fisher 2013). Table 10.1 shows the different levels of evidence that the NHMRC should come to the client. has deemed to indicate the strength of research evidence: whether particular studies have enough veracity to be considered evidence-based. The hierarchy of levels in the table indicates the strength of evidence given by various methods; the strongest are more prone to limitations. Table 10.1

Strength of evidence criteria

Level

Evidence source

I

Systematic review of all relevant randomised controlled trials

II

At least one properly designed randomised controlled trials (alternative allocation or some other method)

III–1

Well-designed pseudo-randomised controlled trials (alternate allocation or some other method)

III–2

Comparative studies with concurrent controls and allocation not randomised (cohort studies), or interrupted time series with a control group

III–3

Comparative studies with historical control, two or more single-arm studies, or interrupted time series without a parallel control group. Source: NHMRC 1999, p. 56

The APS (2010) has published a document that uses NHMRC (1999) criteria for robust research and has listed the following therapies as those that have been investigated by literature review in that document: • • • • • • • • • • •

Cognitive behaviour therapy (CBT) Interpersonal psychotherapy (IPT) Narrative therapy Family therapy and family-based interventions Mindfulness-based cognitive therapy (MBCT) Acceptance and commitment therapy (ACT) Solution-focused brief therapy (SFBT) Dialectical behaviour therapy (DBT) Schema-focused therapy Psychodynamic psychotherapy Emotion-focused therapy

Chapter 10: Ethical Assessment and Intervention

• • •

Hypnotherapy Self help Psycho-education.

The list is not exhaustive but is based on what various reputable organisations (e.g. British Psychological Society, American Psychological Association, Royal Australian and New Zealand College of Psychiatry) have indicated as interventions that were regarded as being established in practice. The APS (2010) has produced a document that describes all the approaches listed and systematically considers what evidence is available to support their effectiveness. In other words, it is a document that facilitates practitioner psychologists to make informed decisions about what therapy is actually supported by evidence. By doing this psychologists are complying with the Code standard B.12.b, which obliges the psychologist to use established and evidenced interventions in their practice. There are other therapies that are more controversial and would be regarded as higher risk. As we have discussed, the main point of intervention is to improve the well-being of a client while also doing him no harm. The APS has produced two sets of Guidelines (2008b, 2011) to remind psychologists that while there can never be an exhaustive list of appropriate therapies, practitioners must operate within their area of competence and protect the rights and dignity of clients at all times. There is uncertainty around whether or not various forms of therapy are effective because the evidence base for them is not as strong. The practice of hypnosis is still regarded as high risk by the APS, and the Guidelines (2008b) provide explicit detail regarding practice, including being aware of being associated with organisations that train people in hypnosis but do not require formal training in any form of counselling or psychology. It seems that the position of organisations such as the APS is to explain to you as psychologists that you must remain within your domain of competence and that you must be able to demonstrate that your practice is ethical and evidence-based. Chris Boyle worked with a practising psychologist in Scotland—let us call her Jacquie—who was also a tarot card reader. Jacquie never allowed these two areas of work to converge in any way but a problem arose when she decided to get business cards printed with both Chartered Psychologist and Tarot Card Reader embossed on them. An anonymous complaint was made to the British Psychological Society (BPS) and Jacquie received a letter from that body instructing her to not have the two terms beside each other as this might confuse members of the public who might think tarot card reading is a branch of psychology. Clearly, the people that Jacquie mixed with were not given much in the way of common sense from the BPS. Anyway, Jacquie removed the tarot element and lived happily ever after. As a side note, however, she should really have been able to foretell that she would be receiving a letter from a tall dark organisation. The point is that organisations such as the APS must maintain their reputation and that of psychology in general so that it can continue to be regarded as a scientific discipline. The following is a checklist to ensure that informed consent is obtained appropriately: •

Have the goals for obtaining treatment been adequately considered and operationally defined?

•

Is the client’s participation voluntary?

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•

Has informed consent been obtained?

•

Has the treatment’s efficacy been evaluated?

•

Has the client’s confidentiality been protected?

•

Is the psychologist or treatment provider suitably qualified and resourced to provide treatment?

•

Is there an exit plan for the cessation of treatment? (APS 2011, p. 3)

If the psychologist has decided on a more unorthodox approach and it is within his area of competence and is adhering to other areas of the ethical code, then the checklist above produced by the APS (2011) should be worth considering. This allows the psychologist to consider the various ethical issues thoroughly; this could be regarded as good practice generally, but makes sense because of the nature of more borderline approaches. Although high-risk interventions such as electroconvulsive therapy (ECT) are used much more sparingly than previously, there is controversy in the psychiatric literature as to whether it is successful in treating chronic depression. EMDR is a controversial therapy but is now endorsed by the American Psychological Association for the treatment of post-traumatic stress disorder, especially with army veterans. Of course, further afield, animal testing is highly controversial and debate rages about the efficacy of such programs and whether from a deontological perspective the end justifies the means. In short, even though some approaches are regarded as being controversial and high risk it does not negate their use as long as extra care is taken to ensure that the Code is adhered to as well as the specific guidelines that deal with aversive therapeutic interventions (APS 2011). Even psychotherapeutic interventions can become problematic if the psychologist is operating outside her area of competence.

Therapies involving psychologist–client physical contact Any form of physical contact between a psychologist and a client has ethical ramifications, arguably more in this field than in more recognised therapies. ‘Psychologists are mindful that procedures/assessments that involve psychologist–client physical contact are more at risk of being construed as sexual than other procedures or assessments’ (APS 2008c, p. 113). Touching another person can mean many things; in a controlled therapeutic environment it can be a polite handshake greeting that is unlikely to be misconstrued as it is socially accepted for people to greet each other in this way. The psychologist needs to be aware of social and cultural norms. In some European countries the standard greeting is not a handshake but a kiss on the cheek. Whatever the greeting it should be remembered that keeping it within cultural norms is acceptable (see Chapter 6). The APS Code C.4 describes the issue of non-exploitation and it is clear that any form of touching must not be to exploit or to take advantage of a vulnerable client. Refer to Chapter 4 for a full discussion on maintaining professional boundaries.

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APS Code C.4 C.4. Non-exploitation C.4.1. Psychologists do not exploit people with whom they have or had a professional relationship. C.4.2. Psychologists do not exploit their relationships with their assistants, employees, colleagues or supervisees.

In order to ensure that if some form of physical touch might be necessary, such as in EMDR, the client is asked to give informed consent and should be advised that he can have a third party in the room if it is necessary. The question of touching may be clinical when you consider that some response instrumentation would necessitate some limited physical touching. However, the spontaneity issue might be more relevant to most psychologists. Consider the scenario with a same-sex client whom you had been working with for around five sessions. The client had problems in dealing with the death of her brother many years before. The session has ended and you are talking to the client as you show her to the door. At that point she becomes teary and tells you that today was the anniversary of her brother’s death. You put your arm around her and make some reassuring comments. She thanks you and after a few minutes leaves your office. The following week your client apologises for her tears and thanks you for being so kind and caring. Now, if you did not show some compassion by using physical contact in that spontaneous situation would the client have thought that you were uncompassionate and cold and wondered whether you really cared? The matter could be complicated if the client was the opposite sex to you, was a younger person, or a much older person. The list could go on with various alternative scenarios but it would not seem that the psychologist acted in any way inappropriately in that spontaneous situation. The main point is that any form of physical contact has the potential to be viewed in a different way from its intention. You must be very aware of the difficulties that are inherent in psychologist–client physical contact during therapy.

Group therapy Group therapy is an approach to intervention that can be potentially difficult Group therapy: A group from an ethical perspective. Many psychologists employ this technique for approach to therapy where more than one client is very many clients, but ‘[i]t seems most unlikely that the goals or best interests involved in an intervention of every client in the treatment room will fully coincide with those of the others’ with the psychologist. (Koocher & Keith-Spiegel 2008, p. 129). With this in mind the psychologist must be alert to the individual needs and issues in this sort of environment. In all situations the psychologist should respect the autonomy and confidentiality of each client (see Chapter 2). It goes without saying that group sessions are not as straightforward as ordinary client–psychologist therapy. There are clear limits to confidentiality within group

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settings and the client must be made fully aware of the potential for a loss of confidentiality over material disclosed. The Code clearly indicates the precautions and care that must be taken when working with multiple clients.

APS Code B.5 B.5. Provision of psychological services to multiple clients Psychologists who agree to provide psychological services to multiple clients: a) explain to each client the limits to confidentiality in advance; b) give clients an opportunity to consider the limitations of this situation; c) obtain clients’ explicit acceptance of these limitations; and d) ensure as far as possible, that no client is coerced to accept these limitations.

There is always a strong argument for ensuring that clients give written permission (agreement) for any type of therapeutic intervention, but this is more so with groups because of the different dynamic inherent in this approach. It would be wise to ensure that the agreement clearly states that the client is under no obligation to participate in group therapy and withdrawal is permissible at any time. Sharing intimate details with strangers is probably  not going to suit all clients, and considering their inherent vulnerability, the voluntary nature of this therapy should be heavily emphasised. All members of the group should also be aware of how or if their interactions will be recorded in their client record and whether any group member can access notes from the sessions at a later date. As the leader of the group therapy, the psychologist must ensure that she sets out clear rules for all participants. Fisher (2013) suggests that if the psychologist is involved in concurrent single and group therapy, particular care must be taken to ensure that she does not divulge confidential client information received in a single therapy session when in the group setting. Ford (2006) emphasises that you cannot guarantee confidentiality in group sessions and there is always the possibility that confidential issues may be divulged in a chat with some group members outside the session. This is something that the psychologist should discuss with clients before they embark on this type of therapy. The psychologist should ensure that all members are aware of how important confidentiality is, and that each group member must refrain from chatting or gossiping about any information discussed in the group session. Again, it is a matter of ensuring that there is informed consent and that particular cognisance is taken of the higher than normal risk of a breach of confidentiality.

CHAPTER SUMMARY This chapter has covered much ground in the different but connected areas of assessment and intervention. When selecting different tools for a psychological assessment, ensure that measures can be regarded as being reliable and valid, and that they are used appropriately. The results of the tests or assessments must be interpreted with a high degree of competence and thus done carefully to ensure that any decisions that come from

Chapter 10: Ethical Assessment and Intervention

your findings do not cause harm based on interpretations that go further than the evidence would suggest. The practice and study of psychology is based on scientific principles. Evidence is required in order to judge whether confidence in a particular intervention’s efficacy is appropriate. The APS (2010) has produced a very robust document that describes many approaches that are evidence-based, and psychologists are advised to apprise themselves of the veracity of the research evidence that is available to support the therapeutic interventions they currently employ. A psychologist must be competent in any intervention that is undertaken. She must be able to demonstrate that she has the required skills and knowledge to take the particular approach. When you produce results or findings it is essential that the audience of the report is able to understand what you have found out. An overly technical report may be inappropriate and unethical. It seems reasonable that a client is able to understand what the findings of your psychological assessment are. After all, we are not lawyers—we want our clients to understand our opinion!

QUESTIONS TO CONSIDER 1

2

3

4

Some psychometric tests are invalid when working with diverse cultural groups. Why is this so? What can be done to ensure that the psychologist acts ethically in this regard? Group therapy is an intervention employed by many psychologists. Discuss some of the ethical issues in this approach and focus especially on the difference between group and individual therapy. In Case Study 10.2 you are the psychologist and you are astonished when you receive a letter from Prof. Love, Chair of the APS Ethics Committee, informing you that you are being summoned to the next meeting regarding your ethical conduct. Why are you astonished? What areas of the Code did you breach in writing a report without having met with the client? Why is it necessary to use evidence-based practice? Give your response from the perspective of both the client and the psychologist.

REFERENCES APS (2008a). Guidelines for the Provision of Psychological Services for, and the Conduct of Psychological Research with, Aboriginal and Torres Strait Islander People of Australia. Melbourne: APS. APS (2008b). Guidelines on the Teaching and use of Hypnosis, and Related Practices. Melbourne: APS. APS (2008c). Guidelines relating to Procedures/Assessments that involve Psychologist-Client Physical Contact. Melbourne: APS. APS (2009). Guidelines for Psychological Assessment and the Use of Psychological Tests. Melbourne: APS.

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APS (2010). Evidence-based Psychological Interventions in the Treatment of Mental Disorders (3rd edn). Melbourne: APS. APS (2011). Guidelines for the Use of Therapeutic Aversive Procedures. Melbourne: APS. Boyle, C. (2014). Labelling in special education: Where do the benefits lie? In A. Holliman (ed.), The Routledge International Companion to Educational Psychology. London: Routledge, pp. 213–21. Boring, E.G. (1923). Intelligence as the tests test it. New Republic 35, 35–7. Corey, G., Corey, M.S. & Callanan, P. (2011). Issues and Ethics in the Helping Professions (8th edn). Belmont, CA: Cengage. Fisher, C.B. (2013). Decoding the Ethics Code: A practical guide for psychologists. Thousand Oaks, CA: Sage Publications. Ford, G.G. (2006). Ethical Reasoning for Mental Health Professionals. Thousand Oaks, CA: Sage Publications. Koocher, G.P. & Keith-Spiegel, P. (2008). Ethics in Psychology: Professional standards and cases (2nd edn). New York: Oxford University Press. LoGiudice, D., Smith, K., Thomas, J., Lautenschlager, N.T., Almeida, O.P., Atkinson, D. & Flicker, L. (2006). Kimberley Indigenous Cognitive Assessment tool (KICA): Development of a cognitive assessment tool for older indigenous Australians. International Psychogeriatrics 18(2), 269–80. NHMRC (1999). A Guide to the Development, Implementation and Evaluation of Clinical Practice Guidelines. Canberra: NHMRC. Shum, D., O’ Gormon, J., & Myors, B. & Creed, P. (2013). Psychological Testing and Assessment (2nd edn). Melbourne: Oxford University Press.

PART

5

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167

Clinical Practice: Privacy Legislation, Records, Delegation, Advertising and Finances

11

CHAPTER OBJECTIVES • • • • • •

To be aware of the ethical issues related to the management of a psychological practice To be aware of the ethical and legal aspects of client records To gain a basic overview of privacy legislation To become aware of the two-part records system To understand the requirements of storage and access to records To be aware of the ethical issues relating to delegation, advertising and financial issues

KEY TERMS Australian Privacy Principles Client records Client service record

Confidential client record Practice contingency plan Privacy

Termination of service Third party payment

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Introduction This chapter will focus on some of the key aspects of operating as a psychologist in private practice or in the employ of others. It will focus on the ethical issues of collection, storage and disposal of client records, fi nancial interactions with clients, advertising of psychological services and related areas of psychological practice. It will also discuss the termination of psychological services through client choice, psychologist referral, death of the client or the psychologist, or end of the psychologist’s employment. While these issues are not as exciting as many aspects of psychology and do not always come naturally to individuals who wish to become psychologists, they are vital to ethical practice. If a psychologist does not pay careful attention to these practical issues there is a strong likelihood that clients will be adversely affected. Psychologists who do not disclose the likely cost of their service, fail to maintain accurate or adequate records, or who do not appropriately prepare for the end of a client’s service put the client at a high risk of harm. This chapter will address these issues to assist psychologists and trainee psychologists in their service provision.

Client records According to the APS Code of Ethics, psychologists need to ensure that they make and keep adequate records (B.2.1). Psychologists must keep the records for at least seven years after the last contact with the client unless there are legal or organisational requirements Client record: It is a minimum ethical standard that specify a different (typically longer) time-frame (B.2.2). However, if a that the psychologist keeps a client is under the age of 18 the psychologist is required to keep the records record of the client’s details until the client reaches 25 years of age (B.2.3). Finally, the Code requires that as well as any therapeutic work that was carried psychologists allow clients to amend inaccurate information in their records out. This would include unless there is a genuine legislative, legal or organisational reason not to allow correspondence from other this (B.2.4). However, the collection, storage, management and access to client professionals and any records is also likely to be governed by federal and state legislation. psychological reports.

APS Code B.2 B.2. Record keeping B.2.1. Psychologists make and keep adequate records. B.2.2. Psychologists keep records for a minimum of seven years since last client contact unless legal or their organisational requirements specify otherwise. B.2.3. In the case of records collected while the client was less than 18 years old, psychologists retain the records at least until the client attains the age of 25 years. B.2.4. Psychologists, with consideration of the legislation and organisational rules to which they are subject, do not refuse any reasonable request from clients, or former clients, to amend inaccurate information for which they have professional responsibility.

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171

The client record must provide the psychologist with the information he needs to facilitate the psychological service between sessions, provide the information necessary to write reports at a later date, allow other psychologists to continue with the service provision where necessary, and provide a justification of why a psychologist chose a particular service for the client (APS 2012a). Given their multitude of uses, it is vital that psychologists consider the method and detail of notes they take as part of the service provision.

Privacy While client confidentiality arises through the relationship between client and psychologist (see Chapter 2), privacy relates to the legal obligation not to disclose some types information such as personal health information (McMahon 2008). All organisations that provide Privacy: The legal health services are required to meet the obligations of the Privacy Act 1988, obligation not to disclose regardless of their size (OAIC 2012). Most psychologists are considered to be certain types of information involved in providing health services, but there are some aspects of such as personal health information. All organisational psychology that may not be considered to be collecting health organisations that provide information. Any psychologist in this situation should seek independent or health services are required workplace legal advice. Also, state and Northern Territory public hospitals are to meet the obligations of the Privacy Act 1988. not covered by the Privacy Act, but may be covered by state Acts (OAIC 2012). Private psychologists and Commonwealth and ACT hospital employees are covered by the Privacy Act (McMahon 2008); Victoria and New South Wales have separate legislation relating to health information. The legal issues are complex and psychologists should always gain information specific to their working situation and its connection to the Privacy Act. This may involve discussing with supervisors and experienced psychologists in their field how the legislation relates to that workplace. Also the Office of the Australian Information Commissioner (OAIC) provides a comprehensive resource for all psychologists. The rest of this section will discuss privacy in situations where psychologists are required to adhere to the Act. However, this section does not cover all aspects of the legislation; psychologists must complete their own evaluation of the Privacy Act and how it relates to their professional services given their specific workplaces. Very few psychologists would not fall under the regulation of the Privacy Act, but their employers may not be aware of this and the implications it may have for an employer. Therefore psychologists should discuss and clarify Australian Privacy Principles: A set of 14 these issues with potential employers. guidelines on privacy that It is important to note that at the time of writing the National Privacy came into force in 2014. Principles (NPP) were in the process of transitioning to the Australian They are not specific Privacy Principles (APP), which took effect on 12 March 2014, though there to psychologists but to organisations and sole were still consultations under way at the time of writing. So while every effort practitioners who hold data has been taken to provide the most up-to-date information, all psychologists about individuals. will need to consult the most recent publications from the OAIC in relation to the APP. As a fi rst step, all psychologists in private practice need to develop a privacy policy (Symons & McMahon 2001). This document outlines to clients their rights in relation to their healthcare information as well as how and where it is stored. This would typically form part

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of the informed consent process. Broadly, psychologists need to be aware of the 13 Australian Privacy Principles as set out by the OAIC (2013). These principles are: APP 1: open and transparent management of personal information APP 2: anonymity and pseudonymity APP 3: collection of solicited personal information APP 4: dealing with unsolicited personal information APP 5: notification of the collection of personal information APP 6: use or disclosure of personal information APP 7: direct marketing APP 8: cross-border disclosure of personal information APP 9: adoption, use or disclosure of government-related identifiers APP 10: quality of personal information APP 11: security of personal information APP 12: access to personal information APP 13: correction of personal information. The following sections will briefly cover the topics most relevant to psychologists. Once again, however, it must be noted that psychologists, in consultation with workplaces, legal advice and supervisors, need to determine how these principles will apply to their practice.

APP 1: open and transparent management of personal information According to the OAIC (2013), the focus of this principle is to ensure that any information that is collected about a client is managed in an open and transparent way. For psychologists, this will typically mean developing a privacy policy covering collection, storage and the uses of the information collected from clients as well as complaints-handling and how clients can access their information. This would then be communicated to clients through the usual informed consent process (see Chapter 2).

APP 2: anonymity and pseudonymity APP 2 relates to organisations treating individuals anonymously unless there is a legal or practical reason not to do so (OAIC 2013). In psychology, with the exception of some research methods, it is very unlikely that clients can ethically be provided services anonymously. Psychologists need to be aware of the client’s personal information to provide services ethically and to protect the client should they pose a risk to themselves or others.

APP 3: collection of solicited personal information This principle relates to the way a psychologist collects his information (OAIC 2013). Consistent with the requirements of the Code of Ethics, this principle requires that the collection of the information is only for the provision of a psychological service and that any information collected is directly related to the service. Further, the client must consent to the collection of

Chapter 11: Privacy Legislation, Records, Delegation, Advertising and Finances

this information. This means that psychologists should only collect and record information that is necessary in providing their clients with the service they have consented to.

APP 4: dealing with unsolicited personal information The focus of this principle is that psychologists should not collect any information that is not covered under APP 3 (OAIC 2013). Any other information should not be sought and if the client inadvertently provides this, it should not be recorded. For example, in a counselling service provision the client may give information about third parties that is not relevant to the service being provided. In this situation the information should not be recorded.

APP 5: notification of the collection of personal information APP 5 states that as soon as possible, preferably before the collection, psychologists should inform their clients of any collection of personal information (OAIC 2013). From an ethical perspective psychologists must always fully inform their clients before any service provision takes place. The only exception to this might be the collection of personal information (such as name, address and DOB) that occurs before the psychologist and the client begin the service provision. In this situation the psychologist would explain to the client how all of their information (including name, address and DOB) would be stored and treated as part of the informed consent procedure.

APP 6: use or disclosure of personal information This principle relates to clients being aware that their information is being collected and how it will be used (OAIC 2013). When psychologists are conducting an informed consent procedure, this principle is typically adhered to. However, psychologists who collect information without consent or researchers using data for purposes for which it was not originally collected will need to consider their position under this principle.

APP 7: direct marketing This principle focuses on information collected from clients being used for direct marketing (OAIC 2013). It is highly unlikely that psychologists would ethically be able to use this form of advertising. However, psychologists attempting to gain participants for research using personal data collected for another purpose would be strongly advised to consult APP 7.

APP 8: cross-border disclosure of personal information The aim of this principle is to ensure that psychologists do not transfer client information to international locations that are not required to maintain the same level of privacy protection (OAIC 2013). These transfers can be made with client consent but the potential risks and benefits must be explained. It would be somewhat unusual, in typical psychological practice, to directly transfer client records internationally without client consent. However,

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the use of some internet (cloud) data storages and electronic services may transfer data internationally, even if the psychologist has not requested it. This principle is also particularly relevant to online research. Many online questionnaire services are located overseas and psychologists using them as part of their research need to consider their status under APP 8.

APP 9: adoption, use or disclosure of government-related identifiers Psychologists must not adopt a client identification number that a Commonwealth organisation or its contractor has allocated to an individual unless there is a regulatory requirement to do so (OAIC 2013). For example, a psychologist must not use a client’s Medicare number as their unique identifier within the psychologist’s filing system. Nor can a psychologist disclose a client’s Commonwealth identification number, except in relation to communications with the organisation or agency that assigned the number (Symonds &     McMahon 2001).

APP 10: quality of personal information Psychologists must ensure that all information collected and stored about a client is accurate, up to date and complete (OAIC 2013). However, APP 10 does state that this needs to be conducted in a way that is reasonable given the circumstances. In a psychology context this is likely to mean ensuring that all information collected at the time of service provision is correct. It would not mean contacting clients to update their record in the seven years between the completion of the service provision and destruction of the client records. However, if a client was seen again before the destruction (e.g. five years after the completion of the original  service)  any  important  information collected in the initial sessions would need to be updated.

APP 11: security of personal information As is required of all psychologists under the Code of Ethics, this principle requires psychologists to keep the information they collect secure from destruction, misuse or unauthorised access (OAIC 2013). This means that all forms of data storage, transmission and destruction need to occur securely, ensuring that only authorised personnel can access data. This is one of the key aspects of record-keeping. Please see the sections below on storage of the client record and see the discussion on electronic competencies in Chapter 2.

APP 12: access to personal information This principle requires a psychologist to allow clients or their legal representatives to access the information stored by the psychologist (OAIC 2013). This request should be responded to within 30 days. Please see the sections below regarding access to the client record.

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APP 13: correction of personal information This principle requires a psychologist to allow clients or their legal representatives to correct the information stored by the psychologist about the client (OAIC 2013). This request should be allowed within 30 days. Please see the sections below regarding corrections/changes to the client record.

Structure of client records While psychologists from different fields, and even psychologists with differing theoretical orientations, will record different information in client records, there are some commonalities that all psychologists need to consider. A recent suggestion by the APS’s David Stokes (2011; APS, 2011b) is that psychologists employ two-part client records (also known as client files). These records are made up of the confidential client record and Confidential client record: Information provided by the the client service record. Using this method, the information that a client, information gathered psychologist gathers about a client is stored in two separate records (and during the service such potentially even two physical locations). While all client information is sensitive as test results and clinical and should remain confidential, except in the situations set out in standard notes, treatment plans and information from other A.5.2 of the Code, the highly sensitive information collected about the client healthcare professionals. would be located in the confidential client record. According to Stokes (2011), this would include information provided by the client (e.g. presenting issues), information gathered during the provision of the psychological service Client service record: This contains information (e.g. test results and clinical notes), treatment plans and information from other on dates and treatment healthcare professionals. This information is highly sensitive and the type, appointment history, confidentiality of this material is vital to the therapeutic relationship. According contact and payment details to Stokes (2011), the client service record would contain information on the and other administrative matters. dates and treatment type, appointment history, contact and payment details and other administrative information. The rationale for this method of record-keeping is that in circumstances where a third party is paying for the service (e.g. private health insurers, Medicare, Veteran’s Affairs) they may have a right to the information that clients give the psychologist. This would be as a result of the client consenting to the third party’s access when they accepted the conditions of the payment. With two-part client records it may be possible to negotiate with third parties that only the client service record is disclosed to these organisations when they require details of treatment. In this way the highly confidential client information that is held in the confidential client record is not disclosed to third party payment agencies. However, clients typically give their consent to the provision of information to the third party payment agency as part of their acceptance of the terms of payment from the third party (Stokes 2011). This will usually have occurred before the client has attended the psychologist and may in fact be considered coerced rather than voluntary consent (APS 2011b). As the client is required to sign the consent form to gain access to health/medical services, he is not freely consenting to the disclosure of his information to the third party, but rather is doing so to gain access to the medical services. Therefore the psychologist should include this provision in her record-keeping procedures to further protect client confidentiality. There may also be

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CASE STUDY 11.1

some instances in relation to court subpoenas where negations may allow for only the client service record to be presented rather than the full record. However, the court will have the final say on what material is needed. Stokes (2011) recommends this method of record-keeping for any client whose payment is made by a third party. However, this method, although more lengthy and complex, may have advantages for all clients. For example, even in a single-psychologist practice with a secretary, this method of record-keeping could allow for an easier management of confidentiality as the secretary would only have access to the client service record rather than the full client record (see later in this chapter for further details on employees and confidentiality). Also, in larger practices with increased electronic storage of records the separation of the client information may make security and access more compliant with confidentiality requirements.

Sandra is a psychologist working in a small private practice. She has implemented the two-part client record for all her clients. There has been a discrepancy in the payment claims between the client and the third party paying for the psychological services. The client, as part of his original agreement with the third party, has consented to the third party accessing his medical files. When the third party contacts Sandra, she negotiates with them to provide access to the client service record only; this lists dates of service provision and payment information. With this information the third party can verify the service provision.

In this scenario, Sandra and the client will have consented to the third party involvement  in the service provision process. This will probably have occurred when Sandra agreed to provide services to the third party (which would have been when she first worked with clients funded by that third party) and the client would have consented when he agreed to have his services paid for by the third party. However, in the case of a transport accident insurer or medical insurer the agreement may have been made many years before the actual service provision occurs. Therefore psychologists must ensure that they (and their clients) are aware of the information that may be required to be shared in third party payment situations. Implementing a dual record system may reduce the disclosure of highly sensitive information in these situations, but will typically require the agreement of the third party.

Content of the client record In accordance with B.2.1 of the Code and the APS’s Guidelines on Record Keeping (2011a, p. 130), psychologists must ensure that they ‘maintain accurate, current and complete records of psychological service’. While this defi nition is broad and will require psychologists in different

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Jenny is an organisational psychologist who is working as a contractor for a large Australian firm providing employment services. A large part of her role is to evaluate employees to determine which individuals would be most suited to working on deep-sea oil-drilling platforms 50 km off the coast. This role does not attract any Medicare funding and it has been made clear to all parties during the informed consent procedure that the company is the client and that Jenny’s role is not to provide welfare services to the employees. What types of information should Jenny keep in her records for each employee she evaluates?

psychologists to keep ethically sound and complete client records. Consider the case of Jenny. To fulfil her ethical requirements Jenny should make careful notes on why she has chosen to use the assessment tools that she has. This justification should be based on the client, his situation and the job setting, and why the selected tool is appropriate to him. Jenny should record how the assessment was carried out, make behaviour observations to assess the reliability of the assessment and record the results of the assessment. She should also include her personal judgments based on her clinical experience. If there is any ongoing or placement-type assessment for suitability to work in an isolated workplace, this should be noted and fluctuations between assessment sessions should be recorded. Detailed notes on these fluctuations in performance and how they were resolved should be recorded. Finally, all fi ndings and recommendations (along with justifications and supporting documentation) should be included; any follow-up or reassessment requirements should also be recorded. In this way Jenny has comprehensively recorded the information she has collected and justified the decisions she has made. Psychologists should also include enough information in the client record for another psychologist to provide ongoing service to the client in the case of illness, death or other cessation of practice of the initial treating psychologist.

CASE STUDY 11.2

fields of practice to maintain a variety of information, there are some commonalities across fields. Within the legislated and ethical requirements of the USA, Wiger (2011) suggests that client records should show the therapeutic effectiveness, appropriateness of service, continuity of service and evaluation of service outcomes. Using this as a starting point, a psychologist should record why a service provision method was chosen, how it was applied to a particular client(s), how the client(s) is progressing or improving and, fi nally, the outcome of the service. The method is not only important for monitoring client outcomes, but also to justify the service provision to a third-party payment provider. This is increasingly important in Australia as many psychologists are providing psychological services that are covered by Medicare. When Medicare audits a psychologist, its main focus is on whether the client was eligible for the service and that the psychologist has provided a service that meets the Medicare billing requirements (Mathews 2011). However, a large number of psychologists work in areas that do not attract Medicare funding. It is important for these and all

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Psychologists in Australia need to be aware that all information relating to the client that the psychologist collects is considered to be part of the client record (Bradford & Stevens 2012). This may include emails, diary entries, transcripts and working notes/hypotheses; even sticky notes attached to records are considered part of the client record (APS 2011a). The client record needs to detail the client’s presenting issues, consent forms, the services he is receiving, the implementation and the outcome of the service, copies of correspondence and reports regarding the client and any other material relating to the service provision. In Australia the client record should include contact information, next of kin details, other treating practitioners, assessment information and case progress notes for every session (Bradford & Stevens 2012). Psychologists should carefully consider the level of detail in their records. They should clearly distinguish the information in the record that is fact from the contents of the record that are based on opinion or are hypotheses. However, psychologists need to consider that their clients may access their record and this should temper the types of opinions that are included in the client record. The primary purpose of the client record is to treat, monitor and evaluate the client and the services being provided to the client. The information collected from clients should not be used for other purposes without the client’s consent unless there is a legal obligation to do so (APS 2011b). However, psychologists should be mindful that over time their records may be required to be presented in court as evidence or in legal disputes regarding the psychologist and the provision of his psychological service. There may be other legislative requirements that necessitate disclosing the contents of client records, such as mandatory notifications to AHPRA. In some circumstances third party payment providers such as Medicare may have agreements with clients that allow access to their client record. Clients also have the right to access their psychological records. Given this, psychologists should be aware that there is the strong possibility over the course of their career that lay people and professionals may have access to the records they have created. Further, as discussed in Chapter 2, clients need to be aware of potential situations where confidentiality may be breached. In some situations the client’s consent will be required in order to release his record (e.g. to other healthcare workers or the client himself). In other situations (e.g. a valid subpoena), the client will not have a choice in the disclosure of the client record. In these situations, however, the client should be advised that a disclosure is going to be made.

Multiple clients and the client record One of the most complex areas of the client record is when several parties are involved. This may eventuate when working with couples or in group therapy. In this setting it can be easier, from a documentation perspective, to have a single record of the session. This can lead to issues of confidentiality as all members of the group may have access to the confidential information of others in the group if they request access to the record (Bradford & Stevens 2012). However, if the psychologist takes individual notes for each client the lengthy process of note-taking may interfere with the service provision. Audio or video recording may alleviate this problem but it also has ethical complications. When working with more than one client the psychologist must ensure that all clients are aware of the issues of confidentiality and how the group’s records will be collected and stored, and the impact this may have on client access at a

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later date. In this way clients are aware of the situation and can decide what level of disclosure they are comfortable with. However, even this can be problematic when working with couples, as the reason for seeking psychological help may be to try to avoid a separation and divorce. It can be difficult to provide a positive therapeutic environment when both parties are concerned that what they say may be used in the divorce proceedings. The APS proposes that in these circumstances the psychologist provides only a summary of the client’s information and does not include any information about the other parties in the group environment because it would unreasonably impact on the privacy of the other parties (Jifkins 2009b). This is consistent with the Australian Privacy Principles. But even this process could be difficult as some or all of the information may be derived from the interaction between the parties.

Ownership of client records While clients of the psychologist will in most cases have access (see the next section) to their records, they do not own the record. Depending on the work situation, the psychologist, the clinic he practices in, or the organisation he works for will own the client record. Before commencing employment or practice, a psychologist needs to consider the ownership and the management of the client records he collects. According to the APS (2011b), when a psychologist is working independently his client records belong to him, but when a psychologist is employed by an organisation the client records are typically owned by the organisation. However, when the psychologist is working as an independent contractor for an organisation or in an interdisciplinary workplace, additional negotiation will need to take place to establish ownership and management. Additionally, the APS states that when psychologists are engaged in a voluntary capacity the same principles are likely to be relevant to ownership of records. When working independently, psychologists will be responsible for the maintenance, storage and access to the client records they create. This will mean ensuring that the records are stored securely and managing client access (see the next sections). In situations where the psychologist does not own the client records and they belong to the organisation or the clinic, the psychologist will still have responsibility for the records. The psychologist will need to ensure that the information contained in the client record is only used in the manner it has been agreed upon, with the client, during the informed consent procedure. This use may be wide-ranging; it may involve access by other health professionals in a clinic or hospital setting. It is important to note that in some cases ownership of the client’s records does not equate to access. For example, if the psychologist works for a large organisation or a school, it is likely that the organisation owns the client’s record, but only the psychologist, the client and anyone else specifically allowed access, either legally or who has been declared in the informed consent procedure, is allowed access to the record. Without consent from the client, school principals, business managers or owners do not have the right to access information that has been collected as part of a psychological service. However, if the information was specifically collected for the school to develop an anti-bullying program, then the school would have access as the psychologist would have explained the reason for the collection of the information to the client during the informed consent process. Consider the following case study.

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John is a registered psychologist who works in a small psychology clinic with three other psychologists. All his files are stored at the clinic. One day a fortnight he provides free psychological services through a charity, and these are conducted in the charity’s office space. John had been taking the client records for the services provided through the charity back to his office and storing them with his other client files. A new welfare manager has started at the charity and believes that the files should be stored at the charity’s offices and that the charity owns them.

In this situation the psychologist would need to refer to the original documentation that was completed when he started providing the services. While this documentation should have clearly outlined how the service was to be provided and the responsibilities for each party, this is not always the case. In this scenario if there was no clear guidance in the original documentation the psychologist would need to consider a number of factors in coming to a decision (see Chapter 3 for the Decision Assistance Model for Australian Psychologists). If the charity had been offering mental health services and John joined this process there could be an argument that he is technically in the same situation as if he were being paid to provide services by a healthcare clinic (even if he is not being paid); in this situation it is not uncommon for the clinic to retain the records. However, if he is simply using the office space of the charity to provide the service, it would be difficult to argue that the charity is the owner of the files. In either ownership scenario, John needs to take adequate steps to ensure that only those people who are authorised to access the files can do so. He also needs to consider the security of the files if he is transporting them between workplaces. If the psychology clinic that John works for owns the files for the clients seen in the clinic, it would be unacceptable if he then stored the files from his charity work there. He would need to have a third secure location to store the files. This case study again points up the need to clarify these matters before providing any services.

Access to the client record According to the Code of Ethics and the Australian Privacy Principles, only authorised people may access the client’s confidential information. It is important to note that there is a very broad definition of confidential client information, which includes the individual’s status as a client. In most situations the only authorised persons are the psychologists, the client and any other individual or organisation that the client consents to allow access. This can be more complex when the client is a child at school or a patient in a hospital. In these situation parents or clients may have consented to allow others in the institution access to the record when they first

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entered into a relationship with it. However, as was pointed out in the discussion on dual records, this form of consent may not be truly voluntary. In most situations there is no opportunity for parents enrolling a child in a school to alter the contractual relationship in relation to psychological services. Therefore, psychologists should remind and inform clients (including parents of children) of the level of confidentiality before any service provision takes place. If clients or previous clients request access to the information that a psychologist has about them, the psychologist is obliged to provide the information in the manner requested by the client (if practicable) within 30 days (OAIC 2013). As will be discussed later in this section, it may not always be possible to provide the information in the manner requested, but the client should receive a response to her request within 30 days or as soon as possible thereafter. Psychologists are required to provide access in some form unless one of the exemptions in the Australian Privacy Principles is relevant. Among these exemptions is that providing access would lead to a serious threat to the client or third parties (APP 12.3.a), there is an unreasonable impact on the privacy of others (APP 12.3.b), the request for access is frivolous or vexatious (APP 12.3.c) or the access would be unlawful (APP 12.3.f). It can be seen that there are some valid reasons not to provide clients with the information that the psychologist holds about them that are supported in the privacy legislation. If a client or previous client makes a valid request to access the information a psychologist holds about her, according to the latest information from the OAIC (2013) a psychologist should provide, where possible, the information in the manner requested. There will be many situations when a psychologist may not be able to provide information in the manner requested. In these situations the psychologist must provide the information about the client in a manner that meets the needs of the client and the obligations of the psychologist (APP 12.5). If a psychologist used a psychological test in an assessment and the client then requested access to that test, it would not be acceptable for the psychologist to provide a copy of the test as the contents of the test cannot be made public (Symons & McMahon 2001). In this case the best option might be for the psychologist to provide a report of the client’s assessment. Further, the psychologist could give a copy of the client’s responses to another psychologist who would be bound by the same ethical obligations in relation to nondisclosure of a test’s contents. In this way a client has been provided with a comprehensive description of the information that the psychologist holds about her, but the content of the test has not been disclosed. Copyright test material may not be disclosed as it would potentially invalidate the assessment tool (APS 2011b). As can be seen, the Code of Ethics and the APP stress the right of clients to access their information, but also allow for some flexibility to ensure that a psychologist’s legal and ethical obligations are maintained.

Correction or alteration to the client record According to APP 13, clients and previous clients have the right to correct personal information that is held by a psychologist which is out of date, misleading, incomplete or inaccurate. Psychologists have an obligation to take reasonable steps to correct this information and respond to clients within 30 days, and the client has an obligation to establish that the information is incorrect or out of date. If the client simply believes that the information is incorrect, but cannot justify this opinion, the psychologist would not be obliged to correct

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the information (Symons & McMahon 2001). When there is a disagreement, however, the psychologist should take reasonable steps to attach a statement in the client record where the contentious information is located, indicating the client’s claim that the information is incorrect (APP 13.3). This form of notation is suggested for all additions or alterations to client records. Psychologists should never directly alter the client record. Rather they should make additions or notations to the record providing clarification or extra information. These changes must be clearly dated to indicate that they were added or clarified at a later date.

CASE STUDY 11.4

Storage of client records

Peter Banks is a psychologist who works in a small medical clinic with a number of other psychologists and medical doctors. There is a central reception, administration and record storage facility within the practice which stores all the client records. Peter is concerned about the security of his client records.

As detailed above, psychologists are required to keep client records for at least seven years after the last client contact or until a client has turned 25 if the client was under the age of 18 when she last had contact with the psychologist. However, there can be organisational or legislative requirements to maintain records for longer; psychologists should consider these matters depending on their work situation. The APS’s Guidelines on Record Keeping (2011a) provide psychologists with a highly detailed discussion of the requirements for storing and maintaining client records. Before commencing practice or gaining employment a psychologist should consider the logistics of record storage. Since some psychologists will need to store client records for up to 25 years the format and the physical location of storage can present some problems. In relation to the storage of records, one of the fi rst things a psychologist needs to consider is the format or medium of the records he currently has control over and those he plans to have in the future. Until the past 15 or 20 years, the vast majority of records were manila folders with handwritten and typewritten notes, faxes and letters, test media and other paper-based materials. There may also have been some limited audio-visual materials stored on cassette. For a psychologist starting his professional practice today, there may be many of the same materials in a client record. There may also be digital materials such as emails, DVDs, electronic files, USB backups, electronic output from assessment tools which are computer-scored and clinical notes made on a tablet computer (see Chapter 2 for

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Mike is a psychologist who is about to take up a position in a large suburban hospital. As part of his employment the hospital requires that all the information he collects and creates about a client needs to be stored in the client’s medical record, which is owned by the hospital and is centrally stored and accessible by all health professionals in the organisation. How does Mike deal ethically with this situation?

CASE STUDY 11.5

competence with computerised systems). All of these materials need to be stored in a secure environment that protects the integrity and confidentiality of the client’s records. It is common practice for paper-based materials to be stored in a locked filing cabinet to which only the psychologist has access. While this may be fairly easy to achieve in a singlepsychologist practice, it can be more difficult to achieve in a larger organisation or even a multi-clinician practice such as is referred to in Case Study 11.4. There need to be some consideration and safeguards in place to limit who can access records, regardless of the type of practice. It is the responsibility of the psychologist who collected the client information, or of the psychologist who has taken over responsibility in the case of the retirement, death or incapacity of the collecting psychologist. Therefore, psychologists need to ensure that they are very conscious of the ethical storage of client records. In small practices where there is one or only a few psychologists, a locked filing cabinet in a secure location within the practice for each psychologist will typically allow for the secure storage of paper-based client records. Electronic records, however, will need to be considered more carefully. Care is needed to secure the various kinds of electronic records. Although there are many computer security programs and fi rewalls, the safest option for small practices is to have a separate computer, or small network of computers, which are not connected to the internet, to store client records. Using this method, as there is no connection to the internet, the risk of unauthorised access from outside the practice is reduced dramatically. However, precautions still need to be taken in regard to other staff and computer service staff within the practice (see the section below on service delegation). An additional computer or computers can then be set up with internet access that allows for research or other practice management activities. In smaller organisations with limited resources or larger organisations that require all computers to have wide network access or internet access, security of electronic records is vital. Psychologists should ensure that client records are encrypted and only accessible via password-protected security systems. In these situations it might be possible to negotiate that only the client service record is placed on the computerised system and the confidential client record is securely stored in some other computerised or hardcopy manner. This leads to broader questions regarding the storage of client records in larger organisations. Consider the case of psychologist Mike.

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In this scenario Mike is limited in his options. It would be very difficult for him to negotiate a records storage system that is different from the one used by the hospital. However, in this situation the client records that Mike creates are going to be stored and managed along with other those of health professionals. If Mike investigated further he might fi nd that there are adequate procedures set up to securely store and manage the client records. However, it might still be possible for other health professionals to access the client record. In this situation section 2.1 of the APS Guidelines (2011a) may be relevant to Mike because they deal with the conflict between the requirements of the APS, the law and the organisation a psychologist works for. In this situation Mike would need to negotiate and investigate the storage, management and access to records. If he felt that he could operate ethically in this environment, he would need to inform all of his clients about the arrangements for the storage, management and access to their records. In this way Mike’s clients would be aware of the treatment of their confidential information and could then decide what information they wanted to share with him in the therapeutic relationship. Alternatively, if Mike felt that it would not be possible to practise ethically he could decline the position.

Office workflow Psychologists need to consider the environment in which they practise. Since client confidentiality is paramount, it is important that there is a degree of privacy in the setting. For example, a psychologist’s office in a shopping strip with glass windows looking into the waiting room would not afford clients an appropriate degree of privacy. Similarly, if a psychologist is working in conjunction with other allied health professionals some thought would need to be given to the communal waiting room. Psychologists need to consider other matters such as using client’s given names rather than their surnames in waiting or communal areas as an added protection of their identity. Other workplace policies such as ensuring that computer monitors face away from public view, that reception staff do not have telephone conversations that may reveal a client’s identity in public areas, and refraining from staff gossip will add to the confidentiality and professionalism of the workplace. It is vital that there is a clearly defined method of transporting client records within the workplace and where necessary between worksites. In small work settings that do not involve a multidisciplinary team, this may involve the psychologist collecting and returning all records for their secure storage. In more complex environments further measures will need to be adopted to ensure that client information is kept secure. When records Termination of service: Occurs when the are being transported outside the workplace they should be in a locked case with psychologist is no longer return address details (APS 2011b).

able to continue offering a therapeutic service to the client. The psychologist is obliged to ensure that the client is as minimally affected with the inevitable change as possible.

Termination of service There are a number of factors that can lead to the termination of service provision to a client.

Chapter 11: Privacy Legislation, Records, Delegation, Advertising and Finances

APS Code B.11 B.11. Termination of psychological services B.11.1. Psychologists terminate their psychological services with a client, if it is reasonably clear that the client is not benefiting from their services. B.11.2. When psychologists terminate a professional relationship with a client, they shall have due regard for the psychological processes inherent in the services being provided, and the psychological wellbeing of the client. B.11.3. Psychologists make reasonable arrangements for the continuity of service provision when they are no longer able to deliver the psychological service. B.11.4. Psychologists make reasonable arrangements for the continuity of service provision for clients whose financial position does not allow them to continue with the psychological service. B.11.5. When confronted with evidence of a problem or a situation with which they are not competent to deal, or when a client is not benefiting from their psychological services, psychologists: (a) provide clients with an explanation of the need for the termination; (b) take reasonable steps to safeguard the client’s ongoing welfare; and (c) offer to help the client locate alternative sources of assistance. B.11.6. Psychologists whose employment, health or other factors necessitate early termination of relationships with clients: (a) provide clients with an explanation of the need for the termination; (b) take all reasonable steps to safeguard clients’ ongoing welfare; and (c) offer to help clients locate alternative sources of assistance.

The most common factor is completion of the service provision to the extent that the client does not need any further assistance from the psychologist. In this situation the psychologist’s ethical and professional obligations to the client relate to ensuring that his record is securely stored as detailed above and the psychologist is refraining from future dual or sexual relationship with the client. Clients may also discontinue with service provision before the completion of the service (e.g. midway through an intervention for anxiety); in this situation the psychologist owes a duty of care to the client. If the psychologist believes that the client is at a level of distress that may place him or identifi able third parties at harm, she may take steps to breach confidentiality to protect him (see Chapter 8). The psychologist should also provide any client who discontinues with referral information for other relevant psychologists in the area. More broadly, psychologists should support any client who desires a second opinion by giving details of other psychologists or information about referral services (B.8.2).

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APS Code B.8.2 To benefit, enhance and promote the interests of clients, and subject to standard A.5. (Confidentiality), psychologists offer practical assistance to clients who would like a second opinion.

When a psychologist discontinues the service provision rather than the client, additional ethical obligations exist (B.11). A psychologist may discontinue the service if it becomes clear that the client is no longer benefiting from the treatment (B.11.1), or if the psychologist is not competent to provide the service the client requires (B.11.5). Unless the client is in need of emergency psychological service, the psychologist should refer him as soon as is practicable once it becomes clear that she does not have the competence to provide the service. If the client is in need of emergency assistance the psychologist may ethically provide emergency care until the client can be safely referred. According to the Code, when terminating the service owing to a lack of competence, the psychologist should explain that the service needs to end (B.11.5.a) and why this is in the client’s best interests. The psychologist must also take steps to protect the client during this process (B.11.5.b) and provide him with alternative sources of assistance (B.11.5.c). She may give him details of a number of psychologists who have the skills to meet his needs in addition to 24-hour help lines and/or online resources where appropriate. This process (B.5.11.a–c) is generally advisable in all situations when the service provision is terminated before the psychologist believes the desired goals have been achieved.

Death or illness of a psychologist The service provision can also be terminated because of the death of the psychologist or the client. In the case of the death of an actively practising psychologist, ongoing clients, their records and all confidential information will need to be appropriately considered; even for psychologists who were not practising at the time of their death there may be records from previous clients that need to be considered. The APS (2012c) recommends that all psychologists have a practice contingency plan (PCP) which would guide another psychologist through the Practice contingency specifics of a psychologist’s practice if she died or was incapacitated. Then, in plan: Guides another the event of her death, serious illness or incapacity, another psychologist could psychologist through the ensure that the incapacitated psychologist’s clients are appropriately cared for. specifics of a psychologist’s The PCP consists of office information and security information, location of practice if she died or was incapacitated. The other client information, instructions for notifying clients, and details of professional psychologist would ensure indemnity insurance (APS 2012c). The specific details to be included would that the first psychologist’s vary greatly depending on the type of practice and the workplace setting. clients were appropriately In a large organisation with many psychologists the PCP would only cover cared for. matters directly related to the individual psychologist (e.g. passwords or location of keys) as other psychologists would be aware of broader matters such as location of records. In a single-psychologist practice the PCP would need to include full instructions ranging from the location of the practice to the method of filing and the passwords to any

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electronic systems. In the case of a single-psychologist practice there should be a primary psychologist who is nominated to be provided with the PCP by the next of kin or the executor of the deceased psychologist’s estate. There should be at least two alternatives as well (APS 2012c). The psychologists who have been listed in the PCP as primary and alternatives must be aware of, and agree to, their nomination and the PCP should be revised regularly with them. The PCP could also be implemented if a psychologist suffered an injury or illness that rendered him incapable of practising or contacting clients. In this situation, the psychologist receiving the PCP could cancel appointments and provide emergency services to the incapacitated psychologist’s clients (B.10.1). If the psychologist is absent or cannot practice, but can communicate with his clients, he could ethically offer clients the opportunity to seek the services of another psychologist (e.g. a locum) (B.10.2). Each client would need to be consulted before such measures could be implemented. It is vital that all psychologists consider issues such as these to ensure clients receive the best possible service provision while the psychologist cannot practise.

APS Code B.10 B.10. Suspension of psychological services B.10.1. Psychologists make suitable arrangements for other appropriate professionals to be available to meet the emergency needs of their clients during periods of the psychologists’ foreseeable absence. B.10.2. Where necessary and with the client’s consent, a psychologist makes specific arrangements for other appropriate professionals to consult with the client during periods of the psychologist’s foreseeable absence.

Client death Broadly, psychologists should treat the confidential information of deceased clients as they do for all clients (Jifkins 2009a). Disclosures should only be made in accordance with the Code. This implies that psychologists should only disclose information if the client has made a specific request that some information is released upon her death or there is a legal obligation for the psychologist to do so (e.g. subpoena). According to Jifkins, if the client has named an executor in her will, this person becomes legally responsible for her affairs and would be able to access her records. It is only this person, with the legal authority, who would have the right, not family members more broadly. There are some legislative protections of deceased person’s information in Tasmania (20 years after death), Victoria and New South Wales (25 years after death); psychologists in other states should be aware of any legislation introduced that may impact on deceased client’s information (Jifkins 2009). Unless there is a court order or coronial inquest under way, psychologists should destroy deceased client records seven years after their last provision of service (or seven years after a child has turned 18), as they would for all clients (Jifkins 2009a).

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Service delegation and other professionals Psychologists may work with a number of professionals in a multidisciplinary team or employ or use a number of non-psychologists in carrying out their practice. For example, there may be support staff, such as receptionists, nurses, research assistants or students filling some of these roles. Psychologists working in the medical fields may interact with doctors, physiotherapists and occupational therapists in developing and providing client services. Psychologists may also need the professional services of lawyers, accountants or computer technicians in running their practice. This section will focus on the ethical issues of working with others when providing psychological services.

Support staff Since support staff are likely to be aware of the name and contact details of the client, handle client information or be aware of the psychological service being provided, these people must be aware of the confidentiality involved. The Code (B.6.a) clearly states that it is the psychologist’s responsibility to ensure that these individuals are aware of the impact of the Code on the activities they are engaged in. For example, reception staff need to be aware that client confidentiality would preclude them from discussing any details of clients with their family or friends. This would include not disclosing the fact that someone was a client at all. As is the case for psychologists, support staff need to be trained in how to deal with chance meetings with clients (e.g. not acknowledging them unless the client initiates contact). The staff and students need to be aware of the negative impact of dual relationships. Students and other staff who may be assisting with service delivery must not put the client at risk, either through their actions in the service delivery or through exploitative relationships (B.6.c). Psychologists should also ensure that these staff are not in a dual relationship with the client that may adversely affect the client (B.6.b). When delegating, a psychologist should consider the delegate’s skills and competencies (B.6.d). Finally, the psychologist should oversee the services provided by the delegate (B.6.e) and he should take full responsibility for the delegate’s actions.

APS Code B.6 Psychologists who delegate tasks to assistants, employees, junior colleagues or supervisees that involve the provision of psychological services: (a) take reasonable steps to ensure that delegates are aware of the provisions of this Code relevant to the delegated professional task; (b) take reasonable steps to ensure that the delegate is not in a multiple relationship that may impair the delegate’s judgement; (c) take reasonable steps to ensure that the delegate’s conduct does not place clients or other parties to the psychological service at risk of harm, or does not lead to the exploitation of clients or other parties to the psychological service;

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(d) take reasonable steps to ensure that the delegates are competent to undertake the tasks assigned to them; and (e) oversee delegates to ensure that they perform tasks competently.

Where support staff are closely involved with clients they should be fully aware of the requirements of the Code. In some circumstances it may be reasonable to require support staff to sign a contract that compels them to be in compliance with the Code. Nevertheless, as with psychologists, all staff should undergo regular training in ethical behaviour and be aware of the latest legislation that may apply to their field of psychology.

Collaborations Psychologists in almost all fields will collaborate with other professionals in providing a service to their clients. In many settings this collaboration will be consented to at the beginning of the service provision (e.g. at admission to hospital). However, psychologists should still fully inform clients before providing any service, explaining the special issues relating to the psychological service rather than the broader service offered as part of their hospitalisation. When clients have consented to the collaboration the psychologist should work productively with other professionals in the best interests of the client to deliver the psychological service (B.8.1).

APS Code B.8.1 To benefit, enhance and promote the interests of clients, and subject to standard A.5. (Confidentiality), psychologists cooperate with other professionals when it is professionally appropriate and necessary in order to provide effective and efficient psychological services for their clients.

There can be conflicting goals, methods and interests when working in a team environment. It is important for psychologists to approach these issues in a collegial and scientific manner. However, the overriding concern must, as always, be the client’s welfare.

Non-healthcare professionals Psychologists will often need to use the services of non-healthcare professionals such as insurers, accountants and lawyers. When these services are required to manage the business of the psychologist rather than provide any kind of service to the client (e.g. bookkeeping) it is vital that these individuals do not have access to client information, including client names. This may require the psychologist and the collaborating professionals to develop systems that allow for the collection of relevant business data without breaching the Code. If the interaction with the professional involves a specific client (e.g. gaining legal advice), psychologists will need to determine their ethical obligations. Given the confidential

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relationship between lawyers and their clients, it may be ethical for a psychologist to divulge more than she typically would. However, without client consent psychologists should still not breach their ethical obligations to their clients when receiving legal advice about a client. When faced with such a situation a psychologist should always seek the guidance of an experienced colleague. When psychologists require technological services they need to take steps to ensure the confidentiality of client information. They may need to consider replacing a computer or other device and restoring client information from backups, rather than having the device repaired. Allowing access to a computer, tablet computer or smart phone that contains confidential client information would be unethical. Psychologists may be able to develop a confidentiality agreement with technicians not to disclose information, but they must not allow technicians to access confidential information.

Advertising Standard C.2.3 of the Code relates to psychologists advertising their services, and AHPRAwide advertising regulations apply to all registered healthcare professionals. Both of these are lengthy and very detailed to account for the wide range of settings in which psychologists, and healthcare workers more broadly, work. It is vital that any psychologist planning to advertise her practice consult these documents in conjunction with the AHPRA documentation on the area of practice endorsement. It is important to note that any form of advertising including business cards and listings in phone/online directories will need to conform to the Code of Ethics and AHPRA guidelines. Very broadly, psychologists must not make misleading or fraudulent claims, use testimonials or claim that their services, products or skills are superior to others (C.2.3). They must not guarantee or even suggest that unlikely positive outcomes are to be expected. They must not appeal to clients’ fears or uncertainties over not receiving the psychological service (‘if you do not have treatment you will be anxious forever’) or use sensationalised, sexist or extreme language (C.2.3). They must use accurate descriptions of their qualifications and skills (C.2.4). They should also challenge a client’s unrealistic or incorrect assumptions about the psychologist or her service (C.2.5). For example, a client may comment to a psychologist that he knows she can cure anybody of their anxiety because she helped his very anxious friend overcome his fear of heights. In this situation the psychologist would need to clarify the likely outcomes of the service and help the client to develop more realistic expectations. The PsyBA (2010) Guidelines for Advertising Regulated Health Services are extremely detailed as they are derived from the AHPRA legislation, which is relevant to all registered healthcare workers. As part of these requirements the PsyBA sets out a list of the acceptable components of advertising and some items it considers to be unacceptable. Psychologists must be aware of the most recent version of this document and ensure that their advertising complies. This includes the banning of testimonials in advertising for all AHPHA-registered healthcare professions, which had been acceptable under the Code in some situations.

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Financial limitations Given the power differential that exists between psychologists and their clients, it is important that psychologists deal ethically and professionally with their clients about their payment. The APS (2012b) has produced Guidelines regarding Financial Dealings and Fair Trading to help psychologists manage their financial transactions ethically. This section will focus on the financial relationship between psychologists, their clients and possible third parties. It is important that all interactions, including fi nancial, between psychologists and their clients are not manipulative. This is primarily about psychologists not benefiting fi nancially from their clients in unethical or inappropriate ways, but it can also be about ensuring that clients do not manipulate the fi nancial relationship. Psychologists should provide clients with clear expectations regarding the benefits and costs of the services, how and when payment is to be made, any auxiliary costs, such as travel, and the cancellation and/or late fee policies (APS 2012b). As with all informed consent information, there should be discussion about the cost involved in any additional service provision before it occurs. The APS (2012b) suggests that exchanging goods or services for psychological services (bartering) is unwise. There can be questions of fi nancial exploitation by the psychologist and/or the client. Transactions of this type require an understanding of the value of goods or services that may not be clear and this can lead to problematic interactions between psychologist and client. It is also highly likely that in providing a reciprocal product or service, a dual relationship would be formed that would breach the Code. It is therefore advisable that all psychological services are provided on a monetary or pro bono basis.

Third party payment Psychologists will often provide services that are paid for by government (e.g. Medicare), private organisations (private health insurance) or individuals (e.g. family member), rather than directly by the client. In these situations psychologists, clients and third parties need to be aware of the expectations of each party and psychologists should aim to safeguard all parties (C.6.2.a).

Third party payment: Psychologists will often provide services that are paid for by government, private organisations or individuals rather than directly by the client.

APS Code C.6.2 Psychologists make proper financial arrangements with clients and, where relevant, third party payers. They: (a) make advance financial arrangements that safeguard the best interests of, and are clearly understood by, all parties to the psychological service; and (b) avoid financial arrangements which may adversely influence the psychological services provided, whether at the time of provision of those services or subsequently.

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In some situations this can be negotiated. However, when working with larger funding agencies these typically only provide guidelines or policies that must be followed to receive funding. In these situations the psychologist and the client will need to be aware of the benefits and limitations that this will mean. This may include discussing with clients the administrative information that some of these funding agencies require. It is important, however, that psychologists avoid funding arrangements that might adversely influence the services required by the client (C.6.2.b), though it must be noted that in many situations government funding bodies will only provide limited funding and psychologists should do everything possible to meet the needs of the client within these limitations.

Referrals According to the Code, it is not ethical for psychologists to engage in a paid referral system. Psychologists cannot pay or be paid for referrals from psychologists or other professionals (C.6.3).

APS Code C.6.3 Psychologists do not receive any remuneration, or give any remuneration for referring clients to, or accepting referrals from, other professionals for professional services.

Psychologists must only take on clients they are competent to work with; they should also refer other clients to relevant psychologists or other healthcare professionals. Moreover, they should only refer to specific individuals when they are referring a client to an unparalleled expert in the area of the client’s need. It is common practice, in the vast majority of cases, for psychologists to give the details of at least three professionals when they provide their clients with referrals. Psychologists should be cautious when they receive an unusually large number of referrals from a single source. When this occurs, it is possible that the professional or service that is referring the clients is doing so because they only know the details of one psychologist or they feel they owe the psychologist in some way. The psychologist should discuss with these referring sources, in a professional manner, her skills and competencies and provide details of other psychologists with differing skill sets. In this way only those clients that require the services the psychologist offers will be referred.

When clients cannot pay Standard B.11.4 of the Code states that psychologists make reasonable arrangements for clients who cannot afford to continue with the service.

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APS Code B.11.4 Psychologists make reasonable arrangements for the continuity of service provision for clients whose financial position does not allow them to continue with the psychological service.

Thus the onus is on the psychologist to find a way to continue with the service provision, find a suitable alternative (e.g. free or community services) or structure the service in a manner that the client can afford (e.g. less frequent contact with the psychologist, with increased homework). Alternatively, the psychologist may be able to offer a longer period to pay for a short-term intervention. Psychologists may also consider providing a percentage of their services without charge each week to low-income clients. Where no other option is available psychologists may discontinue the service provision. However, this must be done in an ethical manner that does not place the client at risk of harm (APS 2012b).

CHAPTER SUMMARY This chapter has covered the Australian Privacy Principles and their relevance to broad psychological practice. Psychologists will nevertheless need to consider the privacy legislation in relation to their specific practice. Psychologists are responsible for the creation, storage and destruction of their records. These records should follow the twopart system developed and supported by the APS. Psychologists should retain their records for seven years, or for seven years from the time a child-client reaches the age of 18. The client record needs to be complete and can be accessed and corrected by the client in many instances. Psychologists need to be aware of the ethical issues relating to their workplace and their employees, students and other professionals. They need to be aware of the APS and the PsyBA’s requirements for advertising. They also need to consider the ethical issues related to client payment and financial transactions.

QUESTIONS TO CONSIDER 1 2 3 4 5

How should psychologists and their employers determine who owns the client file? Is it ethical for reception staff to have access to the client record? What is the ideal layout of a psychology practice? What steps should psychologists take to reduce the impact of their serious illness on their clients? What is the most ethical method of advertising psychological services for each field of psychology?

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REFERENCES APS (2011a). Guidelines on Record Keeping. Melbourne: APS. APS (2011b). Psychologist’s Records: Management, ownership and access. . APS (2012a). The do and don’t of client session notes. Inpsych 34(5), 26–7. APS (2012b). Guidelines regarding Financial Dealings and Fair Trading. . APS (2012c). Who will sort out your private practice if you die suddenly. Inpsych 34(4), 32–3. Bradford, L. & Stevens, B. (2012). What’s in the file? Opening the draw on the clinical recordkeeping in psychology. Australian Psychologist, early online publication. Jifkins, J. (2009a). Managing client confidentiality after a client’s death. Inpsych 31(1). Jifkins, J. (2009b). Legal aspects of managing client records. Inpsych 31(2). Mathews, R. (2011). Medicare compliance audits: An update. InPsych 33(6), 26–8. McMahon, M. (2008). Confidentiality, privacy and health information management. In R. Kennedy (ed.) Allied Health Professionals and the Law. Sydney: Federation Press, pp. 108–30. OAIC (2012). Health Service Providers. . OAIC (2013). Australian Privacy Principles and Information Privacy Principles: Comparison Guide. . PsyBA (2010). Guidelines for Advertising Regulated Health Services. . Stokes, D. (2011). Protecting client privacy through two-part client records. InPsych 33(4), 32. Symons, M. & McMahon, M. (2001). Key privacy issues for psychologists to consider. Inpsych 23(5), 15–17. Wiger, D.E. (2011). The Psychotherapy Documentation Primer. New Jersey: John Wiley & Sons.

12 Gaining and Maintaining Registration

CHAPTER OBJECTIVES • • • • •

To understand the pathways to becoming a registered psychologist To gain a understanding of the importance of AHPRA and the PsyBA in the registration process To become familiar with the post-registration requirements for psychologists to maintain their registration To develop an awareness of the importance of continuing professional development as a psychologist To develop an awareness of the mandatory notification process and the ethical issues involved

KEY TERMS Continuing professional development Mandatory notifications

Peer consultation Practice endorsements

Registered psychologist Voluntary notifications

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Introduction It is a long and complex process to become a registered psychologist and there are a number of requirements to continue practising as a psychologist. The word ‘psychologist’ is legally restricted and can only be used by individuals who have completed adequate and approved training pathways, are registered with the Psychology Board of Australia and continue to develop their professional skills. This chapter will discuss the key steps in gaining registration as a psychologist and what is required to maintain registration. It is important to note that registration and professional development requirements are regularly updated; for the most up-to-date information see .

Pathways to becoming a registered psychologist There are a number of pathways to becoming a registered psychologist . They all involve four years of university-level study followed by at least two years of further development specific to professional practice in psychology. The initial four years of study Registered psychologist: In Australia, a person focus on the general aspects of psychology that are relevant to all fields and who practises as a can lead to provisional registration as a psychologist. Provisional registration psychologist is required by allows students or interns to complete their training and the supervised law to be registered with the Psychology Board of practice necessary to qualify for general registration as a psychologist. During Australia; only those with this period provisional psychologists will study or work under supervision. appropriate qualifications Because of their registration with AHPRA through the PsyBA, all codes and and registration are entitled regulations set out by AHPRA that regulate behaviour and appropriate practice to use the term. will apply to provisionally registered psychologists. The subsequent two or more years of training provide provisional psychologists with the knowledge and skills required to apply for general registration as psychologists. If undertaken in a tertiary institution, the training can take the form of an accredited master’s degree in a specific field of psychology (a two-year course comprising coursework, supervised placement and a 16 000 word [approx.] thesis); an accredited professional doctorate in a specific field of psychology (a three-year course comprising coursework, supervised placement and a 70 000 word [approx.] thesis); or a 5+1 program that involves a year of coursework and supervised placement followed by a full-year internship. The 4+2 path to general registration is a two-year training program under the supervision of a psychologist that does not involve university study. Specific requirements for these paths of training can be found on the PsyBA website . Each of these paths to registration has unique strengths and weaknesses. Students should consider the benefits and opportunities that each of the methods offers for gaining the skills needed for general registration. Each method can lead to general registration. However, some employers and professional organisations have particular motives and expectations regarding which path they prefer students to follow. There can also be difficulties obtaining endorsement if some methods of training are undertaken (see below). Provisional psychologists who began their training after 1 July 2013 may need to pass the National

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Psychology Exam to be eligible for general registration; see for more information (PsyBA 2012a).

Code of Ethics All psychological practice in Australia is governed by the APS Code of Ethics, which has been designated by the PsyBA (n.d.) as the Code that applies to all psychologists. It is therefore vital that all psychologists, regardless of their association with the APS, are fully aware and compliant. Standard B.1.2.c of the Code states that to provide services competently, psychologists must practise in accordance with the Code and the various APS Guidelines, which for APS members can be found at .

APS Code B.1.2 Psychologists only provide psychological services within the boundaries of their professional competence. This includes, but is not restricted to: c) adhering to the Code and the Guidelines;

The Guidelines are frequently updated and it is important that psychologists are aware of the most current versions; six individual Guidelines were updated between February 2011 and June 2012, for example. Therefore, psychologists must constantly be aware of changes and updates to the Guidelines to ensure that their practice is competent. As mentioned above, adherence to the Code is required for both fully registered and provisionally registered psychologists. Adherence to the APS’s ethical guidelines is necessary to meet the Code’s description of competent practice. If a complaint were to be made against a psychologist and she was not complying with the APS ethical guidelines it would be difficult for her to present her behaviour as professionally competent.

Insurance All psychologists registered under AHPRA, including provisionally registered psychologists, must have professional indemnity insurance that meets the PsyBA minimum requirements (PsyBA 2012b). According to the PsyBA, the only group of psychologists who do not need indemnity cover are those who are not practising; but these psychologists and psychologists who have retired need to have insurance that covers the periods when they were practising. Some workplaces may have broad indemnity insurance that covers all psychologists that work for the organisation. However, psychologists who are also engaged in other work, paid or voluntary, will need to have additional insurance if their workplace policy does not cover these situations. Psychologists also need to consider if workplace policies will continue to provide cover for their actions when they were employed if they leave that employer. Provisional psychologists should also check their coverage under workplace or university policies to ensure they have adequate coverage. The current minimum level of coverage can

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be found at , and psychologists should monitor these guidelines to ensure their coverage meets these requirements.

After registration Once a psychologist has gained general registration, there are a number of ongoing professional and ethical requirements placed upon them under the AHPRA legislation. In addition to the matters of insurance and adherence to the Code and Guidelines raised above, which apply to all individuals registered under AHPRA, psychologists must also undertake professional development and make mandatory notifications. There are also restrictions placed on psychologists regarding advertising (see Chapter 11) and the way that they present their qualification and titles to the public.

Continuing professional development The PsyBA (2011), in its Guidelines on Continuing Professional Development, outlines the continuing professional development (CPD) requirements for registered psychologists. These requirements do not apply to provisional psychologists who are undergoing training. Provisionally registered psychologists have their own set of requirements, requiring higher levels of professional development. The basis for professional development is Continuing professional an attempt to ensure that all registered psychologists regularly develop their development: In order to maintain registration skills and knowledge and engage in a review of their practice. Through this as a psychologist certain process it is anticipated that psychologists will engage in effective evidenceeducational and practical based practice and avoid burnout (PsyBA 2011). Each psychologist should plan activities must be their CPD to target a specific area in need of development, given their practice undertaken every year so as to ensure recency in the and location. For example, a psychologist who works in research is likely to field of practice. have an entirely different CPD plan from a psychologist who works in an early intervention clinic. However, psychologists should also attempt to maintain their knowledge about substantial changes in all fields of practice and general areas such as ethics. Psychologists must develop a learning plan each year that structures their learning goals; the plan can be updated to cover new or emerging professional needs throughout the year (PsyBA 2012). The PsyBA (2012) sets out minimum amounts of professional development for each psychologist to undertake each year, which can be found on the Codes, Guidelines and Policies section of the PsyBA website. Professional development is typically made up of active peer consultation and other CPD activities. The PsyBA defi nes active CPD as activities that involve learning and application; many of the examples set out in the PsyBA documentation involve some form of assessment or presentation. Psychologists also need to evaluate Peer consultation: their own practice and behaviours as part of their peer consultation. According A psychologist discussing to the PsyBA, peer consultation should develop and evaluate the psychologist’s his practice with another practice in accordance with their learning plan and can be in a group or psychologist. individual format. Other CPD activities suggested by the PsyBA may include

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attending lectures or study groups, writing or reading scholarly or professional publications and reviewing the work of others. Professional groups, Medicare and endorsement status (see below) may need additional or other minimum requirements for CPD. While the need for continuing professional development is vital, there are some ethical issues that should be considered. One of the most important is that of psychologists providing CPD activities to other psychologists, more specifically whether the provision of CPD develops a professional relationship between the psychologist providing the service and a client (the psychologist receiving the service). In the case of peer supervision, the individual receiving the supervision is considered the client as the Code’s defi nition of clients includes individuals receiving supervision. Given the focus on the clinical practice and personal development of psychologists receiving the service, there could be a sound argument that peer consultation closely resembles peer supervision. This would make the psychologist receiving the consultation the client of the psychologist giving the consultation. This would dictate that the ethical issues of confidentiality, mandatory notifications (see below) and dual relationships need to be considered. If peer consultations, as part of CPD, do constitute a psychologist–client relationship, then consultations within an organisation, reciprocally or among colleagues, would be ethically problematic because of the dual relationship issue. These relationships need further clarification from regulatory and professional groups supported by research from the field. However, all psychologists should be aware of the potential ethical issues in the peer consultation component of CPD.

Mandatory notifications There are number of healthcare provider behaviours that AHPRA has deemed potentially harmful to clients of all professionals registered under AHPRA (see for a list of professions). When a psychologist has a reasonable belief that another psychologist, or other professional registered under AHPRA, is engaged in these behaviours Mandatory notifications: he is required to report them to AHPRA (PsyBA 2010). According to the PsyBA, The compulsory reporting a reasonable belief requires a stronger level of knowledge than mere suspicion, by psychologists, and other but does not require conclusive proof. The employers and educators of healthcare professionals registered under AHPRA, of healthcare workers who are registered under AHPRA are also required to inappropriate conduct such make mandatory notifications under the AHPRA legislation, even if the as intoxication or sexual employer/educator is not registered under AHPRA. The aim of mandatory behaviour with a client in notifications is to ensure that all practitioners are behaving in an ethical and other practitioners. professional manner. PsyBA reports from the early years of the system indicate that mandatory notifications are being made and acted upon by the national registration boards. The four areas of behaviour that are included in the notification system are practising while intoxicated, sexual misconduct, practitioner impairment and significant departures from accepted professional standards.

Practising while intoxicated The PsyBA’s (2010) Guidelines for Mandatory Notifications highlights the potential dangers to clients when their psychologist is under the influence of alcohol or other drugs as being the primary reason for the inclusion of this behaviour. It is important to note that the PsyBA states

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that intoxication relates to impairment or effect on ability to practise. The PsyBA Decision Guide states that psychologists must report other healthcare professionals who are registered under AHPRA if they directly observe them practising while intoxicated or if they have a reasonable belief that they are practising while intoxicated. It is important to note that this notification behaviour covers all drugs that may lead to impairment or affect the psychologist’s interaction or ability to work with clients or peers.

Sexual misconduct The PsyBA’s (2010) mandatory notification standards are different from those of the APS Code that govern psychological practice. According to the Code, psychologists must not engage in sexual activity of any kind with clients or former clients or close relations of clients or a former client for a period of at least two years from the conclusion of service provision. Even after two years have elapsed there are many situations in which it would never be ethical for a psychologist to have a sexual relationship with a former client because of the power imbalance.

APS Code C.4.3 Psychologists: (a) do not engage in sexual activity with a client or anybody who is closely related to one of their clients; (b) do not engage in sexual activity with a former client, or anybody who is closely related to one of their former clients, within two years after terminating the professional relationship with the former client; (c) who wish to engage in sexual activity with former clients after a period of two years from the termination of the service, first explore with a senior psychologist the possibility that the former client may be vulnerable and at risk of exploitation, and encourage the former client to seek independent counselling on the matter; and (d) do not accept as a client a person with whom they have engaged in sexual activity.

Under AHPRA, psychologists must report another healthcare professional if he is engaging in a sexual relationship with a current client or a person closely related to that client. They must also report a healthcare professional who is engaging in a sexual relationship with a former client if the client’s vulnerability would indicate that such a relationship represented misconduct. If a psychologist is aware of a psychologist who is engaging in a sexual relationship with a former client and two years have not passed since the termination of the service provision, the psychologist should make a voluntary notification (see below). This is a breach of the Code even though it does not necessarily constitute notifi able conduct under the PsyBA Guidelines.

Practising with an impairment This aspect of notifiable conduct, as defi ned by the PsyBA (2010), relates to a healthcare professional who has an impairment such as disability, condition or impairment that detrimentally affects or is likely to detrimentally affect the person’s ability to practise.

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To warrant a notification the healthcare professional must have placed the public at risk of substantial harm. The PsyBA Guidelines state that a psychologist with a blood-borne virus who practises appropriately and safely would not warrant a notification, but a psychologist with a cognitive impairment would warrant a notification. The PsyBA has not clarified at what point a behaviour becomes an impairment other than when it constitutes a risk to clients and the public, but it does say that work conditions and the monitoring or supervision of the impaired healthcare professional may reduce the risk to the public. This potentially indicates that some healthcare professionals with low or variable impairment, who have ongoing support and supervision that ensures public safely, may not need to be reported.

Significant departures from accepted professional standards The PsyBA advises psychologists that they are also required to report psychologists and other healthcare professionals registered under APRHA, if the public is placed at risk through their departures from accepted professional standards. In relation to psychologists reporting other psychologists, this process can be relatively simple. If a psychologist becomes aware of a psychologist who is practising in a manner that does not have empirical, theoretical or clinical support and places the public at risk, she would need to consider a notification. It is important to note that the departures need to be substantial and they cover all aspects of professional practice. However, it may be difficult if a psychologist is interacting with professionals from other fields of healthcare who are registered through AHPRA. Psychologists should only make notifications if the other healthcare professional is deviating from the standards of his own field, not psychology. While this can be difficult given the differences in standards of practice across fields, it is part of the requirements of registration.

Mandatory notifications regarding students Educational institutions and supervisors are also required to make mandatory notifications. These requirements are in addition to any mandatory notification requirements that may exist due to a staff member’s registration with AHPRA. Educators are required to report students who are involved in or assisted with their clinical training if the provider believes that the student has an impairment that may place the public at substantial or considerable risk of harm (PsyBA 2010). Impairment relates to physical or mental impairment, disability, condition disorder (including substance abuse or dependence) that affects, or is likely to affect, the student’s training (PsyBA 2010). These measures are an attempt to ensure that client and public safety is maintained during the training procedures of psychologists.

Penalties for not making a mandatory notification At the time of publication there are no direct fi nancial penalties for the failure of healthcare professionals, employers, organisations or education providers to make mandatory notifications. According to the PsyBA (2010), however, individuals may be subject to health, conduct or performance actions. If an educational provider does not make a report when necessary, she may be named in AHPRA publications. Employers of practitioners may be subject to state ministerial review and the Minister will address the matter further with industry accreditation bodies and/or health compliance entities.

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Voluntary notifications In addition to mandatory notifications, there is also the facility for healthcare practitioners or the public to make voluntary notifications regarding other problematic behaviour. They can also make notifications about behaviour that relates to the mandatory notification Voluntary notifications: Notifications regarding areas but does not meet the threshold for mandatory notifications (PsyBA, n.d). problematic behaviour that The PsyBA states that as part of the AHPRA legislation educators, employers healthcare practitioners or and healthcare workers are protected from litigation if the notification is made the public are able to make in good faith and without malice. to the PsyBA.

Other issues with mandatory notifications The PsyBA (2011) states that the AHPRA legislation indicates that making a notification is not a breach of ethics or professional standards. However, while this is the position in the legislation, there is some debate in the literature about the effectiveness and appropriateness of mandatory reporting of health professionals (e.g. Arnold 2008; Skerritt 2010; Starr 2010). Breen (2011) goes as far as to suggest that many healthcare professionals may not seek help out of a fear of being reported by their treating physician or psychologist. Indeed, there is some evidence of this concern in the Western Australian AHPRA legislation. The PsyBA’s Guidelines for Mandatory Notifications (2010, p. 8) point out that in Western Australia psychologists are not required to report clients who are healthcare professionals receiving treatment even if they are displaying behaviour that would typically necessitate a mandatory notification. In all other states and territories of Australia, psychologists (and other healthcare professionals  registered under AHPRA) are required to report other psychologists (and other  healthcare professionals registered under AHPRA) who are clients if they display behaviour requiring mandatory notifications. This would potentially include psychologists working with other psychologists in a mentoring role or as part of the continuing professional development requirements. A more complex issue that has not yet been extensively covered in the literature is that of healthcare professionals who are in social, intimate or marital relationships with other healthcare professionals registered under AHPRA. For example, a psychologist may become aware that his friend who is a pharmacist has started to a have a sexual relationship with a client. A potentially extremely complex set of circumstances may arise when two psychologists are married or in a de facto relationship. The couple may discuss treatment methods over dinner. One partner may become aware that the other’s methods of treatment would be a significant departure from accepted professional standards. Further, after a birthday celebration a wife may ask her husband to drive her to work as she thinks she may be over the blood alcohol limit. This could indicate that the wife is about to practise while intoxicated, and her husband is required to make a mandatory notification. These issues are yet to be fully examined in the literature; currently information gained about professional behaviours in social relationships would necessitate a mandatory notification.

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Confidential client information and mandatory notifications As was mentioned above, there are instances where psychologists are required to breach confidentiality and make mandatory notifications about other healthcare professionals who are clients (except in Western Australia). This breach of confidentiality is considered acceptable by the PsyBA (2011, p. 2), which points out that ‘mandatory notification requirements override privacy laws’. This means that protecting confidential client information is not a justification for failing to make a mandatory notification in regard to another healthcare practitioner. It also means that information that is given by clients who are not in the healthcare profession about other healthcare professionals could be used in making mandatory notifications. It should be noted that negative comments from a single client about another healthcare professional would probably not reach the level of reasonable belief required by AHPRA to make a notification. Similar negative experiences from several clients, or a single formal communication from another healthcare professional that a client provides (e.g. a psychological report), may be enough evidence to form a reasonable belief. In this way is possible that confidential client information may form the basis of a mandatory notification. Furthermore, given the legal requirement to make a mandatory notification, a psychologist is not required to gain a client’s consent before using her information for the purpose of making a notification. Indeed, the 2012 version of the AHPRA notification form specifically states that client consent is recommended, but is not necessary, to make a notification. This is ethically problematic as the healthcare professional against whom the notification is being made will likely be provided with the details of the client or healthcare professional involved in the complaint. Clients who are healthcare professionals or students must be informed that the psychologist may have to make a notification against them if they disclose that they have been engaging in notifi able behaviour. Further, all clients need to be made aware that their confidential information may be used to make a mandatory notification against another healthcare professional. So psychologists need to update their informed consent procedures to reflect this. First, psychologists should add an additional clause to the informed consent documentation on instances when they may breach client confidentiality. Notifications to AHPRA have become another legal reason that client information may be disclosed. Additionally, psychologists should specifically inform clients that if they disclose that they are a healthcare professional, registered under AHPRA, the treating psychologist is required to report any notifi able conduct to AHPRA (except in Western Australia). While there is no empirical investigation at this time, anecdotal information would suggest that some psychologists do not request the specific occupation of clients to avoid the potential need to disclose all notifi able conduct. The psychologist would then specifically enquire about a client’s occupation if his behaviour could potentially harm the public and then inform AHPRA where appropriate. This approach is yet to be thoroughly investigated or assessed in terms of its ethical standing. It is certainly not recommended, but is used as an example of the kinds of issues faced by psychologists in the current regulatory environment.

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A final note about mandatory notifications Mandatory notifications are an important tool to protect the public from unprofessional and potentially dangerous healthcare clinicians. Many of the behaviours that necessitate a mandatory notification are consistent with the types of behaviour in colleagues that psychologists would have previously reported to registration boards or industry associations. It is only their mandatory nature, removing any expert discretion, that has made the process somewhat controversial. While there has been substantial debate in the literature about their implementation, further debate and investigation are needed to determine how they are to be used to maximise ethical practice. The key issue for psychologists to address is the increase in information that must be given to potential clients in the informed consent procedure. In this way clients can decide what information to provide to psychologists in the practice setting. However, psychologists also need to be mindful of their interactions with other professionals in personal or social settings. Any information gained in these settings about another healthcare professional’s practice is also relevant in making mandatory notifications.

Practice endorsements Under the National Registration Scheme for psychologists, it is possible to gain registration as a provisional psychologist (students and interns), a generalist psychologist or an endorsed psychologist in a specific area. To be eligible for generalist registration as detailed above requires six years of study or training and, for some students, passing the Practice endorsements: The PsyBA allows national psychology exam. Generalist psychologists may be eligible for psychologists to be endorsement in one of the areas listed on the PsyBA website. To be eligible for endorsed in certain endorsed status through the PsyBA a psychologist needs to have an accredited areas of practice such as doctorate and one year’s supervised practice with a board-accredited clinical or educational and developmental. To supervisor; an accredited master’s degree with two years’ supervised practice be eligible a psychologist with a board-accredited supervisor; or another qualification that the board needs to have various views as equivalent. Psychologists with general registration cannot refer to PsyBA-accredited qualifications. themselves as endorsed, specialist or as a psychologist with specialist skills in any of the endorsed areas (such as a ‘Counselling Psychologist’ as counselling is one of the endorsed areas). However, it is important for early-career psychologists to be aware that while they have generalist registration they must only practise in their area of training. So while a generalist psychologist with a doctorate in counselling must only work in the counselling field he may not call himself a counselling psychologist.

CHAPTER SUMMARY This chapter has described the paths to gaining general registration as a psychologist. It has also detailed the compulsory requirements and obligations of psychologists as dictated by the PsyBA. These include adherence to the Code and APS Ethical Guidelines, maintaining professional skills and insurance.

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This chapter has covered the mandatory reporting requirements for all psychologists and the ethical issues of which psychologists should be aware. It has also covered the process of gaining endorsement in the specialty fields of psychology.

QUESTIONS TO CONSIDER 1 2 3 4 5

Are the many paths to registration as a psychologist a positive for the profession? Should there be more (or less) CPD or its component parts in psychology (or other healthcare fields)? At what level of impairment should a psychologist be reported to AHPRA under the mandatory notifications process? If two AHPRA-registered healthcare professionals are in close personal or social relationships, how should they manage their mandatory notifications obligations? How can psychologists develop an awareness of standard practices in other AHPRA fields to help in the mandatory notifications process?

REFERENCES Arnold, P.C. (2008). Mandatory reporting of professional incompetence. Medical Journal of Australia 189(3), 132–3. Breen, K.J. (2011). Doctors’ health: Can we do better under national registration? Medical Journal of Australia 194(4): 191–92. PsyBA (2010). Guidelines for Mandatory Notifications. . PsyBA (2011). Guidelines on Continuing Professional Development. . PsyBA (2012a). National Psychology Examination Curriculum. . PsyBA (2012b). Professional Indemnity Insurance Arrangements Registration Standard. . PsyBA (n.d.). Codes, Guidelines and Policies. . Skerritt, P. (2010). AMA (WA)’s mandatory reporting stand will benefit the community. Medicus 50(8), 23. Starr, L. (2010). Mandatory reporting: a panacea for poor practice? Australian Nursing Journal 18(3), 21.

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APPENDIX Annotated APS Code of Ethics

These appendices are designed to assist you in understanding and interpreting the three General Principles of the APS Code of Ethics (2007): A, Respect for the rights and dignity of people and peoples; B, Propriety; and C, Integrity. Each section of the Code (or ‘standard’ as they are called) is followed by a section of clarification that brings out some of the key points, concepts and considerations that you need to be aware of when reading this section of the Code. The examples provided do not cover all circumstances that are relevant to that particular section. However, they will help you to understand the types of issues you will need to be cognisant of when involved in psychological activities that are relevant to that section. The following is the preface, preamble, defi nitions interpretation and application of the APS Code of Ethics. An electronic copy of the Code can be downloaded from the APS website www.psychology.org.au

Preface The Australian Psychological Society Limited (the Society) adopted this Code of Ethics (the Code) at its Forty-First Annual General Meeting held on 27 September 2007. This Code supersedes the Code of Ethics previously adopted at its Thirty-First Annual General Meeting held on 4 October 1997, and modified on 2 October 1999; on 29 September 2002; and on 4     October 2003. The Code of Ethics is subject to periodic amendments, which will be communicated to members of the Society, and published on the Society website. Members must ensure that

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they are conversant with the current version of the Code. An electronic version of the Code is available at www.psychology.org.au. This Code may be cited as the Code of Ethics (2007) and a specific ethical standard should be referred to as ‘standard A.2. of the Code of Ethics (2007)’. Amended standards can be referred to as: standard A.2. of the Code of Ethics (2007) (as amended in …). In a reference list the Code can be referenced as: Australian Psychological Society. (2007). Code of ethics. Melbourne, Vic: Author. Ethical Guidelines that accompany the Code of Ethics will be produced, amended and rescinded from time to time, and members are advised to ensure their versions of the Guidelines are current. Psychologists seeking clarification or advice on the matters contained herein should write to the: Executive Director The Australian Psychological Society Limited PO Box 38 Flinders Lane Victoria 8009 AUSTRALIA 27 September 2007; reprinted April 2009; reprinted February 2011; reprinted June 2012

Preamble The Australian Psychological Society Code of Ethics articulates and promotes ethical principles, and sets specific standards to guide both psychologists and members of the public to a clear understanding and expectation of what is considered ethical professional conduct by psychologists. It is important that the codes of professional associations should be reviewed regularly to ensure that they remain relevant and functional in the face of the evolution of the relevant association and changes in its environment. Accordingly, since its inception in 1949, the Code of Ethics (which was at times called the Code of Professional Conduct) of the Australian Psychological Society has been reviewed in 1960, 1968, 1986, and 1997. In undertaking the current review, the Society has attempted to reflect established ethical principles in the practice of the profession within the context of the current regulatory environment. The current Code has been developed through a process of ongoing reflection within the Society about the ethical responsibilities of psychologists and a formal review of the 1997 Code with reference to comparable national and international professional codes of ethics. The Code is built on three general ethical principles. They are: A. Respect for the rights and dignity of people and peoples B. Propriety C. Integrity. The general principle, Respect for the rights and dignity of people and peoples, combines the principles of respect for the dignity and respect for the rights of people and peoples, including the right to autonomy and justice.

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The general principle, Propriety, incorporates the principles of beneficence, nonmaleficence (including competence) and responsibility to clients, the profession and society. The general principle, Integrity, reflects the need for psychologists to have good character and acknowledges the high level of trust intrinsic to their professional relationships, and impact of their conduct on the reputation of the profession. The Code expresses psychologists’ responsibilities to their clients, to the community and society at large, and to the profession, as well as colleagues and members of other professions with whom they interact. Each general principle is accompanied by an explanatory statement that helps psychologists and others understand how the principle is enacted in the form of specific standards of professional conduct. The ethical standards (standards) derived from each general principle provide the minimum expectations with regard to psychologists’ professional conduct, and conduct in their capacity as Members of the Society. Professional conduct that does not meet these standards is unethical and is subject to review in accordance with the Rules and Procedures of the Ethics Committee and the Ethics Appeals Committee contained in the Standing Orders of the Board of Directors of the Society. These standards are not exhaustive. Where specific conduct is not identified by the standards, the general principles will apply. The Code is complemented by a series of Ethical Guidelines (the Guidelines). The purpose of the Guidelines is to clarify and amplify the application of the general principles and specific standards contained in the Code, and to facilitate their interpretation in contemporary areas of professional practice. The Guidelines are subsidiary to the relevant sections of the Code, and must be read and interpreted in conjunction with the Code. Psychologists who have acted inconsistently with the Guidelines may be required to demonstrate that their behaviour was not unethical. Psychologists respect and act in accordance with the laws of the jurisdictions in which they practise. The Code should be interpreted with reference to these laws. The Code should also be interpreted with reference to, but not necessarily in deference to, any organisational rules and procedures to which psychologists may be subject.

Definitions* For the purposes of this Code, unless the context indicates otherwise: Associated party means any person or organisation other than clients with whom psychologists interact in the course of rendering a psychological service. This includes, but is not limited to: (a) clients’ relatives, friends, employees, employers, carers and guardians; (b) other professionals or experts; (c) representatives from communities or organisations.

*

Defined terms are designated in the Code by appearing in italics

Annotated APS Code of Ethics

Client means a party or parties to a psychological service involving teaching, supervision, research, or professional practice in psychology. Clients may be individuals, couples, dyads, families, groups of people, organisations, communities, facilitators, sponsors, or those commissioning or paying for the professional activity. Code means this APS Code of Ethics (2007) as amended from time to time, and includes the defi nitions and interpretation, the application of the Code, all general principles, and the ethical standards. Conduct means any act or omission by psychologists: (a) that others may reasonably consider to be a psychological service; (b) outside their practice of psychology which casts doubt on their competence and ability to practise as psychologists; (c) outside their practice of psychology which harms public trust in the discipline or the profession of psychology; (d) in their capacity as Members of the Society; as applicable in the circumstances. Guidelines mean the Ethical Guidelines adopted by the Board of Directors of the Society from time to time that clarify and amplify the application of the Code of Ethics. The Guidelines are subsidiary to the Code, and must be read and interpreted in conjunction with the Code. In the case of any apparent inconsistency between the Code and the Guidelines, provisions of the Code prevail. A psychologist acting inconsistently with the Guidelines may be required to demonstrate that his or her conduct was not unethical. Jurisdiction means the Commonwealth of Australia or the state or territory in which a psychologist is rendering a psychological service. Legal rights mean those rights protected under laws and statutes of the Commonwealth of Australia, or of the state or territory in which a psychologist is rendering a psychological service. Member means a Member, of any grade, of the Society. Moral rights incorporate universal human rights as defi ned by the United Nations Universal Declaration of Human Rights that might or might not be fully protected by existing laws. Multiple relationships occur when a psychologist, rendering a psychological service to a client, also is or has been: (a) (b) (c) (d)

in a non-professional relationship with the same client; in a different professional relationship with the same client; in a non-professional relationship with an associated party; or a recipient of a service provided by the same client.

Peoples are defi ned as distinct human groups with their own social structures who are linked by a common identity, common customs, and collective interests.

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Professional relationship or role is the relationship between a psychologist and a client which involves the delivery of a psychological service. Psychological service means any service provided by a psychologist to a client including but not limited to professional activities, psychological activities, professional practice, teaching, supervision, research practice, professional services, and psychological procedures. Psychologist means any Member irrespective of his or her psychologist registration status. Society means The Australian Psychological Society Limited.

Interpretation In this Code unless the contrary intention appears: (a) words in the singular include the plural and words in the plural include the singular; (b) where any word or phrase is given a defi ned meaning, any other form of that word or phrase has a corresponding meaning; (c) headings are for convenience only and do not affect interpretation of the Code.

Application of the Code This Code applies to the conduct of psychologists as defi ned above. Membership of the Society, irrespective of a Member’s grade of membership or registration status, commits Members to comply with the ethical standards of the Code and the rules and procedures used to enforce them. Members are reminded that there are legislative requirements that apply to the use of the professional title, “psychologist”, and that where applicable, they must abide by such requirements. Members are also reminded that lack of awareness or misunderstanding of an ethical standard is not itself a defence to an allegation of unethical conduct.

General Principle A: Respect for the Rights and Dignity of People and Peoples

Psychologists regard people as intrinsically valuable and respect their rights, including the right to autonomy and justice. Psychologists engage in conduct which promotes equity and the protection of people’s human rights, legal rights, and moral rights. They respect the dignity of all people and peoples.

Explanatory Statement Psychologists demonstrate their respect for people by acknowledging their legal rights and moral rights, their dignity and right to participate in decisions affecting their lives. They recognise the importance of people’s privacy and confidentiality, and physical and personal integrity, and recognise the power they hold over people when practising as psychologists. They have a high regard for the diversity and uniqueness of people and their right to linguistically and culturally appropriate services. Psychologists acknowledge people’s right to be treated fairly without discrimination or favouritism, and they endeavour to ensure that all people have reasonable and fair access to psychological services and share in the benefits that the practice of psychology can offer.

A.1. Justice The primary focus of this section of the Code is the broad treatment of clients and the attitudes that a psychologist adopts in working with a diverse range of clients. The APS Code of Ethics, as

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it should, takes a strong stance on the fair and equitable treatment of individuals with a diverse range of beliefs and attitudes and from a range of religious, cultural and sexual backgrounds.

A.1.1. Psychologists avoid discriminating unfairly against people on the basis of age, religion, sexuality, ethnicity, gender, disability, or any other basis proscribed by law. Standard A.1.1 states that psychologists must avoid discriminating against individuals based on their diversity. Psychologists often work with individuals who are having difficulty interacting with others, their community, individuals outside their community, their families, peers or partners. Psychologists also frequently assist clients in understanding and dealing with their thoughts and emotions about themselves or others. Given these types of service provision, psychologists will often work with clients from diverse, disadvantaged and minority groups. It is important that an individual or individuals from these groups are offered a competent service that is appropriate to their needs. To achieve this, a psychologist must be aware of the broad issues that may be common to each of these groups, while ensuring that generalisations are not made and that each client is assessed and treated as an individual. To facilitate this, ongoing professional development is needed, including consultation with experts on these groups. Psychologists must also be extremely aware of their own views, values and attitudes towards these groups. Psychologists should seek supervision if their own views are likely to influence their treatment of any group in the community. The APS, in its Guidelines for Psychological Practice with Lesbian, Gay and Bisexual Clients (APS 2008), reiterates research fi nding that homosexuality and bisexuality are not indicative of mental illness. This is to counter outdated fi ndings that are sometimes presented to support this notion. The APS and research fi ndings indicate the individuals who identify themselves as homosexual, heterosexual or bisexual have similar psychological well-being (APS 2008).

A.1.2. Psychologists demonstrate an understanding of the consequences for people of unfair discrimination and stereotyping related to their age, religion, sexuality, ethnicity, gender, or disability. Psychologists need to gain an understanding of the negative outcomes for some individuals that may result from a being member of one of these groups. Prejudice, discrimination, isolation, stigmatisation and violence may feature in a client’s life or background through their membership of one or many of these groups. Therefore it is vital that a psychologist understands these issues and has the competence to deal with them in the therapeutic relationship. However, it is also important for psychologists to consider that individuals may derive pride, joy and meaning from their membership of a group. It is vital for a psychologist to gain an understanding of each individual client’s perspective of their group status and not assume that any group membership is a rigid positive or negative experience.

General Principle A

A.1.3. Psychologists assist their clients to address unfair discrimination or prejudice that is directed against the clients. It falls within appropriate psychological practice for a psychologist to assist their client in addressing any inappropriate behaviour towards them that results from their identification with or membership of groups from other any other groups or individuals. However, the psychological principles of autonomy, confidentiality etc. need also to be considered.

A.2. Respect Given that psychologists occupy a position of power in the community, it is vital that they consider the way they interact and communicate with all other parties. This relates to their interactions with clients, colleagues, the general public and other professionals. A  psychologist’s  behaviour and communication reflect not only on herself but on the profession of psychology more broadly.

A.2.1. The course of their conduct, psychologists: (a) communicate respect for other people through their actions and language; This relates not only to their actual behaviour and communication, but also through their inaction. Psychologists need to ensure that they are aware of their own thoughts and beliefs and seek supervision when these run counter to appropriate norms for psychologists.

(b) do not behave in a manner that, having regard to the context, may reasonably be perceived as coercive or demeaning; Psychologists need to be mindful of not only directly coercive or demanding behaviour, but also actions that may be perceived as coercive or demanding due to a power differential between psychologist and client. For example, clients or students under the supervision of a psychologist may construe offers, suggestions or general conversation as a direct instruction or a request. This can occur as clients or supervisees may perceive a psychologist as a knowledgeable, experienced or expert individual whose thoughts or views are highly valuable and must be carried out. For this reason psychologists should always check a client’s or supervisee’s understanding of the context of a discussion.

(c) respect the legal rights and moral rights of others; and In accordance with standard A.1, psychologists should always respect and do their upmost to understand the legal and moral rights of those (clients, other professionals, etc.) they interact with. To facilitate this, psychologists must be aware of the legal environment in which they practice. In some instances there will be national regulation (e.g. registration) applying to all practising environments. However, there will be state (e.g. privacy) or local government (when and where a practice can be operated) regulation that will impact on the practice of a psychologist.

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Psychologists also need to be aware of the moral rights of those they interact with. These rights may vary depending on the location and type of psychological practice being conducted and the client groups that a psychologist works with. It is vital that the psychologist makes an effort to understand and accommodate the moral norms of the area and client group into their practice.

(d) do not denigrate the character of people by engaging in conduct that demeans them as persons, or defames, or harasses them. As with A.2.1.b) above, psychologists need to be aware not only of direct behaviour that demeans, defames or harasses an individual, but also indirect behaviour that may be inferred to demean, defame or harass due to a psychologist’s position of power. The psychologist may have a position of power in relationship to an individual or in the community more broadly. Therefore psychologists need to ensure that their behaviour is appropriate not only in its direct appraisal, but also given the esteem in which some individuals hold psychologists.

A.2.2. Psychologists act with due regard for the needs, special competencies and obligations of their colleagues in psychology and other professions. Psychologists are highly trained and have a range of legal and ethical obligations. It is important that psychologists are mindful that the professionals they work with will have their own set of legal and ethical practice requirements. It is important for psychologists and other professionals to discuss these issues before their collaboration. Through an understanding of the ethical and legal obligations of all parties, they can deliver appropriate services while maintaining legal and ethical requirements of all parties.

A.2.3. When psychologists have cause to disagree with a colleague in psychology or another profession on professional issues they refrain from making intemperate criticism. It is important that disagreements be handled in a scientific manner. For example if there is a disagreement between a psychologist and a medical practitioner about a psychological intervention to be used with a client, it should be discussed from an evidenced-based perspective rather than either party claiming they are senior and that their decision is fi nal. Even in situations where an agreement/compromise cannot be reached among appropriately  qualified professionals, psychologists should still refrain from inappropriate criticism and instead focus on the empirical support of their position.

General Principle A

A.2.4. When psychologists in the course of their professional activities are required to review or comment on the qualifications, competencies or work of a colleague in psychology or another profession, they do this in an objective and respectful manner. As above, it is important to evaluate on the basis of empirical support or expertise rather than status or personality. It is also important to highlight both the negative and positive aspects in reviews and comments.

A.2.5. Psychologists who review grant or research proposals or material submitted for publication, respect the confidentiality and proprietary rights of those who made the submission. These requirements are particularly relevant to the supervision of student research and for those psychologists that involved in the review and publication of research. It is important for psychologists to understand the propriety rights in their legal jurisdiction and also discuss with participants, students and colleagues the ownership of data and research.

A.3. Informed consent Informed consent is one of the key pillars on which ethical psychological practice is built. It ensures that the client is clearly aware of what the professional relationship between themselves and the psychologist will entail. If the relationship changes or new procedures, interventions, research, etc are used, additional informed consent may need to be obtained.

A.3.1. Psychologists fully inform clients regarding the psychological services they intend to provide, unless an explicit exception has been agreed upon in advance, or it is not reasonably possible to obtain informed consent. It is vital that a client is aware of the psychological services that they will be involved in. While A.3.1 does allow for some exceptions these are not common in the provision of most psychological services. It is important for the client to understand the service that will be provided and what this will entail; for example the expected duration, cost, types of activities that will be involved and the procedures, if any of these conditions change. The client should also be made aware of the record-keeping procedure, privacy and their access to their

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stored information. Psychologists should also provide information relating to confidentiality and how it will be maintained, and the situations in which confidentiality may be breached. Organisational issues such as fee structure and cancellation policy should also be addressed. In the rare instances that informed consent is not required, it is usually due to an emergency  situation or a client pre-approving a course of action, given a particular antecedent.  However, in these situations completed notes on the reasoning and the actions that took place must be kept.

A.3.2. Psychologists provide information using plain language. It is important that psychologists not only provide details of the service provision, but that they do so in a manner that is understandable for the client. This means that if a psychologist treats a range of client groups they may need to have a number of informed consent documents. For example, if a psychologist works with couples to resolve marriage difficulties, or with older clients who have recently lost a partner, the type of information provided may vary. If the psychologist also works with clients with poor English language skills, additional informed consent procedures could be required. For example, if a client can communicate verbally but has difficulty with written language, an audio version of the informed consent documentation might be appropriate.

A.3.3. Psychologists ensure consent is informed by: (a) explaining the nature and purpose of the procedures they intend using; A psychologist should explain the tools and techniques they will be using in the provision of the psychological service (or research). The client should be aware of the time and effort typically required for someone in their circumstances. The psychologist should explain the empirical support for the service being suggested and the support for any potential alternatives.

(b) clarifying the reasonably foreseeable risks, adverse effects, and possible disadvantages of the procedures they intend using; Through the use of empirical fi ndings and professional experience the psychologist should clarify the risks and benefits of any psychological service offered. It is important that psychologist use the techniques that are most suited to the client in his individual situation rather than those techniques that the psychologist typically uses. Each service provision should have a strong evidence base for the particular client.

(c) explaining how information will be collected and recorded; The psychologist must detail the collection of all personal information regarding the client and the interactions in the sessions. The psychologist must also detail how information will be collected (is interaction between a client and psychologist recorded via written notes, audio-tape, computerised?) and stored (electronically, locked filing cabinet). The provision of

General Principle A

this information allows clients to make informed decisions about what information they share with the psychologist.

(d) explaining how, where, and for how long, information will be stored, and who will have access to the stored information; In addition to the information provided in A.3.3.c, the psychologist should provide details of access to client information, particularly in an environment where there is a team of professionals working with the client. For example, in a hospital setting do all professional staff at the hospital have access to the psychological records or only some selected staff ? While the APS provides guidelines on data retention, individual workplaces may have additional requirements and these policies need to be communicated to the client.

(e) advising clients that they may participate, may decline to participate, or may withdraw from methods or procedures proposed to them; It is important for clients to be made aware that they are under no obligation to continue with any form of treatment, research or other psychological service. Due to the power imbalance that can exist between clients and psychologists, it is vital the client understands that it is his decision to engage in any activity and that he should not feel pressured into participation. The onus is on the psychologist to ensure that the client is engaged in any activity through free choice and not through any implied pressure (real or perceived) from the psychologist.

(f) explaining to clients what the reasonably foreseeable consequences would be if they decline to participate or withdraw from the proposed procedures; It is important for a client to know that he can discontinue his treatment, research involvement or other psychological service at any time. It is the role of the psychologist to clearly explain the foreseeable consequences of this withdrawal. In many cases there may be no negative outcomes. However, if a client is in the middle of an intervention there may be significant negative psychological outcomes. Further, if the client is undergoing treatment as per a court order or other contractual situation there could be negative outcomes. Given the circumstance of a client discontinuing, it is important for the psychologist to provide all possible information about cessation of treatment. This might include contact details of other appropriate alternative services or 24-hour help lines.

(g) clarifying the frequency, expected duration, financial and administrative basis of any psychological services that will be provided; While it can be difficult to give precise details about a psychological treatment, a psychologist should provide as much detail as possible to a client. This might include the specified length of treatment (including number of sessions) if a manualised treatment is being employed. In other circumstances psychologists can provide details of the typical length of treatments reported in the literature for a given treatment. When specific services such as a cognitive assessment are being conducted exact fi nancial and time requirements should be provided.

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(h) explaining confidentiality and limits to confidentiality (see standard A.5.); It is vital that clients are informed of the structure of confidentiality in the professional psychological relationship. When psychological services are provided in a one-to-many situation (e.g. family counselling, group assessment) or with some groups (e.g. minors), additional considerations are required. See A.5 below.

(i) making clear, where necessary, the conditions under which the psychological services may be terminated; and It is important that both the client and the psychologist view the provision of psychological services in a problem-focused manner. In this way psychologists and clients view the treatment  process as a relatively short procedure that focuses on dealing with a specific client  i ssue(s). In contrast to media portrayals, the provision of psychological services is not typically a lengthy one in which the psychologist becomes an ongoing support to the client. When the specified psychological issue(s) has been dealt with the treatment phase can conclude. It is important that this is communicated to clients as it is not always their expectation. There should also be some coverage of referral when the psychologist lacks specific skills and is unable to make any progress with the treatment. Of course the client should be aware that they may terminate the service at any time (see A.3.3.e above).

(j) providing any other relevant information. Psychologists should provide any other relevant information to the client about their treatment. The information provided will vary according to the services being provided and the location of the service delivery. Complex service delivery locations (e.g. correctional institutions, education settings, etc.) will require substantially more information.

A.3.4. Psychologists obtain consent from clients to provide a psychological service unless consent is not required because: There are some very limited circumstances when consent is not required, but these are relatively infrequent in most areas of psychology.

(a) rendering the service without consent is permitted by law; or There are some situations, often in emergency care, where consent is not required. When a psychologist is working in these environments it is important to consult with colleagues and supervisors in order to gain and develop an understanding of how to balance the ethical requirements set out in the code and the needs of the client and the workplace.

(b) a National Health and Medical Research Council (NHMRC) or other appropriate ethics committee has waived the requirement in respect of research. There are some research methodologies that ethics committees may decide do not require consent. These are typically observational studies that do not require any interaction with participants who are performing normal daily activities.

General Principle A

A.3.5. Psychologists obtain and document informed consent from clients or their legal guardians prior to using psychological procedures that entail physical contact with clients. In the provision of typical psychological services, there is an expectation that there will not be any physical contact between psychologist and client. There are limited legitimate circumstances under which physical contact between a client and a psychologist is appropriate. An empirically supported psychological intervention in which physical contact is required is one such instance. In this situation a psychologist can explain to a client the procedures involved and discuss the salient issues. In this circumstance it is also advisable to have a parent or guardian present if working with a child or older adult who cannot give consent. According to the APS’s Guidelines relating to procedures or assessments that involve psychologist–client physical contact (APS 2008), it is necessary for a third party to be in the vicinity of such treatment, for example a friend, associate, family member of the client or another person (e.g. the practice administrative assistant). It can be negotiated between the psychologist and the client who this person will be (with the primary focus being the well-being and comfort of the client). It can also be negotiated where this person will be located. The client may choose to have this person present in the room where the treatment is occurring. There may also be situations, when working with a range of clients, where psychical contact is required to ensure the safety of the client. For example, if a psychologist is working with a child who displays self-injurious behaviour some physical contact might be needed to protect the child in some treatment situations. In both these situations the APS’s 2008 Guidelines on physical contact suggest that clear and comprehensive notes should be recorded regarding the physical contact. A fi nal category of client–psychologist physical contact is that of greeting and consoling. The APS (2008) Guidelines relating to procedures/assessments that involve psychologist –client physical contact state that in some circumstances physical contact may be an appropriate reassurance. However, this should not be considered if there are social or cultural norms that preclude such actions. Psychologists without experience or who are treating client groups of which they do not have experience should discuss physical contact in greetings and consoling with experienced psychologists in the field, and seek clarification from outside experts with a knowledge of cultural norms.

A.3.6. Psychologists who work with clients whose capacity to give consent is, or may be, impaired or limited, obtain the consent of people with legal authority to act on behalf of the client, and attempt to obtain the client’s consent as far as practically possible. When working with individuals who cannot give consent it will be the legal guardian of that individual who gives consent for the individual receiving treatment. However, it is important

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for the psychologist to explain and gain consent from the individual receiving treatment whenever possible. This can be particularly complex when working with adolescents, or older adults with impaired ability to give informed consent. See Chapter 5 for further discussion of this topic.

A.3.7. Psychologists who work with clients whose consent is not required by law still comply, as far as practically possible, with the processes described in A.3.1., A.3.2., and A.3.3. It is important from an outcome focus as well as an ethical one that clients feel involved in the consent process. Therefore, wherever possible, the full informed consent procedure should be carried out for all clients even when not required by law.

A.4. Privacy There is both Commonwealth and state legislation that relates to the provision of psychological services and record-keeping. Every psychologist must be aware of the impact of this legislation on their practice.

(a) Psychologists avoid undue invasion of privacy in the collection of information. This includes, but is not limited to: collecting only information relevant to the service being provided; and It is important that in the course of the provision of psychological services the psychologist only gathers information related to the treatment of the client. Additional information about the client or other individuals or organisations should not be collected or stored. When providing some services (e.g. human resource activities for a large organisation) individuals are likely to offer a large amount of information not relevant to the service being provided. It is import that this information is not recorded unless it is relevant to the service being offered.

(b) not requiring supervisees or trainees to disclose their personal information, unless self-disclosure is a normal expectation of a given training procedure and informed consent has been obtained from participants prior to training. During training and supervision it is common for students to engage in activities that may closely resemble being a client in actual psychological services or therapy. In these situations it is vital that the informed consent procedures detailed in A.3 are observed. Further, since students or trainees may have only partially developed understanding of the activities they are involved in, additional information or debriefi ng about the typical feelings or outcomes can be necessary.

General Principle A

A.5. Confidentiality One of the key aspects of the psychological relationship is the confidentiality of information provided by the client to a psychologist. While confidentiality is not absolute between a psychologist and the client (i.e. it can be breached in some circumstances), it is the high priority it is given that makes it a key to the relationship. A more detailed coverage of confidentiality can be found in Chapter 2.

A.5.1. Psychologists safeguard the confidentiality of information obtained during their provision of psychological services. Considering their legal and organisational requirements, psychologists: It is important that psychologists are aware of their legal and organisational requirements and understand how these fit within their obligations under the APS Code. The psychologist then needs to ensure that she informs the client and any relevant third parties of her obligations under the Code, the law and any organisational obligations.

(a) make provisions for maintaining confidentiality in the collection, recording, accessing, storage, dissemination, and disposal of information; and Psychologists must ensure they meet their state privacy legislation. The implementations of practices to meet these requirements for each psychologist will vary based on the location and type of service provision. In private counselling practice, this might entail a psychologist taking notes in a client’s file and storing them in a locked filing cabinet for the duration of a client’s treatment. When treatment concluded for an individual client, his record would be stored for seven years and then destroyed. However, if a psychologist was working in a large hospital setting the procedures to protect a client’s privacy would be more complex and would need to be negotiated between the psychologist and their supervisor. The confidentiality requirements would have to be clearly explained to a client during the informed consent process, before a client decided to receive treatment. The system put in place in a hospital setting would need to cover such matters as access to psychological records (all healthcare practitioners or only psychologists), what information would be shared with specialists and how this would occur (patient consent for each instance or a broad agreement). The psychologist would also need to consider how to dispose or retain psychological information that may need to be stored for a different duration than other medical information.

(b) take reasonable steps to protect the confidentiality of information after they leave a specific work setting, or cease to provide psychological services. At the commencement of any psychological practice psychologists should consider and negotiate with an employer how their records will be stored and managed, not only while they are in their current position but also when they leave. This allows for ongoing care

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for client files for up to 25 years (client records need to be kept for seven years or for seven years after a minor has turned 18) where necessary. Two of the more common approaches are that the client files are solely the responsibility of the psychologist or that the files are notionally the responsibility of the organisation of that employs the psychologist, but are overseen by the psychologist. In the fi rst situation the responsibility for maintaining the privacy of client files remains the responsibility of the psychologist. In the second scenario it remains the responsibility of the organisation. However, ethically, the responsibility still lies with the psychologist as she collected the information and are responsible for maintaining confidentiality and privacy. If the psychologist is leaving the organisation and is being replaced by another psychologist there is the potential for a handover of responsibilities for the files. If the organisation is closing or not employing another psychologist the original psychologist must take all steps practicable to protect the confidentiality and privacy of the client files.

A.5.2. Psychologists disclose confidential information obtained in the course of their provision of psychological services only under any one or more of the following circumstances: The onus is on the psychologist to respect the confidentiality of client information in most situations. This sections details the typical instances when information about the client can be divulged to a third party(s).

(a) with the consent of the relevant client or a person with legal authority to act on behalf of the client; The clearest instance for the disclosure of client information is at the request of the client. However, psychologists should discuss with clients the potential ramifications of disclosing the information to any third party. Psychologists must also ensure that they do not release non-client information (information about another person that is included in the files, e.g. a parent or spouse) or information that cannot be disclosed publicly (e.g. test forms or details of manualised interventions).

(b) where there is a legal obligation to do so; When a psychologist is required by law to disclose client information (e.g. a legal and valid subpoena) it is important for a psychologist to review legal request and the client information before providing any information. It is also advisable to inform the client (potentially a child’s legal guardian) of the request. In reviewing the legal request it is important for a psychologist to understand the contents of the file and the relevance of the material. In the case of a subpoena it may be possible for some parts of a client’s file to remain confidential if it is not relevant to the matter before the court. However, decisions such as these will be decided on by a judge and a psychologist should always obtain independent legal advice in court matters.

General Principle A

(c) if there is an immediate and specified risk of harm to an identifiable person or persons that can be averted only by disclosing information; or When a psychologist reasonably believes that a client poses an immediate risk for harm to himself or an identifiable third party, she may breach confidentiality to protect the client or the identifiable third party. However, the APS Code (2007) specifies that this disclosure may only occur if there is no other way for the third party to be protected. The APS (2008) Guidelines for working with people who pose a high risk of harm to others focuses on physical harm rather than a risk of harm to property. The process and implications of this concept are complex; see Chapters 7 and 8 for a detailed coverage of this matter.

(d) when consulting colleagues, or in the course of supervision or professional training, provided the psychologist: When a psychologist encounters a difficult case or is facing an ethical dilemma she may discuss it with a colleague or supervisor. It is also common for educators in psychology to use case studies to assist in developing student understanding. The following section details how to ensure that a client’s privacy and confidentiality are maintained in these situations.

(i) conceals the identity of clients and associated parties involved; or Using this method of client protection, a psychologist may discuss the case with students or colleagues so long as no information is provided that could reveal the identity of the client or other individuals or organisations involved in the case. If it is a case with very specific details, in a unique location or has gained media attention, the psychologist must ensure that the details provided do not identify the client. For teaching purposes psychologists might merge cases or change pertinent details to ensure that confidentiality is maintained.

(ii) obtains the client’s consent, and gives prior notice to the recipients of the information that they are required to preserve the client’s privacy, and obtains an undertaking from the recipients of the information that they will preserve the client’s privacy. In situations where students are observing actual interactions with clients, or when seeking clarification or discussing a difficult case with colleagues, it may difficult to conceal the identity of a client. In these cases a psychologist must obtain the client’s consent before their involvement and/or identification. It is also the responsibility of the psychologist to ensure that any students or colleagues who become aware of the client’s identity act in a manner that will protect the client’s identity and privacy.

A.5.3. Psychologists inform clients at the outset of the professional relationship, and as regularly thereafter as is reasonably necessary, of the: (a) limits to confidentiality; and It is important that psychologists clearly explain the limits to confidentiality and the instances  stated above in standard A.5.2 when confidentiality can be breached before

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any  psychological service is provided. This standard highlights that the informed consent procedure is an ongoing process and that clients should be reminded of these matters throughout the professional relationship. If a client requests a new psychological service (e.g. a personality assessment in addition to a cognitive assessment) or has a change in his circumstances (e.g. a partner moves in with the client: do they still want the psychologist to telephone at home to confi rm appointments?) this can lead to additional informed consent requirements.

(b) foreseeable uses of the information generated in the course of the relationship. As part of the informed consent procedure, as it relates to confidentiality, psychologists must clearly explain to clients how the information collected during the psychological service will be used. Clients must be informed of any use of their information. In a sole counselling practice there may be no use of a client’s information except in the management of the psychological service being provided to the client. In other circumstances client’s information might be used in research or be used by other professionals in their treatment of the client. Further, if the payment of the service is through Medicare or a private health insurer some information may need to be shared for payment processing. However, the client needs to be made aware of these potential uses, and consent to them, before any collection of information can take place.

A.5.4. When a standard of this Code allows psychologists to disclose information obtained in the course of the provision of psychological services, they disclose only that information which is necessary to achieve the purpose of the disclosure, and then only to people required to have that information. When a psychologist discloses confidential information, in accordance with A.5.2, it is vital that only the relevant information is disclosed. For example, if a client requests that information relating to their specific phobia is disclosed to his medical doctor, the psychologist must not send the client’s entire file to the doctor. Any information on other assessments, information on the client’s family or sensitive test information should not be disclosed as this is not necessary in meeting the client’s request. Similarly if a client’s file is requested through a court order or subpoena, the psychologist should attempt to negotiate the information disclosure. This should be done through the appropriate means for the court in question and the psychologist must adhere to the legal requirements of the court. However, the psychologist should endeavour to ensure that only the information relevant to the matter before the court is provided.

General Principle A

A.5.5. Psychologists use information collected about a client for a purpose other than the primary purpose of collection only: During the initial (and ongoing) informed consent procedures the psychologist will have informed the client of the uses of any information that is collected during the provision of the psychological service. This section relates to the use of client information for other purposes.

(a) with the consent of that client; The client may consent to the use of the data for other purposes. However, since the client and the psychologist are now in a professional relationship the onus is on the psychologist to ensure that there is no coercion in the client’s decision.

(b) if the information is de-identified and used in the course of duly approved research; or While it is always preferable to gain consent directly, there are some circumstances where ethics boards may allow the use of de-identified client information for research purposes.

(c) when the use is required or authorised by or under law. There are some situations under which a psychologist may be legally required to provide information to the court through a legal subpoena. A psychologist may also have some mandatory reporting and mandatory notification requirements. While these disclosures may not require consent, the psychologist should still make the client aware of these issues in the informed consent procedure.

A.6. Release of information to clients In considering legislative exceptions and their organisational requirements, psychologists do not refuse any reasonable request from clients, or former clients, to access client information for which the psychologists have professional responsibility. There are some circumstances under which legal proceedings or legislation may limit the ability of a psychologist to provide client information to clients. There may also be organisational policies that limit the type of information that can be disclosed. Further, sensitive test data that cannot be released to the public is not released to clients. In most other circumstances, however, appropriate client information should be released to clients or former clients. It is important that this information is presented in a meaningful way. Typically, psychological reports would be provided to clients directly. More detailed results or fi ndings might be directly provided to other professionals at a client’s request.

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A.7. Collection of client information from associated parties This section relates to the collection of information about the client from sources other than the client. This could be information collected from family members, other healthcare professionals or organisations (e.g. school reports or transitional work program). Psychologists need to be very careful when attempting to collect information from third parties, since by approaching a third party for information about a client, the third party will become aware that the client is receiving a psychological service. In work, education and social settings this could lead to difficulties for the client. Therefore psychologists need to consider the potential harms and benefits to the client before attempting to gain information on the client from third parties. See section A.5 for a broader discussion of confidentiality.

A.7.1. Prior to collecting information regarding a client from an associated party, psychologists obtain the consent of the client or, where applicable, a person who is authorised by law to represent the client. It is vital that the psychologist obtains written consent for the collection of information from third parties. As part of this procedure the psychologist must ensure that she informs the client of all aspects of the information collection as set out in A.7.4. When the client is unable to give consent his legal representative should be made aware of the information sent out in A.7.4 before consent is sought.

A.7.2. Psychologists who work with clients whose capacity to give informed consent is, or may be, impaired or limited, obtain the informed consent of people with legal authority to act on behalf of the client, and attempt to obtain the client’s consent as far as practically possible. When working with individuals who cannot give consent, it will be the legal guardian of that person who gives consent for the collection of information from third parties. However, it is important for the psychologist to explain and gain consent from the person receiving treatment as far as possible. This issue can be particularly complex when working with adolescents, or older adults with impaired cognitive functioning. See Chapter 5 for further discussion of this topic.

General Principle A

A.7.3. Psychologists who work with clients whose informed consent is not required by law nevertheless attempt to comply, as far as practically possible, with the processes described in standards A.7.1., A.7.2., and A.7.4. It is important from an outcome focus as well as an ethical one that clients feel involved in the consent process. Therefore, wherever possible the full informed consent procedure should be carried out for all clients even when not required by law.

A.7.4. Psychologists ensure that a client’s consent for obtaining information from an associated party is informed by: When collecting information about a client from a third party the client needs to consent to the contact with the third party and the request for information in most situations. There may be some emergency circumstances or workplace protocols where this is not possible, but these are unusual and should be discussed with supervisors to ensure that the client is protected. As detailed in A.7, the psychologist must consider the potential costs and benefits to the client in approaching third parties for client information.

(a) identifying the sources from which they intend collecting information; The psychologist must clarify with the client which third parties will be contacted for further information. The client should consent to contact with the third party and consent to collecting information from the third party. The third party may be an individual in the client’s everyday life or it could be a recorded information source.

(b) explaining the nature and purpose of the information they intend collecting; The psychologist must detail for the client the information that she intends to collect from the third party. She must also explain to the client why it is necessary to collect the information from a third party rather than the client himself. With this level of explanation, the client can then make an informed decision about the collection of the data.

(c) stating how the information will be collected; The psychologist needs to inform the client of how information will be collected. The client can then make an informed decision about that collection. There could be a written request for files or reports from other professionals or organisations. The information collection could also be in the form of direct contact with a family member or employer. The information could be in the form of interviews, questionnaires, etc. However, it is vital that only the forms of collection consented to by the client are employed.

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(d) indicating how, where, and for how long, information will be stored, and who will have access to the stored information; Psychologists must ensure they meet the privacy legislation in their state. The implementations of practices to meet these requirements for each psychologist will vary according to the location and type of service provision. The psychologist must inform the client of how information will be stored and kept secure (computerised and hardcopy materials). The psychologist must also clarify who will have access to the files (only the psychologist or other healthcare workers, etc.).

(e) advising clients that they may decline the request to collect information from an associated party, or withdraw such consent; Clients must be made aware that information collection from third parties only occurs with their consent and that consent can be withdrawn at any time. This is another occasion where the psychologist needs to ensure that the client does not feel pressured into conforming to the psychologist’s requests or suggestions and is making his own decision.

(f) explaining to clients what the reasonably foreseeable consequences would be if they decline to give consent; Clients should always be made aware of the reasons for collecting information from third parties. They should also be made aware of the implications of not allowing such information collection. For example, if a client has had previous psychological assessment, but does not allow for the collection and integration of that information in the current assessment, a less detailed overall assessment report will be provided. There may be other occasions where information from third parties is needed to support a client’s contentions. In these situations psychologists need, without pressuring the client, to explain to the client the different way in which the information will be presented in any reports (self-report compared to verified by a third party) that the psychologist writes.

(g) explaining the associated party’s right to confidentiality and limits thereof; and It is important that a client understands the rights of the third party in the collection of information about the client. For example, a third party may offer information to the psychologist about the client that is limited in some way or is constrained by legislation. It may also be necessary to protect the confidentiality of third parties over and above the right of the client to be made aware of the information. In a human resources position, for example, it may be a requirement of the psychologist’s employment that reports made about the client by managers are used in the client’s evaluation but are not made directly available to the client. This type of stipulation would need to have been clarified with the client and the manager before any psychological services were provided.

(h) providing any other relevant information. In different practice settings there may be specific information that is relevant to the client and the third parties in the collection of information from third parties. The client should be

General Principle A

made fully aware of these issues before he gives consent. For example, are there any potential difficulties for the client in attempting to collect information from their family members?

A.7.5. Prior to collecting information about a client from an associated party, psychologists obtain the associated party’s consent to collect information from them by, as appropriate to the circumstances: This standard focuses on protecting and informing third parties, specifically third parties whom a psychologist may contact for information about a client. While they are not a client, the psychologist has a duty to protect and inform these parties before they consent to the provision of any information.

(a) providing the associated party with demonstrable evidence that the client had given consent for the collection of such information; The psychologist needs to provide any third party with evidence that the client has consented to the psychologist contacting them and has authorised her to collect the information. However, this needs to be done in a manner that maintains the confidentiality of the client. For example, when asking a family member for a detailed medical history of a client, a psychologist does not need to reveal the psychological service being provided or the symptoms the client is displaying. In this way the psychologist has provided the third party with the requisite client approval but has not specifically detailed why the client is seeking the psychological service.

(b) explaining the nature and purpose of the information they intend collecting; When a psychologist requests information from a third party, it is the psychologist’s responsibility to inform the third party of the likely use of the information being collected. The psychologist should not reveal the full details of the client’s situation, but should reveal more broadly what the information collected will be used for. For example, if a psychologist is contacting a child’s teacher (with the consent and approval of the child’s legal guardian), the psychologist should inform the teacher of the purpose for the information he provides. A teacher may provide different content if it is being used as background information for the psychologist to follow up on, as opposed to information that is directly going into reports or client files.

(c) stating how the information will be collected; The psychologist should fully inform any third party of the method of information collection before a third party consents to the collection. Details should include the method of collection, time requirements and any other relevant details.

(d) indicating how, where, and for how long, information will be stored, and who will have access to the stored information; The psychologist must inform the third party of how information will be stored and kept secure (computerised and hardcopy materials). The psychologist must also clarify who will have access to the information (only the psychologist or other healthcare workers, etc.). The

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psychologist should also clarify with the third party whether the client is going to have access to the information he provides or if it is only for the psychologist.

(e) advising them that they may withdraw their consent at any time; It is important that third parties are made aware that they are under no obligation to commence or continue with any form of information provision.

(f) explaining to them what the reasonably foreseeable consequences would be if they withdraw their consent; While this can be a difficult situation, it is important that third parties do not feel pressured into providing information (or continuing to do so). However, third parties should be made aware of the consequences, to themselves and the client, of withdrawing their consent  to  provide information. For example, in a health psychology-type situation a psychologist may be relying on a family member to report on the diligence of a client in taking his medication. If the family member stops providing this information it might be necessary to hospitalise the client. It is important that the third party is made aware of this. However, the situation should not be used as leverage to encourage the family member to continue providing information.

(g) explaining the associated party’s right to confidentiality and limits thereof; and Before giving consent to provide information, third parties must be made aware of their rights in relation to confidentiality. It is important that the psychologist initially clarifies that relationship between themselves, the third party and the client. The third party needs to be informed that the psychologist’s role is to collect information and not to provide any psychological service to the third party. In doing so the psychologist needs to clarify the confidentiality of the information being provided by the third party in accordance with A.7.5 b,c. Depending on the setting and the third party involved, it may be necessary to inform the third party of a psychologist’s responsibility to disclose confidential information to protect identifiable parties and that some information may be disclosed when required by law.

(h) providing any other relevant information. Taking into account the setting and the third party involved, the psychologist should provide any other relevant information to the third party that is related to their provision of information relating to the client.

General Principle B: Propriety

Psychologists ensure that they are competent to deliver the psychological services they provide. They provide psychological services to benefit, and not to harm. Psychologists seek to protect the interests of the people and peoples with whom they work. The welfare of clients and the public, and the standing of the profession, take precedence over a psychologist’s self-interest.

Explanatory Statement Psychologists practise within the limits of their competence and know and understand the legal, professional, ethical and, where applicable, organisational rules that regulate the psychological services they provide. They undertake continuing professional development and take steps to ensure that they remain competent to practise, and strive to be aware of the possible effect of their own physical and mental health on their ability to practise competently. Psychologists anticipate the foreseeable consequences of their professional decisions, provide services that are beneficial to people and do not harm them. Psychologists take responsibility for their professional decisions.

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B.1. Competence The primary focus of this part of the Code is that psychologists must have the skills, knowledge and proficiency to provide the psychological services they offer. Without competence psychologists can potentially harm not only the client but also the psychologist’s reputation and the standing of psychology in the community. Therefore it is vital that psychologists only offer and provide services that they are competent to deliver. See Chapter 3 for a full discussion of competence.

B.1.1. Psychologists bring and maintain appropriate skills and learning to their areas of professional practice. Psychology covers such a broad range of workplaces and specialisation that it is unlikely that any psychologist will have the competence required to offer all psychological services. Therefore psychologists should focus on developing their skills and knowledge in the area(s) in which they practice. For example, a psychologist who only works with older adults would need to ensure that they had, and continued to develop their skills for working with older people and the disorders and issues associated with older age. While the psychologist should be aware of developments in psychological tools and techniques for working with children, this would not be their focus. In this situation the psychologist would be competent to provide services to older adults but not children.

B.1.2. Psychologists only provide psychological services within the boundaries of their professional competence. This includes, but is not restricted to: (a) working within the limits of their education, training, supervised experience and appropriate professional experience; Through their training psychologists will have developed a basic set of skills. These skills will form the foundation of their practice and will guide the areas in which they initially practice (e.g. psychologists who undertake a clinical psychology degree will work with clients with severe mental disorders). Over time they will develop their knowledge of this field through further training and professional development. They may also take on further training to provide services to a broader range of clients (e.g. undertaking work placement assessments). However, they would only provide services in areas in which they had expertise and training.

(b) basing their service on the established knowledge of the discipline and profession of psychology; Psychologists should only use tools and techniques that are empirically sound; that is, a psychologist should only use tools and techniques she has found to be effective with the client groups with whom she is using them. Each time a psychologist undertakes a service

General Principle B

provision she should ensure that the service she is offering is in the best interests of the client. Therefore, psychologists should use extreme caution when considering new or developing tools or techniques. There will be some instances where there is little empirical support due to a client’s unique circumstances (e.g. they are a member of a very small cultural group for which there are no known effective tools or techniques). In these situations the psychologist will need to use her professional judgment and seek advice from experts in order to provide the most appropriate service.

(c) adhering to the Code and the Guidelines; This standard points out that for psychologists to practise in a competent manner in Australia they must conform to the APS Code of Ethics and the APS Ethical Guidelines.

(d) complying with the law of the jurisdiction in which they provide psychological services; and This standard lays down that for psychologists to practise in a competent manner in Australia they must conform to applicable State and Federal Government legislation (see Chapters 11 and 12).

(e) ensuring that their emotional, mental, and physical state does not impair their ability to provide a competent psychological service. From an ethical perspective psychologists need to maintain their physical and mental wellbeing to ensure that they provide ethical services to clients. A psychologist who is suffering from severe pain from a broken arm may not be able to communicate or empathise with the clients as she typically would. Similarly, a psychologist suffering from severe depression may not have the required mindset to work with clients. In severe cases these behaviours may require a mandatory notification to AHPRA (see Chapter 12).

B.1.3. To maintain appropriate levels of professional competence, psychologists seek professional supervision or consultation as required. Psychology can be a complex and stressful occupation and, because of this, psychologists should  seek assistance where necessary. When psychologists are working in a complex situation, with a difficult client or providing services to a group they have not worked with before, they should seek advice and assistance. This should be done while maintaining client confidentiality (see Chapter 3) and the psychologist should seek out experts who can provide ethically sound and clinically useful information. As was pointed out in B.1.2.e, it is vital that psychologists maintain their own well -being. However, they should also seek supervision (professional counselling with another psychologist) if they are having difficulty maintaining their objectivity or are falling into stereotypical thinking about their clients.

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B.1.4. Psychologists continuously monitor their professional functioning. If they become aware of problems that may impair their ability to provide competent psychological services, they take appropriate measures to address the problem by: Professional functioning may relate to a psychologist’s physical or mental health, or their skills and knowledge in providing services.

(a) obtaining professional advice about whether they should limit, suspend or terminate the provision of psychological services; If psychologists begin to question their ability to competently and ethically provide a service, they should always seek advice or supervision. By discussing the issue they may gain an understanding of not only the issues involved, but also the steps that may help to resolve it. Psychologists should always consider clients’ best interest as paramount and should take steps to ensure they are provided with the appropriate level of service.

(b) taking action in accordance with the psychologists’ registration legislation of the jurisdiction in which they practise, and the Constitution of the Society; This standard is highly relevant to the mandatory notification requirements that are now part of registration under AHPRA (see Chapter 12). It is important that psychologists protect the public and report any problematic behaviour they observe in other psychologists.

(c) refraining, if necessary, from undertaking that psychological service. If the psychologist is not competent to provide the service she should discontinue it and refer the client to an appropriate psychologist. However, psychologists should try to avoid allowing this situation to arise by maintaining their well-being, monitoring their practice and continuing to develop their professional skills. In this way psychologists can be competent to provide their services. However, if it becomes evident to a psychologist that she does not have the requisite competencies to work with the client she should discontinue the service provision and refer the client.

B.2. Record keeping Psychologists are required to undertake extensive record-keeping. There are also ethical and professional requirements regarding the storage of the records and their disposal. See Chapter 11 for comprehensive coverage of this topic.

B.2.1. Psychologists make and keep adequate records. According to the APS, the client record must provide the psychologist with the information needed to facilitate the psychological service between sessions, provide the information necessary to write reports at a later date, allow other psychologists to continue with the

General Principle B

service provision where necessary, and provide a justification as to why a psychologist chose a particular service for the client. Psychologists in different work situations will need to record different information to meet these requirements in their particular workplace.

B.2.2. Psychologists keep records for a minimum of seven years since last client contact unless legal or their organisational requirements specify otherwise. Psychologists must keep the records for at least seven years after the last contact with the client unless there are legal or organisational requirements that specify a longer time-frame.

B.2.3. In the case of records collected while the client was less than 18 years old, psychologists retain the records at least until the client attains the age of 25 years. Psychologists must keep the records for at least seven years after a client who was under 18 years of age reaches 18 years of age (i.e they reach 25 years of age). Psychologists who work extensively with young people will need to consider the logistical issues involved in storing records for up to 25 years.

B.2.4. Psychologists, with consideration of the legislation and organisational rules to which they are subject, do not refuse any reasonable request from clients, or former clients, to amend inaccurate information for which they have professional responsibility. Psychologists have an obligation, in many cases, under the national privacy legislation to allow client access and amendment to their client file. While the psychologists would not release all information directly to clients they may have to provide the information in some form. See Chapter 11 for more detail on this question.

B.3. Professional responsibility Psychologists provide psychological services in a responsible manner. Having regard to the nature of the psychological services they are providing, psychologists: The role and standing of psychologists in the community necessitates a professional level of service provision to clients. This means that psychologists need to act in a manner that is more regulated than most professions in Australia.

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(a) act with the care and skill expected of a competent psychologist; Psychologists need to ensure that their provision of services is competent (see Chapter 3 and B.1 above) and have based on their training and professional development (see Chapter 12).

(b) take responsibility for the reasonably foreseeable consequences of their conduct; The well-being of clients should always be the psychologist’s main concern in the provision of any psychological service. Psychologists need to consider the potential outcomes of service provision and ensure that they comply with both their ethical and professional obligations.

(c) take reasonable steps to prevent harm occurring as a result of their conduct; Psychologists need to take reasonable steps to ensure that there is no harm to clients as a result of the services they provide. If there is a risk of harm, the psychologist should clearly explain this to the client during the informed consent process (see Chapter 3). During this explanation the psychologist should describe the risks and the potential for harm to occur.

(d) provide a psychological service only for the period when those services are necessary to the client; Most psychological services are of brief duration; it is somewhat unusual for a client to work with a psychologist for an extended period. Psychologists should help their clients deal with specific issue(s) or help the client develop the skills, tools and/or techniques to deal with ongoing issues, with only minor or occasional support from the psychologist. If the psychologist cannot assist the client with their presenting issue they should refer the client.

(e) are personally responsible for the professional decisions they make; Psychologists are often in a powerful position relative to their clients or the community, so they must be mindful of the decisions they make. Further, psychologists need to consider the impact of their actions. When they make suggestions or recommendations they are going to be considered more authoritative than most people in the community. Therefore psychologists need to carefully consider their actions as, ethically, they are personally responsible for them.

(f) take reasonable steps to ensure that their services and products are used appropriately and responsibly; Psychologists must ensure that the services they provide are used responsibly and in line with empirically supported practices. For example, psychologists need to ensure that a weightloss intervention service they provide is not used by a client who is already significantly underweight. If psychologists offer any form of psychological assessment they need to ensure that the tools used are empirically supported in relation to the construct being assessed.

(g) are aware of, and take steps to establish and maintain proper professional boundaries with clients and colleagues; and Psychologists must ensure that their professional relationships do not overlap with their personal relationships. For more information on dual and multiple relationships see Chapter 4. Broadly speaking, however, psychologists should only have a relationship with the client, within

General Principle B

the professional psychologist–client relationship. Any additional professional or personal relationship between the psychologist and the client is likely to lead to negative outcomes for the client. Psychologists should also be mindful of their relationships with colleagues and ensure that where any non-professional relationships exist these do not impact on the client’s well-being. Psychologists also need to be aware of the mandatory notifications (see Chapter 12) in relation to reporting non-professional behaviour to AHPRA and the national boards.

(h) regularly review the contractual arrangements with clients and, where circumstances change, make relevant modifications as necessary with the informed consent of the client. It is important that as the service provision develops, any additional harms, benefits, rights and responsibilities are explained to the client. This should initially be done as part of the formal informed consent procedure (see Chapter 3). However, as the service provision progresses and new tools, techniques, assessments or interventions are used, the informed consent information may need to be updated. This may take the form of a brief discussion or a complete informed consent procedure with a signed document.

B.4. Provision of psychological services at the request of a third party Psychologists who agree to provide psychological services to an individual, group of people, system, community or organisation at the request of a third party, at the outset explain to all parties concerned: When working with a client whose service provision is initiated or paid for by a third party, additional ethical considerations need to be considered. These situations can arise when a parent seeks psychological services for their child, a court orders a psychological service or when a third party (e.g. Medicare) funds the psychological service.

(a) the nature of the relationship with each of them; At the outset of any service provision involving an individual or group that the psychologist is working with and a third party, the psychologist must clarify the rights and responsibilities of all parties during the informed consent procedure. As part of this process the parties will need to agree on who is the client (see Chapter 3) and the role of all other parties.

(b) the psychologist’s role (such as, but not limited to, case manager, consultant, counsellor, expert witness, facilitator, forensic assessor, supervisor, teacher/ educator, therapist); The psychologist must clearly inform all parties of the purpose of the psychologist’s service. This would form part of the informed consent procedure. Only after all parties are aware of this can an informed decision be made about the service provision. The psychologist should clarify her role and the purpose of the service provision. For example, in a human

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resources role the psychologist would need to clarify if she was primarily working to improve the well-being of staff (the client is a staff member) or to increase the productivity of the workplace (the client is the workplace/company). Once all parties are aware of this, she can make an informed decision on what information they would share with her.

(c) the probable uses of the information obtained; As was discussed in B.4.b, the role of the psychologist must be clarified, as this will dictate the way that information will be used in the service provision (and must form part of the informed consent process). In the previous example, if the psychologist’s primary purpose was to improve the well-being of the staff the information the psychologist gathered might be used to help reduce a staff member’s anxiety. However, if the psychologist was working to improve productivity the information gathered may be used to determine which staff are fi red, transferred or promoted. It is vital that the person working with the psychologist is aware of how the information is going to be used so he can decide what information to share.

(d) the limits to confidentiality; and As part of the informed consent procedure the psychologist must clarify with all parties what, if any, information will be shared. Again, this information will dictate what information each party decides to share with the psychologist given their role. See the example about information-sharing in a third-party situation involving a parent and a child in Chapter 5.

(e) the financial arrangements relating to the provision of the service where relevant. It is very important that all parties understand the payment arrangements and what, if any, impact these will have on the service provision. In some situations a client may automatically give permission for an external funding agent to access his psychological records when he accepts the third party’s funding. Even though the psychologist may not be directly involved in this process she should inform and remind the client during the informed consent procedure. It is also important to note that payment does not constitute a right to access. There will be many situations where the person or organisation funding the psychological service will have no access to the confidential client information. As with all the issues covered in standard B.4, the psychologist must work hard to ensure that all parties are aware of their rights and responsibilities when third parties are involved.

B.5. Provision of psychological services to multiple clients Psychologists who agree to provide psychological services to multiple clients: Psychologists will often work directly with more than one client. This could be in the context of couples, family or group-based service provision. When working in these situations psychologists must make certain that all members of the group or couple are aware of the

General Principle B

specific issues that are relevant to group work before consenting to participating in the group. These are complex issues and only skilled and experienced psychologists, with a sound understanding of the ethical and therapeutic issues involved, should provide these services.

(a) explain to each client the limits to confidentiality in advance; Before entering into a group/couples service provision a client must be fully informed of the service being provided, especially the unique risks regarding confidentiality and how a group setting can impact on confidentiality. This should occur in a one-to-one setting before the client has consented to being part of the service. This allows the client to make an informed decision without any pressure from the group. The psychologist must point out to all members of the group that confidentiality is paramount and reciprocal between group members. The psychologist should also point out the potential difficulties, despite signed contracts and the psychologist’s skill and professionalism, in maintaining confidentiality in a group setting. This must be phrased in a way that is not condoning or encouraging breaches but rather highlighting them as a potential issue.

(b) give clients an opportunity to consider the limitations of the situation; After the psychologist has informed the client about the confidentiality issues raised in B.5.a, she should present any other limitations regarding the group/couples service provision and allow the client time to consider the issues. The psychologist may choose to raise the potential of a group service in one session and allow the client to consider it and then discuss it again, covering any questions the client has at the next session. It is important that clients get the opportunity to fully consider the positive and potentially negative aspects of the service.

(c) obtain clients’ explicit acceptance of these limitations; and Even if the psychologist has previously been working with the client in another psychological context, group/couples service provision will require a new informed consent procedure. The full informed consent procedure should be carried out in accordance with standard A.3 (see Chapter 3) and the documentation signed by the client.

(d) ensure as far as possible, that no client is coerced to accept these limitations. As with all psychological services, clients should voluntarily consent to their participation. However, given the potential ethical issues involved when working in a group/couples context is it vital that clients are not coerced in any way. It is important that psychologists who work in institutional settings, work to ensure that the clients consent to their involvement (see Chapter 5 for clients who cannot consent). It is also important in couples or family work that one or many clients, are not pressured into psychological treatment by other members of the family or group. As with all service provision, the psychologist should not coerce the client, but rather explain the potential risks and benefits of any service provision, linking them to the client’s presenting issue.

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B.6. Delegation of professional tasks Psychologists who delegate tasks to assistants, employees, junior colleagues or supervisees that involve the provision of psychological services: (a) take reasonable steps to ensure that delegates are aware of the provisions of this Code relevant to the delegated professional task; Psychologists who rely on other staff or provisionally registered psychologists to carry out parts of the psychological service need to ensure that the clients are protected. Part of this process is to ensure that all individuals working directly with clients or who have access to client information act in a manner that is consistent with the Code. It is the psychologist’s responsibility to make sure that this occurs.

(b) take reasonable steps to ensure that the delegate is not in a multiple relationship that may impair the delegate’s judgement; In much the same way that psychologists should not have any dual or multiple relationships with clients, any individual working with clients or who has access to clients should not have such a relationship. The issues with dual and multiple relationships (see Chapter 4) are similar when a trainee or staff member is involved. The potential harm to the client is just as real. Direct relationships such as not providing services to a family member can be easily dealt with, but more indirect relationships can be more complex. For example, if a client knows the receptionist they may become concerned that the receptionist will read their file or tell someone that they are seeing a psychologist. To reduce the impact of this situation a psychologist should inform clients as to the policies in place to protect client information, including their status as a client. The psychologist should also have a contractual arrangement with all staff and trainees regarding the non-disclosure of client information.

(c) take reasonable steps to ensure that the delegate’s conduct does not place clients or other parties to the psychological service at risk of harm, or does not lead to the exploitation of clients or other parties to the psychological service; Psychologists need to ensure that if they delegate tasks, the client is not placed at an increased risk of harm. They should only delegate tasks to staff or trainees if the staff member or trainee has the professional and ethical competence to undertake them. It is also vital that the delegation does not lead to fi nancial or any other form of exploitation. Psychologists should consider themselves personally responsible for the tasks carried out in their name and ensure that clients are protected.

(d) take reasonable steps to ensure that the delegates are competent to undertake the tasks assigned to them; and It is essential to maintaining client well-being and the standing of the field of psychology, that all psychological services are undertaken in a competent manner. This extends to any person

General Principle B

or organisation a psychologist delegates work to. See Chapter 3 and standard B.1 for a full coverage of competence.

(e) oversee delegates to ensure that they perform tasks competently. Psychologists need to oversee delegates to ensure that they are competent, are not in dual relationships and do not harm clients. It is vital that psychologists assist in training trainee psychologists and utilise the skills of professional staff. All of this needs to be done in a manner that does not disadvantage clients.

B.7. Use of interpreters Psychologists who use interpreters: (a) take reasonable steps to ensure that the interpreters are competent to work as interpreters in the relevant context; If a psychologist requires an interpreter it is vital that the interpreter has the requisite language and translation skills. The exact skills required will vary according to the workplace (e.g. knowledge of technical terms or ability to work with children). Most psychological services require an in-depth knowledge of gesture, nonverbal communication and cultural norms, as well as language skills. It is also important that the psychologist has undertaken training in the effective use of interpreters in the provision of psychological services.

(b) take reasonable steps to ensure that the interpreter is not in a multiple relationship with the client that may impair the interpreter’s judgement; When working with an individual from a linguistic group with few members, it can be difficult to fi nd an interpreter who is not in another relationship with the client. Often it will be a family member who is fi rst identified as an interpreter. However, it is vital that an independent and, preferably, trained interpreter assists in communicating with the client. If a family member is acting as an interpreter they may filter the information flow between the psychologist and the client, make the client uncomfortable or not recognise key nonverbal information. Therefore wherever possible a trained independent interpreter should be used.

(c) take reasonable steps to ensure that the interpreter will keep confidential the existence and content of the psychological service; An interpreter will be privy to all communication between the psychologist and the client. This means that the interpreter will be aware of all the confidential information shared between the client and the psychologist. Stringent confidentiality agreements therefore need to be in place between the parties. This should be in the form of a signed confidentiality agreement between the client, the psychologist and the interpreter. The issue of confidentiality is another area that makes it very complex to have a family member acting as interpreter.

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(d) take reasonable steps to ensure that the interpreter is aware of any other relevant provisions of this Code; and In addition to the issue of competence and confidentiality, psychologists need to ensure that interpreters are aware of other aspects of the Code that are relevant to the service provision. These may relate to communication with other professions or family members.

(e) obtain informed consent from the client to use the selected interpreter. One of the most complex aspects of using an interpreter is gaining the client’s consent to using an interpreter. If the client does not have the basic language skills needed to communicate with the psychologist he will need an interpreter present for the informed consent procedure. In this situation the most likely outcome is for a family member to be involved in the informed consent procedure regarding the use of an interpreter. If the client consents to the use of an interpreter, the interpreter can then work with the client and the psychologist to complete the full informed consent procedure regarding the service provision.

B.8. Collaborating with others for the benefit of clients B.8.1. To benefit, enhance and promote the interests of clients, and subject to standard A.5. (Confidentiality), psychologists cooperate with other professionals when it is professionally appropriate and necessary in order to provide effective and efficient psychological services for their clients. When a client consents to it, psychologists should work with other professionals in the best interests of the client. Consent is the key issue. Clients need to be informed of what information will or will not be shared with the other professional. Working with other professionals can be challenging and psychologists will often have to negotiate with other professionals to determine the role of the psychologist in the process. Psychologists must still be mindful of their ethical obligations and focus on client well-being.

B.8.2. To benefit, enhance and promote the interests of clients, and subject to standard A.5. (Confidentiality), psychologists offer practical assistance to clients who would like a second opinion. When a psychologist is asked for a second opinion she should facilitate this to the greatest extent possible with the client’s consent. If the client wants a second opinion, the psychologist should provide details of other experts that she could consult and with the client’s consent forward the relevant material (and other material if requested by the client) to the other psychologist. If a psychologist is contacted by a client to give a second opinion she should be mindful of the profession as a whole when giving that opinion, but should act ethically and provide her expert opinion based on her assessment of the client.

General Principle B

B.9. Accepting clients of other professionals If a person seeks a psychological service from a psychologist whilst already receiving a similar service from another professional, then the psychologist will: Psychologists will often work with clients who are receiving services from other healthcare professionals. Psychologists primarily need to be mindful of the well-being of the client, but also need to have some consideration of the other professional and public perception (see the example of the fortune teller in Chapter 10).

(a) consider all the reasonably foreseeable implications of becoming involved; Psychologists will often work directly with other professionals in providing services to a client; for example working with occupational therapists in a rehabilitation setting or with speech therapists when working with children who have a language delay. In these situations the details and nuances of working in a team environment will be coordinated by the professionals in the best interests of the client. The client will have been informed of the process and have given consent. Conflicts and differences may still occur but they can be resolved through communication in the team environment, with the client’s overall well-being as the focus. However, when the client is receiving services from a number of professionals who are not directly working together it can be more complex. For example, if a psychologist and a GP are both working with a client on reducing his depression, but the client has not consented to the psychologist and the GP communicating or working together, problems can arise. Are both professionals offering advice or interventions that are in conflict? Psychologists must be vigilant with difficulties of this kind and, where possible, gain consent from the client to work with the other professionals rather than trying to guess what the other professional is doing. Psychologists also need to be cautious when disagreeing about client issues with other professionals.

(b) take into account the welfare of the person; and Psychologists should always have the best interests of the client as their focus. However, when there are several professionals involved it is important that each individual professional and the group as a whole are working towards the best interests of the client cohesively. As was stated above, when the professionals are not communicating this can put the client at a greater risk of harm. Where possible, professionals should try to work together to help the client with their presenting issue. Even if the professionals are not working with the client on the same issue they should be aware of each other to ensure that there is no inadvertent overlap that might harm the client in some way.

(c) act with caution and sensitivity towards all parties concerned. Not only should psychologists be mindful of the client’s well-being but they should also have some concern for the other professionals. Healthcare professionals should avoid voicing

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unnecessary criticism to the client or using disrespectful language about fellow professionals. When there are major clinical or scientific differences of opinion the psychologist should take these up directly with the other professional. Disagreements will occur frequently, but open hostility between professionals, with the client trapped in the middle, is unlikely to be in the best interests of the client. Also, psychologists should be mindful of their mandatory notification responsibilities when working with other healthcare professionals registered under AHPRA (see Chapter 12).

B.10. Suspension of psychological services If the psychologist is going to be unavailable for an extended period she should put in place resources and other psychological services for her client’s needs.

B.10.1. Psychologists make suitable arrangements for other appropriate professionals to be available to meet the emergency needs of their clients during periods of the psychologists’ foreseeable absence. As with any period of unavailability, the psychologist should have emergency contacts ready to hand. This may be in the form of 24-hour help lines or medical facilities. In other practices the emergency needs of clients may be more acute and 24-hour psychological assistance may need to be available. The focus is that whenever a psychologist cannot provide her services to clients, she should have emergency resources available.

B.10.2. Where necessary and with the client’s consent, a psychologist makes specific arrangements for other appropriate professionals to consult with the client during periods of the psychologist’s foreseeable absence. If the psychologist is going to have a planned absence from her service provision she should make provision for another psychologist to provide services in her place. For example, if a psychologist is going on an extended holiday or having a scheduled medical procedure she should have an alternative psychologist ready to take over. This could be another psychologist working in her practice (a locum) or someone from another psychological practice who is capable of taking on her clients while she is unavailable. As the client record will need to be available to the psychologist taking on her workload, specific confidentiality and consent will need to be considered.

General Principle B

B.11. Termination of psychological services This section of the Code covers the ethical issues related to the conclusion of the service provision. This can be because the client has achieved his desired result or for other reasons.

B.11.1. Psychologists terminate their psychological services with a client, if it is reasonably clear that the client is not benefiting from their services. Psychological service provision is typically of a relatively short duration. A client seeks out the support of a psychologist to resolve an issue or to deal with a specific situation and once this is resolved the service provision ends. If after some time it does not appear that the client is improving or moving towards his goal, despite the psychologist using her skills and appropriate tools or techniques, the psychologist should consider stopping the service provision. If the client is not reaching his goals or seeing an improvement in his condition, a continuation of the service provision is not in his best interests. However, the psychologist should then take steps to ensure that the client continues to receive assistance or support (see B.11.2 to B.11.6).

B.11.2. When psychologists terminate a professional relationship with a client, they shall have due regard for the psychological processes inherent in the services being provided, and the psychological wellbeing of the client. Psychologists need to consider the service being provided and the state of the client when they end the service provision (regardless of the reason for termination). The well-being of the client should be paramount throughout the service but it is extremely important at the conclusion of the service, especially if the client has not achieved his goal or has not seen a significant improvement in his condition. In these circumstances, the psychologist will need to take steps to ensure that the client’s well-being is protected. Also, depending on the service provision, the psychologist will need to consider the client’s mental state. If he has undergone a long treatment for a severe anxiety the conclusion of the treatment may be a stressful or anxiety-provoking situation. If the psychologist has seen the client once for an IQ test there will be a different level of concern or support needed. In situations where there is some concern regarding the well-being of the client, professional, community or family supports may need to be put in place.

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B.11.3. Psychologists make reasonable arrangements for the continuity of service provision when they are no longer able to deliver the psychological service. Psychologists need to consider the impact of illness and death on their service provision (in addition to any matters that arise at times when clients cannot see them, e.g. weekends or holidays). Psychologists should have a practice contingency plan (see Chapter 11) that sets out how their clients can be cared for if they suddenly cannot provide services.

B.11.4. Psychologists make reasonable arrangements for the continuity of service provision for clients whose financial position does not allow them to continue with the psychological service. A psychologist’s overriding obligation is to the well-being of their client. Just because a client can no longer afford the service that the psychologist was providing does not mean the psychologist has a different level of responsibility to that of a client who is capable of paying. Psychologists should attempt to provide a level of service to the client in a more affordable manner (e.g. less frequent sessions, discounted rate for healthcare card holders). If the client cannot manage this fi nancial commitment the psychologists should connect the client to community or government service providers.

B.11.5. When confronted with evidence of a problem or a situation with which they are not competent to deal, or when a client is not benefiting from their psychological services, psychologists: (a) provide clients with an explanation of the need for the termination; If a psychologist is not competent to deal with the issue that the client is seeking assistance with, and it is not an emergency situation (see Chapter 2), she should refer the client to an appropriate psychologist or service. She should explain why the referral is necessary and point out that a psychologist with the skills to deal with the client’s issues is in the best interests of the client. Similarly, if the client is not benefiting from the service (see B.11.1), the psychologist should explain that working with another psychologist may be more beneficial. In both these situations the psychologist should say that the need for a referral is not the client’s fault. Psychologists may need to emphasis this point with some clients and help them realise that it is the psychologist who does not have the skills to work with the client, rather than the client being too difficult to help.

(b) take reasonable steps to safeguard the client’s ongoing welfare; and The psychologist should put in place a plan to protect the client before attending the new psychologist. This can vary from telling them to come back if they need emergency help, to

General Principle B

a more supportive plan involving community or other healthcare professionals. The main focus is to ensure the client is safe and has access to the resources needed if his condition deteriorates.

(c) offer to help the client locate alternative sources of assistance. Generally a psychologist will provide the details of three other psychologists (or other professionals if that is the type of referral needed) who will be competent to provide the service the client requires. This should be done with consideration of the type of service the client needs. It is vital that the client does not have to be referred again, so the referred psychologist must be able to provide the service needed. However, the client should not be pressured into using the suggestions the psychologist makes, since he may want to fi nd another psychologist on his own.

B.11.6. Psychologists whose employment, health or other factors necessitate early termination of relationships with clients: Also see Chapter 11 for discussion of a practice contingency plan.

(a) provide clients with an explanation of the need for the termination; As with standard B.11.5, communication is the key. It is important to explain to the client why the service provision must stop (being mindful to share only information that is clinically relevant to the client).

(b) take all reasonable steps to safeguard clients’ ongoing welfare; and The psychologist should set up a plan to protect the client between his fi nal session and attending the new psychologist(s). This can vary from giving him emergency contact details of another psychology service to a more supportive plan involving community or other healthcare professionals. The main focus is to ensure the client is safe and has access to the resources needed if his condition deteriorates.

(c) offer to help clients locate alternative sources of assistance. Generally a psychologist will provide the details of three other psychologists who will be competent to provide the ongoing service the client requires. There may also be an option for the client to continue on with a locum provider or another psychologist in the same practice. Competent service provision to the client must again be the focus.

B.12. Conflicting demands Psychologists will often fi nd that there is conflict between their ethical obligations as psychologists and organisational requirements or practices. This conflict could occur in the workplace or with other organisations that the psychologist or client is interacting with, such as an insurance company or government organisation.

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B.12.1. Where the demands of an organisation require psychologists to violate the general principles, values or standards set out in this Code, psychologists: In these situations there is conflict between the psychologist’s obligations and workplace /organisation philosophy, expectations or policies. Psychologists should always work to resolve these issues. In extreme circumstances the psychologist may decide not to offer her services to that organisation if a compromise cannot be reached.

(a) clarify the nature of the conflict between the demands and these principles and standards; The psychologist fi rst needs to determine how and why the conflict is occurring. It could be that there is a direct conflict (e.g. the organisation requires client records to be destroyed after five years) or a broader issue such as that the psychologist does not feel that the organisation is respecting the client’s autonomy.

(b) inform all parties of their ethical responsibilities as psychologists; Once the psychologist has established that there is a conflict she should inform all parties of their obligation to follow the Code. In some situations individuals within the organisation may not realise that psychologists have a very specific set of ethical obligations. This can be the case particularly in larger organisations.

(c) seek a constructive resolution of the conflict that upholds the principles of the Code; and Psychologists should try to fi nd a resolution that meets the needs of the organisation while still adhering to their ethical requirements. In some situations it could be that once the organisation and individuals within it are aware of a psychologist’s ethical obligations and principles, the organisation can adapt. In other situations the psychologist may have to alter the way she provides services or the types of services she offers to ensure that she can meet her ethical obligations.

(d) consult a senior psychologist. As in many situations in psychology, it can be highly beneficial to contact experienced psychologists for advice. If the conflict is with a large organisation there may be some experienced psychologists who have had to deal with the same ethical issues. These individuals may be able to provide insights into how to work with the organisations or ways to alter the service provision to ensure ethical standards are met. However, it is vital that the psychologist check to ensure that the suggestions provided by the senior psychologist are ethical. Sometimes experienced psychologists who have been working with an organisation for a long time can become apathetic about the ethical issues involved in working with that organisation.

General Principle B

B.12.2. Psychologists who work in a team or other context in which they do not have sole decision-making authority continue to act in a way consistent with this Code, and in the event of any conflict of interest deal with the conflict in a manner set out in B.12.1. Psychologists must not act in an unethical manner simply at the direction of another healthcare professional. When conflicts arise between psychologists and other professionals the psychologists should explain their ethical obligations and attempt to resolve the issue based on Standard B.12.1. s

B.13. Psychological assessments For many psychologists, psychological assessments will form a large part of their service provision. There are a number of ethical issues related to assessment and these are covered in more detail in Chapter 10.

B.13.1. Psychologists use established scientific procedures and observe relevant psychometric standards when they develop and standardise psychological tests and other assessment techniques. This standard points out that psychological assessment tools need to be developed in a way that is consistent with the established standards in psychology. This typically means they need to be empirically supported and have been thoroughly psychometrically assessed before they are made available for use. For standardised psychological tests this typically means there are norms against which a score is compared. These norms need to be representative of the population in question.

B.13.2. Psychologists specify the purposes and uses of their assessment techniques and clearly indicate the limits of the assessment techniques’ applicability. When a psychologist develops an assessment tool or technique she needs to clearly explain the purpose of the tool and how it should be used. For many assessment tools there will be highly detailed manuals and guides as to their correct use and administration. Part of this material should cover how and under what circumstances the assessment tool is to be used and with whom it should be used. Psychologists’ training and qualifications may limit the tools they can ethically use.

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B.13.3. Psychologists ensure that they choose, administer and interpret assessment procedures appropriately and accurately. Psychologists need to ensure that they choose assessment procedures that are the most relevant to the particular client. It is unethical for a psychologist to simply use the same assessment tools and strategy for every client. Each referral question, due to client variability, will be unique. Therefore, psychologists need to tailor their assessment to the specific needs of the individual client. This may mean that a different assessment tool is used, or that the assessment takes place at a time or location that is appropriate to the situation. It can also mean taking into account the directions in an assessment tool’s manual, altering the assessment procedure to meet the needs of the client or situation.

B.13.4. Psychologists use valid procedures and research findings when scoring and interpreting psychological assessment data. Not only should psychologists use appropriate assessment tools, but they must also interpret them in a way that reflects established knowledge in the field of psychology. This will typically mean that psychologists follow the interpretation guides in the manuals of the well-established assessment tool they are using. For some tools, however, there are no formal instructions for interpretation or the tool has been adapted for other uses since it was created. In these situations psychologists need to use the published literature to guide their scoring and interpretation. It is vital that psychologists use assessment tools in the appropriate manner and are guided by peer-reviewed research and the guidelines published by the developer of the assessment tool.

B.13.5. Psychologists report assessment results appropriately and accurately in language that the recipient can understand. It is vital that psychologists communicate the fi ndings of any assessment in a manner that is understandable to the intended recipient (see Chapter 10 for an example of this). There is no point conducting any form of assessment if the results cannot be understood by the intended user of that information. To achieve this, psychologists may have to produce multiple versions of reports (e.g. separate reports for GP, community mental healthcare worker and client) or alter their verbal communication style to meet the needs of the intended recipient. It is also vital that psychologists do not use unnecessarily complex or jargon-heavy language when communicating with clients. Psychologists should also check a client’s understanding of reports during a follow-up meeting and ensure that the key information is well understood.

General Principle B

B.13.6. Psychologists do not compromise the effective use of psychological assessment methods or techniques, nor render them open to misuse, by publishing or otherwise disclosing their contents to persons unauthorised or unqualified to receive such information. Psychologists must do everything practicable to protect the integrity of psychological assessment tools. For example, if the questions on an IQ test became public, it would render the test useless as everyone would be able to fi nd out the answers before taking the test. Therefore, psychologists need to ensure that this information is not made public. Similarly, some questionnaires have questions that assess the socially desirable responses that are embedded in them. Again, if these questions become publicly available the usefulness of these items would be eroded. Therefore psychologists need to ensure that only authorised individuals have access to test materials (both the physical assessment materials and any other materials that may contain sensitive information). This means that often clients will not have access to their specific responses (in reports or if they ask for access to their records at a later date) as this will potentially reveal information about the assessment tool.

B.14. Research All psychologists will engage with research at some stage in their practice. For some psychologists this will be in the form of reading peer-reviewed research to develop their practice. Other psychologists will be heavily involved in conducting research. In both situations psychologists must be aware of the ethical issues involved. Ethical practice not only protects those involved in the research, but gives confidence to the consumers of research that that it was conducted appropriately. See Chapter 9 for detailed coverage of research ethics.

B.14.1. Psychologists comply with codes, statements, guidelines and other directives developed either jointly or independently by the National Health and Medical Research Council (NHMRC), the Australian Research Council, or Universities Australia regarding research with humans and animals applicable at the time psychologists conduct their research. These groups set out a range of guides to protect participants and the public when research is conducted. Psychologists, especially given the field’s poor track record of research practices, must ensure that they meet these basic standards and submit all proposed research to the relevant ethics committee for consideration and approval.

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B.14.2. After research results are published or become publicly available, psychologists make the data on which their conclusions are based available to other competent professionals who seek to verify the substantive claims through reanalysis, provided that: There is an ethical expectation that psychologists who conduct research will allow others access to their data to verify their results, once the psychologist has published her results.

(a) the data will be used only for the purpose stated in the approved research proposal; and This standard points out that the data is not to be used for another purpose, but for verification only. Given this expectation, it is wise to include this possibility of verification in any informed consent documentation.

(b) the identity of the participants is removed. It is vital that any identifying information that may have been part of the data collection process is removed before anyone is allowed access to the data for verification. As has been covered previously, identifiable information is not only name, address, email etc. but also any information that is so unique that it inadvertently discloses the individual. For example, if the research involved only one workplace and there was only one female in that workplace, it would be very easy to identify that individual in that data set.

B.14.3. Psychologists accurately report the data they have gathered and the results of their research, and state clearly if any data on which the publication is based have been published previously. Psychologists are ethically obliged to be honest in the research process. They need to clearly identify where, when and how the research took place, while maintaining an overriding concern for the participant’s confidentiality. Many psychologists will not engage in research after the completion of their university studies. For those who do, and for the vast number of professionals who rely on that research, psychologists engaging in research must maintain the highest levels of ethical integrity.

General Principle C: Integrity

Psychologists recognise that their knowledge of the discipline of psychology, their professional standing, and the information they gather place them in a position of power and trust. They exercise their power appropriately and honour this position of trust. Psychologists keep faith with the nature and intentions of their professional relationships. Psychologists act with probity and honesty in their conduct.

Explanatory Statement Psychologists recognise that their position of trust requires them to be honest and objective in their professional dealings. They are committed to the best interests of their clients, the profession and their colleagues. Psychologists are aware of their own biases, limits to their objectivity, and the importance of maintaining proper boundaries with clients. They identify and avoid potential conflicts of interest. They refrain from exploiting clients and associated parties.

C.1. Reputable behaviour C.1.1. Psychologists avoid engaging in disreputable conduct that reflects on their ability to practise as a psychologist. Psychologists need to consider the public perception of themself and of psychologists more broadly. Psychologists should consider their public actions as psychologists, but also their

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private actions that can be viewed by the public. For example, if a psychologist has personal social media presence (such as a Facebook page), she needs to consider the impact any content placed upon it will have on the profession and her clients if they gain access to it. If the psychologist has comments or images on her profile that reflect poorly on her character this could negatively influence client perceptions. This can potentially lead to client concern about the professionalism of the psychologist who is working with them.

C.1.2. Psychologists avoid engaging in disreputable conduct that reflects negatively on the profession or discipline of psychology. Psychologists also need to consider the overall perception of psychologists that may be derived from their behaviour or comments. They need to consider not only how they are perceived, but also the broader perception of psychologists. For example, if a psychologist worked only in research and did not provide any services directly to clients, she would still need to ensure that her behaviour did not reflect negatively on the profession as a whole even if she did not have any clients that would be directly affected.

C.2. Communication C.2.1. Psychologists communicate honestly in the context of their psychological work. It is vital that psychologists are open and honest in their communication with clients, other professionals and any other third party (while maintaining any confidentiality obligations). They should also consider the client’s characteristics (e.g. age, level of understanding) and ensure that they are communicating in a manner that the client can easily understand and that minimises distress. Psychologists should also note that honesty is different from confrontation, criticism or direction, and that client autonomy is still important. Nor does acting honestly suggest that psychologists disclose personal information about themselves to the client.

C.2.2. Psychologists take reasonable steps to correct any misrepresentation made by them or about them in their professional capacity within a reasonable time after becoming aware of the misrepresentation. Psychologists need to be aware of the comments they make that are published or reproduced by others. This could be in newspapers, journals, websites or social media. Psychologists need to be aware of what information or comments are attributed to them and ensure they are accurate and appropriate and have been placed in a meaningful context. If not, the

General Principle C

psychologists should ensure that they are removed or corrected and an appropriate notice is placed with the corrected material or in place of the deleted material.

C.2.3. Statements made by psychologists in announcing or advertising the availability of psychological services, products, or publications, must not contain: This represents a very broad range of communications; psychologists should carefully check all advertising and promotional materials (including websites and online profiles) to ensure that they do not violate this standard.

(a) any statement which is false, fraudulent, misleading or deceptive or likely to mislead or deceive; Psychologists should refrain from any form of advertising that does not accurately represent their competencies and the skills and services they offer.

(b) testimonials or endorsements that are solicited in exchange for remuneration or have the potential to exploit clients; Under the advertising requirements developed by AHPRA and the PsyBA, testimonials or purported testimonials cannot be used in advertising. Therefore psychologists may face disciplinary action if they use testimonials in their promotional materials. The APS has highlighted this in its online version of the Code.

(c) any statement claiming or implying superiority for the psychologist over any or all other psychologists; Psychologists need to be balanced and realistic in their advertising. Individuals seeking psychological services can often be in a delicate or vulnerable state. Unrealistic expectations can be developed from verbose or overly self-promoting advertising. Additionally, different clients may connect or develop a better therapeutic relationship with different psychologists and receive a better service as a result. The nature of psychological service provision makes this form of advertising dishonest.

(d) any statement intended or likely to create false or unjustified expectations of favourable results; As mentioned above, clients are often in a vulnerable state when they are seeking psychological service. For this reason psychologists need to be mindful of the types of outcomes any advertising suggests. For example, advertising suggesting that a psychologist can ‘cure depression’ would be unethical. Without a complete assessment of the situation and client, a psychologist would not be aware if she was competent to work with the client, let alone reduce the client’s depression.

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(e) any statement intended or likely to appeal to a client’s fears, anxieties or emotions concerning the possible results of failure to obtain the offered services; It is unethical for a psychologist to appeal to a client’s fears or anxieties to promote their service or advertise. For example, any form of advertising that suggested a client would be miserable and lonely if they did not see a psychologist to treat their social anxiety would be unethical.

(f) any claim unjustifiably stating or implying that the psychologist uses exclusive or superior apparatus, methods or materials; and Clients are often in a vulnerable state when they are seeking psychological service, so it is unethical to suggest that one particular tool or service is going to be the best for such a client. A claim like this lacks any consideration of the client’s unique circumstances or issues. Psychologists, when they advertise, should simply highlight the services and/or groups in the community that they are likely to be competency to provide services to.

(g) any statement which is vulgar, sensational or otherwise such as would bring, or tend to bring, the psychologist or the profession of psychology into disrepute. Psychologists should take great care in advertising the services they offer and their areas of competence. Any form of advertising other than that mentioned under C.2.3 is likely to lead to misconceptions and unrealistic expectations in the client. These can be highly detrimental to a client’s experience of the psychological service and the profession more broadly.

C.2.4. When announcing or advertising the availability of psychological services or at any time when representing themselves as a psychologist, psychologists use accurate postnominals, including the  postnominals used to represent their grade of membership with the Society. When advertising (and on business cards/letterhead) psychologists must ensure that all of their details are correct and cannot be easily misinterpreted. This includes their registration status, their endorsements (if any), their qualifications and professional memberships. Some of these classifications are regulated by AHPRA and there are substantial penalties for incorrect use.

C.2.5. Psychologists take reasonable steps to correct any misconceptions held by a client about the psychologist’s professional competencies. Psychologists should always ensure that their clients are aware of the services that the psychologist provides. As part of this they must discuss with clients their skill set and the matters that they can assist with. Psychologists should also make sure that clients have

General Principle C

accurate expectations of the likely outcome of the psychological service. Clients may often have misconceptions about how the service will work and expect quick and simple solutions (i.e. there are no magic solutions). Psychologists must work with the client to help them understand that psychological service can often be time-consuming and almost always requires effort on the part of the client.

C.3. Conflict of interest Psychologists must be sure that all business and personal relationships do not adversely affect their practice. Part of this process is an evaluation of any potential conflicts of interest.

C.3.1. Psychologists refrain from engaging in multiple relationships that may: Multiple relationships exist when a psychologist has any relationship with a client (or someone close to the client) other than the professional client–psychologist relationship, such as the psychologist and the client’s partner owning a business together.

(a) impair their competence, effectiveness, objectivity, or ability to render a psychological service; Psychologists need to be aware of the potential negative impacts on the client when there are multiple relationships. For example, if the psychologist was working with the husband of a person she was in business with, there could be a conflict of interest that might influence her. If she decided that the client needed intensive services or hospitalisation, she might begin to consider what impact this could have on her business relationship with the client’s wife. The client’s wife might need to spend less time at work and more time with the client, which would have a negative impact on the business. While obviously this should not influence the psychologist’s decision, it might, or there could be a perception that it would.

(b) harm clients or other parties to a psychological service; or In the above example, if the psychologist was to choose a treatment that was not in the client’s best interest but in the best interest of another relationship she had with the client, there is a substantial risk of harm. This is why multiple relationships should be avoided where possible. All psychological services should take place with a focus on the best interests of the client in relation to their psychological needs. Any other relationship between the client and the psychologist has the potential to impact negatively on the client.

(c) lead to the exploitation of clients or other parties to a psychological service. When psychologists and clients are in multiple relationships there is the possibility that the psychologist can, deliberately or inadvertently, exploit the client. For example, if the psychologist suggests (or manipulates) in the therapeutic setting that the client should do

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something that is going to lead to a benefit to her in another relationship (e.g. that the client should sell an item that the psychologist believes she will be able to buy at a discounted price).

C.3.2. Psychologists who are at risk of violating standard C.3.1., consult with a senior psychologist to attempt to find an appropriate resolution that is in the best interests of the parties to the psychological service. If there are organisational or situational constraints (see C.3.3) that lead to the potential for multiple relationships that pose the threat of a conflict of interest, psychologists should take steps to address it. This would include consulting with an experienced and ethically aware psychologist to negotiate and investigate the issue with a focus on protecting client interests and welfare. The Decision Assistance Model for Australian Psychologists may help with this (see Chapter 3).

C.3.3. When entering into a multiple relationship is unavoidable due to over-riding ethical considerations, organisational requirements, or by law, psychologists at the outset of the professional relationship, and thereafter when it is reasonably necessary, adhere to the provisions of standard A.3. (Informed consent). There will be some circumstances whereby a multiple relationship, at least in the short term, will be unavoidable. In these situations the psychologist must ensure that all parties are aware of the situation, the existence of a multiple relationship and what steps are in place to protect the client. This should be done as part of the informed consent process before any psychological services have been provided. Alternatively, if the service provision is already underway when the multiple relationship comes into effect, the client and any third parties (subject to any confidentiality issues) should be informed. The client can then decide if he wants to continue the service provision or what additional protections he might put in place (e.g. not disclosing certain information).

C.3.4. Psychologists declare to clients any vested interests they have in the psychological services they deliver, including all relevant funding, licensing and royalty interests. Psychologists have an obligation to be open about their fi nancial interests in relation to the service they are providing to their clients. In addition to information given to clients about the costs of the service, the psychologist should also inform the client of any fi nancial interests that she has in assessment tools, interventions, intellectual property or any other additional relevant income stream. If clients are aware of these matters they can make informed decisions

General Principle C

about the service provision or research involvement. However, psychologists must always make  decisions based on the best interests of their clients, regardless of the disclosure of the conflict.

C.4. Non-exploitation C.4.1. Psychologists do not exploit people with whom they have or had a professional relationship. Psychologists are in a position of power relative to their current and previous clients. It is vital that they do not use this power imbalance to exploit the current or former clients.

C.4.2. Psychologists do not exploit their relationships with their assistants, employees, colleagues or supervisees. Psychologists need to be aware that there will often be a power differential between themselves and staff they employ or the individuals they are supervising. This may arise from their employment status or because they are viewed as knowledgeable and professionals to be respected. Psychologists must ensure that these issues do not lead to the exploitation of their staff and supervisees (e.g. does a supervisee offer to buy morning tea every morning because of a power differential?).

C.4.3. Psychologists: (a) do not engage in sexual activity with a client or anybody who is closely related to one of their clients; Due to the inherent power differential that exists between a psychologist and her client, sexual relationships between psychologists and their clients are completely unethical. Given the position of power, even if a client consents or initiates a sexual relationship it is unacceptable and unethical. Psychologists will have specific information that the client has revealed during the professional relationship which makes any other relationship highly problematic and is likely to lead to further psychological difficulties for the client. This prohibition extends to sexual relationships between psychologists and individuals close to the client. For example, if a psychologist began a sexual relationship with the client’s mother, there could be serious negative consequences for the client.

(b) do not engage in sexual activity with a former client, or anybody who is closely related to one of their former clients, within two years after terminating the professional relationship with the former client; There are several reasons why psychologists need to avoid sexual relationships with past clients or individuals closely related to past clients. Once the psychological relationship has

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ended, the power differential will remain: the client may be grateful or feel that he owes the psychologist in some way. The psychologist will still be seen as a knowledgeable and powerful individual, which highlights the power imbalance. Also, past clients will often seek assistance from the same psychologist in the future. If a client has begun a non-professional relationship with the psychologist he will need to fi nd a new psychologist to assist him this time. The two-year rule should be interpreted very conservatively. If the psychologist has had a long and intense professional relationship with a client, a sexual relationship is unlikely ever to be appropriate (see C.4.3.b). For more brief service provisions (e.g. a single career assessment) or when the individual seen was not the client (e.g. a parent is the client, but an 8-year-old child was the individual the psychologists was working with), the two-year rule may in some situations be appropriate.

(c) who wish to engage in sexual activity with former clients after a period of two years from the termination of the service, first explore with a senior psychologist the possibility that the former client may be vulnerable and at risk of exploitation, and encourage the former client to seek independent counselling on the matter; and As was pointed out in C.3 and C.4, clients are in a vulnerable position and it can be easy for a psychologist to, deliberately or inadvertently, take advantage of this power imbalance. Therefore, if a psychologist is considering entering into a personal relationship with a client after two years have passed, she must seek the supervision of an experienced and ethically aware psychologist. She should also encourage the former client to seek advice from an independent psychologist to investigate their situation before starting a personal relationship. This process aims to minimise the risk of harm to the former client.

(d) do not accept as a client a person with whom they have engaged in sexual activity. Due to the issues raised in C.4.3, psychologists must not accept a client with whom they have previously had a close personal relationship. The power differential again would lead to the potential for significant negative outcomes for the client. This prohibition is another reason that psychologists should consider carefully before starting any form of relationship with previous clients, as it will mean that the psychologist will not be able to work with them as a client again.

C.5. Authorship C.5.1. Psychologists discuss authorship with research collaborators, research assistants and students as early as feasible and through the research and publication process as is necessary. Psychologists should, as with all service provisions, ensure that all parties are informed on the conditions under which the service will take place. This includes in the research sphere, where they should discuss any research project with the other researchers they are working with (as well of course as participants). There are usually well-established processes when

General Principle C

working as part of a research team in an institution that conducts regular research. However, the psychologists must ensure that all parties are aware of these processes, paying particular attention to vulnerable parties such as supervisees (see C.5.3).

C.5.2. Psychologists assign authorship in a manner that reflects the work performed and that the contribution made is a fair reflection of the work people have actually performed or of what they have contributed. Psychologists and other collaborators in the research need to discuss and clarify roles and responsibilities within the research context and ensure that relevant authorship is attributed. This is to ensure that individuals who have meaningfully contributed are recognised. It should also be noted that it is unethical to include individuals in the authorship if they have not contributed to the work.

C.5.3. Psychologists usually list the student as principal author on any multiple-authored article that is substantially based on the student’s dissertation or thesis. It is typical for the fi rst authorship to be granted to the student if the publication is based on his thesis. In some circumstances if the analysis needs to be redone and the paper has to be completely rewritten and the student did not participate in this, then the supervisor who completes this work may be listed as the primary author. There should be a clear discussion of this between the student and the supervisor before the research is commenced and again before the reanalysis.

C.5.4. Psychologists obtain the consent of people before identifying them as contributors to the published or presented material. Psychologists must ensure that all authors consent to their identification in the publication process.

C.6. Financial arrangements C.6.1. Psychologists are honest in their financial dealings. Psychologists need to ensure that they are honest in their fi nancial dealings with clients and third parties. Psychologists need to be aware of their powerful position and check with clients and third parties regarding their understanding of fi nancial obligations. This should be done during the informed consent procedure and again as required throughout the service provision.

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C.6.2. Psychologists make proper financial arrangements with clients and, where relevant, third party payers. They: (a) make advance financial arrangements that safeguard the best interests of, and are clearly understood by, all parties to the psychological service; and Psychologists should discuss and clarify all fi nancial matters before the provision of the service. They should discuss with clients, and third parties where relevant, the cost of the service provision and discuss if it is going to be feasible. If not, other service provisions may need to be considered that may meet the client’s needs given the fi nancial considerations.

(b) avoid financial arrangements which may adversely influence the psychological services provided, whether at the time of provision of those services or subsequently. To the greatest extent possible, psychologists need to consider the client’s ability to pay for the service. It can be counterproductive to begin a service provision that the client or third party will not be able to pay for. Psychologists may also need to consider the relative importance of the service provision if a client is in need of several services. Psychologists should also avoiding bartering (swapping services with a client); this may lead to a dual relationship and may also lead to conflict over the value, or future value, or the goods or services exchanged.

C.6.3. Psychologists do not receive any remuneration, or give any remuneration for referring clients to, or accepting referrals from, other professionals for professional services. It is ethically unacceptable for a psychologist to pay or receive a fee from a referral system between professionals. Psychologists and other professionals should refer clients according to their needs and the competence and skills of the other professional. It is common practice for the referring professional to provide a number of options when referring. It should be noted that this is different from paying a third party for advertising of a psychologist’s services.

C.7. Ethics investigations and concerns C.7.1. Psychologists cooperate with ethics investigations and proceedings instituted by the Society as well as statutory bodies that are charged by legislation with the responsibility to investigate complaints against psychologists. Psychologists are ethically obliged to be forthcoming about a disciplinary proceeding, though they should still be mindful of other ethical obligations they have. See Chapter 12 regarding mandatory notifications obligations.

General Principle C

C.7.2. Psychologists who reasonably suspect that another psychologist is acting in a manner inconsistent with the ethical principles and standards presented in this Code: It should be noted that reasonable suspicion is above mere speculation.

(a) where appropriate, draw the attention of the psychologist whose conduct is in question directly, or indirectly through a senior psychologist, to the actions that are thought to be in breach of the Code and cite the section of the Code which may have been breached; As a fi rst step psychologists should attempt, in a collegial and professional manner, to make the other psychologist aware of the breach. Sometimes this information will be enough to raise the awareness of the other psychologist and deal with the problematic behaviour without any further action. For a more serious breach, a report of the psychologist’s behaviour to the relevant professional authority may be appropriate.

(b) encourage people directly affected by such behaviour to report the conduct to a relevant regulatory body or the Ethics Committee of the Society; or If a psychologist is made aware of a breach of the Code, but does not have any direct involvement or has not observed the breach, she should encourage the affected party to report the breach. This may involve encouraging, and supporting, a client who feels that he has been subjected to a breach.

(c) report the conduct to a relevant regulatory body or the Ethics Committee of the Society. Where the psychologist has a reasonable suspicion of a serious breach, she has an ethical obligation to report the matter directly to the relevant authority.

C.7.3. Psychologists do not lodge, or endorse the lodging, of trivial, vexatious or unsubstantiated ethical complaints against colleagues. Psychologists should only lodge, or encourage a client to report, a matter that is to the best of their knowledge reasonable. It should be reasonable in terms of its genuine status as a breach and its occurrence. However, if the psychologist has a reasonable belief that a breach has occurred they should take the necessary steps to report it.

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Glossary Action phase The action phase is an important part of DA-MAP (see Chapter 3) and helps the psychologist make her decision. It is likely to be unique for each decision that needs to be made. Each decision will require the consultation of literature specific to the client’s situation. AHPRA (Australian Health Practitioner Regulation Agency) AHPRA is the overarching government registration body for health practitioners in Australia. Its main purpose is to protect the public in accordance with each state and territory’s Health Practitioner Regulation National Law, which came into being in July 2010 and transcends all state and territory boundaries. Currently there are 14 National Boards across various health professions. The Psychology Board of Australia (PsyBA) is the Board relevant to psychologists (see separate glossary entry). APS Code of Ethics The Code is the overarching document that puts forward the minimum acceptable ethical standards for psychological practice. It provides guidance for psychologists and demonstrates to the public the required standards that psychologists should adhere to. The Code is made up of three general ethical principles: • Respect for the rights and dignity of people and peoples • Propriety • Integrity. APS Ethical Guidelines (AEG) The Australian Psychological Society Guidelines are specifically designed to complement the APS Code of Ethics. The guidelines go into much more detail than the Code and contain more discussion of the issues. The AEG has published Guidelines on such issues as confidentiality, supervision and hypnosis. Australian Privacy Principles (APPs) The APPs are a set of 14 guidelines on privacy as set out by the Office of the Australian Information Commissioner (OAIC) and came into force in March 2014. They are not specific to psychologists but to organisations and sole practitioners who hold data about individuals. See Chapter 11.

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Autonomy Refers to the client having the right to make decisions for himself. Psychologists are advised to be mindful of a client’s autonomy vis-à-vis any discussions on any service provided. Beneficence (Benefit) This is the default ethical position for practising psychologists in that whatever treatment and /or service is offered the client should receive some benefit from that interaction. Body language Communication with clients, especially when considering different ethnicity and culture, may be influenced by body language. This can take the form of nonverbal communication where certain signals are sent without the use of verbal language. For example, making eye contact in most western cultures is regarded as a sign of sincerity and politeness. However, in some indigenous cultures this is avoided and may infer dominance or disrespect. Boundary crossing A boundary crossing is generally regarded as being a departure from commonly accepted practices but which could potentially benefit clients. Boundary violation A boundary violation of professional boundaries is a severe breach that damages the client– psychologist therapeutic relationship and inevitably results in harm to clients and is therefore unacceptable and unethical. Breach of confidentiality The therapeutic relationship between a psychologist and the client is based on confidentiality, but there are occasions where breaching confidentiality may be necessary. For example, if you are ordered to do so by a court or if your client or another identifiable person is in danger, then it may be necessary to breach confidentiality. In all cases, and as far as possible, you should inform your client that a breach has to take place. Checking phase The checking phase is an important part of DA-MAP (Chapter 3) and helps the psychologist make his decision. The checking phase is about the acquisition of professional and ethical knowledge and should be a lifelong process developed over a psychologist’s career. Psychologists should start gathering this information and knowledge in their training and continue to build on it. Child abuse In general, child abuse is the maltreatment of children by adults or other children significantly older than the child victims. According to the Australian Government’s Institute of Family Studies, child abuse can include the following categories: physical abuse, emotional maltreatment, neglect, sexual abuse, and the witnessing of family violence. Client A client is a person, persons, or organisation who have taken on the services of a psychologist. This could involve direct psychological intervention, research, supervision, or teaching. A client can be in many forms such as that of a company, individual, group, couple, or in essence any group or person paying for or seeking psychological input or advice.

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Client diversity Psychologists will provide services to a diverse range of clients. These clients will vary in terms of their physical and cognitive abilities, their cultural and ethnic background, their religious or spiritual beliefs, their location, their sexual orientation and their gender. These are some of the core aspects of each individual’s identity. Client record(s) It is a minimum ethical standard that the psychologist keeps a record of the client’s details as well as therapeutic work that was carried out. The general record would also contain documents such as correspondence received from other professionals as well as any psychological reports. Client records are usually in two parts: a client service record and a confidential client record. Client service record Part of the two-part client record along with the confidential client record. The client service record would contain information regarding the dates and treatment type, appointment history, contact and payment details and other administrative information. Competency or competence Psychologists must ensure that they have, and maintain, the skills needed to practise in their field (the Code, B.1.1) and psychologists only provide psychological services in which they are competent (B.1.2). In this form, competency relates to their knowledge, training/education, supervised experience (B.1.2.a) and that the service is based on established knowledge of the field. Confidential client record Part of the two-part client record along with the client service record. This would include information provided by the client (e.g. presenting issues), information gathered during the provision of the psychological service (e.g. test results and clinical notes), treatment plans, and information from other healthcare professionals. This information is highly sensitive and the confidentiality of this material is vital to the therapeutic relationship. Confidentiality There is an ethical expectation that when the client enters a therapeutic relationship with the psychologist certain details are protected and should remain confidential between the parties. Of course, there are limits to confidentiality such as that enforced by legal requirements or when the client’s best interests need to be protected. Conflict of interest In order to ensure objectivity the psychologist must ensure that a conflict of interest does not exist either in perception or in actuality. For example, researchers are required to declare any vested interests that could be regarded as compromising the integrity of the researcher and thus the accuracy of the results. Consent Consent is the agreement to participate in an act, relationship or contract. In psychology clients need to consent to take part in the psychological service. However, see informed consent (separate entry) as this details the type of information a client should be provided with before they are asked to consent to the the psychological service.

Glossary

Continuing professional development (CPD) In order to maintain registration as a psychologist certain educational and practical activities must be undertaken every year so as to ensure recency in the field of practice. Court order service This is a situation where the court instructs a certain psychological service to be carried out which does not require client consent. For example, a court may order an individual to undergo a psychological assessment to determine if they are capable of standing trial. Decision assistance model The purpose of a decision assistance model is to help a psychologist systematically consider all aspects of an issue before deciding on an outcome which is both ethical and focused on client welfare. See Decision Assistance Model for Australian Psychologists (DA-MAP). Decision Assistance Model for Australian Psychologists (DA-MAP) DA-MAP is a specific decision assistance model that will focus on the process required to develop ethical and client-focused decisions in an applied psychological context. DA-MAP is explained in detail in Chapter 3. Deliberate self-injurious behaviour From an ethical perspective self-injurious behaviour focuses on clients who are deliberately harming themselves. This form of behaviour can include clients cutting, scratching or burning their body, but can also include clients punching themselves or using objects to cause pain. Duty of care Ensuring that no harm comes to your client through your practice as well as considering that the client’s welfare is always of primary importance. For example, your client who had extreme suicidal ideation missed an appointment, and it would be your responsibility to check on the welfare of that client. This could be by attempting to make contact or through appropriate agencies. Ethical conduct Ethical conduct relates to behaviour that could reasonably be construed as being within the bounds of ethical norms. This could refer to conduct in the practising situation or in other areas of life. Ethical decision-making By the nature of the role of the psychologist, difficult situations requiring complex judgment calls, together with broad and extensive practice requirements, arise frequently. Psychologists need a systematic decision assistance process to deliver efficient and ethical services to all clients and client groups. One of the key tools used to achieve this is a comprehensive yet flexible decision assistance model. See Decision Assistance Model for Australian Psychologists (DA-MAP). Ethics Ethics is the study of moral principles that govern or should govern behaviour. At an individual level, it relates to a person’s principles, possibly unformulated, that underlie his or her conduct.

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268

Glossary

Evidence-based practice According to the Code, psychologists should be practising in a manner in which there is evidence that a particular therapy or approach is effective with a certain group of clients. Usually evidence would be in the form of peer-reviewed studies, although other forms of evidence may be acceptable. Group therapy Instead of one-to-one psychological therapy, many psychologists employ a group approach to therapy where more than one client is involved in an intervention with the psychologist. Usually all the clients participating in the group would be requiring support for the same issues, for example depression or alcohol abuse. Identifiable third parties This is a person or persons who are discussed and identified by the client in a therapeutic interaction. This term mostly refers to situations where another person may be at risk of harm based on information provided by the client. INconsenting adults While adults are presumed to be capable of consenting to receive psychological services, there are a small number of individuals over the age of 18 years whom psychologists may need to consider as INconsenting adults. This means that they are incapable of consenting to the provision of a service, not unwilling to consent to it. In many cases these adults are legally allowed to make decisions but a psychologist may have some concerns about their ability to make informed decisions. Informed consent When providing a psychological service to any client, a psychologist must give a detailed overview of his qualifications, the service being provided, the confidentiality of the issues being addressed, the costs associated with that service and how the service will end. When the client is aware of these factors she can then make an informed decision about receiving the psychological service. Learning experiment As the term would suggest, this is where the study of human behaviour involves an experiment where the ability of the subject to do learning tasks is investigated. A learning experiment is contained within Milgram’s infamous obedience experiment from the 1960s (see Chapter 9) where a subject (stooge) was required to remember word pairs. Legal guardian Usually this is a person who is appointed by a court to act legally on behalf of another person because they are deemed to be vulnerable. These reasons can include being under 18 years of age, having a severe cognitive impairment, or other reasons usually deemed by the court to be acting in the person’s best interests. Mandatory notifications The compulsory reporting by psychologists, and other healthcare professionals registered under AHPRA, of inappropriate practitioner conduct such as intoxication or sexual behaviour with a client.

Glossary

Mandatory reporting of child abuse Mandatory reporting of child abuse in Australia relates to the legal requirement in some states for psychologists to report actual or suspected child abuse to the appropriate authorities. Mandatory reporting should not be confused with mandatory notifications. Manualised interventions Interventions that have a standardised procedure for their implantation. These interventions have typically been evaluated in terms of their effectiveness with the target group. Mature minor When working with a young person the key issue that needs to be established is the ability of the young person to give consent. If the psychologist can be confident that a person who is under 18 can make an informed decision about treatment interventions or other psychological assessment, then this person can be regarded as a mature minor. Media portrayal There can be a particular presentation of a person or group developed through the media that may or may not be accurate. The psychologist should be aware of the potential for inaccuracy of any media portrayal of groups. Minors Generally minors are regarded as persons under 18 years of age and therefore not legally able to make decisions about psychological treatment. The exception is someone classed as a mature minor. Multi-agency report Various professionals are involved in a particular assessment of a client which leads to the collaborative multi-agency report. An example would be a joint report by the psychologist, school teacher, speech pathologist, who all worked together to assess a child for autism spectrum disorder. Multiple relationships Multiple relationships occur when a psychologist providing a psychological service to a client may also have had or is having another kind of relationship with the client. The APS guidelines give several examples of this, one of which is that the psychologist is ‘a recipient of a service provided by the same client’. Neglect A reasonable level of care is not given by a person who is responsible for providing support. There are different types of neglect, e.g. physical or emotional. Neglect is a more passive form of abuse where it is more about what is not given rather than what is (negatively). Non-maleficence It is one of the cornerstones of good ethical practice that whatever the intervention or service that is offered, no harm to the client should result from it. Psychologists have a duty to ensure that the minimisation of any risks in treatment is paramount in the psychologist’s approach to appropriate intervention.

269

270

Glossary

Peer-reviewed publications Any published material that has been reviewed by peers in the particular specialist field. Peer reviewed material can be in the form of books, chapters, journal articles. Not all publications are peer-reviewed and if peer review has not taken place then the quality of the material cannot be relied upon as the scrutiny is, at best, sparse. Peer consultation This involves a psychologist discussing his practice with another psychologist. According to the PsyBA, peer consultation should develop and evaluate the psychologist’s practice in accordance with his learning plan and can be in a group or individual format. Practice contingency plan This would guide another psychologist through the specifics of a psychologist’s practice if she died or was incapacitated. Then, in the event of the death, serious illness or incapacity of the psychologist another psychologist could ensure that the incapacitated psychologist’s clients are appropriately cared for. Practice endorsements The PsyBA allows psychologists to be endorsed in certain areas of practice, for example clinical or educational and developmental. To be eligible for endorsed status through the PsyBA a psychologist needs to have an accredited doctorate and one year’s supervised practice with a Board-accredited supervisor, an accredited master’s degree with two years’ supervised practice with a Board-accredited supervisor; or another qualification that the Board views as equivalent. Practitioner A person who practises in his or her respective fields. In our area, a psychologist who practises psychology would be regarded as a practitioner. Privacy Privacy relates to the legal obligation not to disclose certain types of information such as information on personal health. According to the OAIC all organisations that provide health services are required to meet the obligations of the Privacy Act 1988 irrespective of their size. Professional development (PD) See continuing professional development. Protection, care and support plan (PCSP) A plan that is put in place to ensure that vulnerable clients have a clearly formulated strategy for treatment and support. Psychologists need to consider each individual’s situation including their risk and supportive factors, their underlying psychological issues and their social situation. Psychology Board of Australia (PsyBA) The PsyBA fits under the umbrella of AHPRA and, as the name would suggest, is the Board that deals with all matters relating to the registration of psychologists in Australia. The PsyBA manages complaints about psychologists from members of the public or other health practitioners. Psychologists must be registered with AHPRA in order to practise psychology in Australia.

Glossary

Psychological assessment A psychological assessment can have many different properties and be conducted for many different purposes. An assessment is usually designed to provide information to the psychologist, a third party, and of course the client, so that a particular course of action can be undertaken. Psychological harm Whether in research or practice, the psychologist is required to do no harm to the client. Psychological harm is where the client is subjected to a situation where she becomes uncomfortable (or potentially more serious) and is cognitively affected. An example could be research interview questions where the subject is asked about a traumatic event earlier in her life. While there may be no obvious physical signs the emotional effects may be significant. Psychological test Broadly, a psychological test is a set of items that have normed scores whose properties meet the standards of reliability and validity. They are usually designed for testing on individuals, for example cognitive assessment, personality inventory, dyslexia screening. Psychometrics Psychometrics is the measurement of psychological properties, usually in the form of a test. Personality tests and cognitive tests are examples of psychometric assessments. Registered psychologist In Australia, a person who practises as a psychologist is required by law to be registered with the Psychology Board of Australia (part of AHPRA). The title ‘Registered Psychologist’ is a reserved term and only those with appropriate qualifications and registration are entitled to use it. Research participant A person (subject) who is taking part in a project involving some form of experimental design, for example a standard experiment or survey which in this case would be conducted by a psychologist. Respect Practising as a psychologist, one would be expected to work with various people who may have very different belief systems or background from others. However, a psychologist is expected to have due regard for diversity and that other people’s opinions may differ from one’s own. Self-harm See deliberate self-injurious behaviour. Self-reporting People reporting on their own behaviours or thoughts, typically as part of an assessment. There is a range of assessment tools that use self-report questionnaires. Sex and/or gender diversity Some people do not consider themselves to be male or female and do not identify with the sex they were assigned at birth, or the gender they have may been have labelled. In international research individuals with these perspectives are sometimes referred to as transgendered.

271

272

Glossary

Stereotypes Stereotypes are instances of gross generalisations where certain character traits or cultural nuances are presumed across a large group of people where there is no evidence that this is the case. An example would be believing the stereotype that all lecturers are bungling oafs based on your experience with a few lecturers that you might have come across. Suicidal ideation A client who may be considering or attempting to take his own life. Suicide The deliberate act of a person taking his own life. Suicide risk assessment If a client is suspected of potentially being at risk of suicide the psychologist is obliged to carry out a suicide risk assessment. The assessment considers the demographic and personal risk and resilience factors of the client. These may include his age and gender, his cultural, geographic and physical environment and the supports and risks present within them, previous suicide attempts, drug and alcohol issues, and any recent interpersonal issues in the home or workplace. Supervision Professional counselling from another psychologist, usually in the form of peer advice where the various issues of practice are discussed in order to improve one’s own practice but also to seek advice on current cases. Termination of service The termination of the psychological service is where, for a multitude of reasons, the psychologist is no longer able to continue offering a therapeutic service to the client. The obligation is on the psychologist to ensure that the client’s welfare is appropriately considered and that they are as minimally affected with the inevitable change as possible. Third party payment Psychologists will often provide services that are paid for by government (e.g. Medicare), a private organisation (e.g. private health insurance) or individuals (e.g. family member), rather than directly by the client. Voluntary consent Voluntary consent is a term that refers to a client being able to give permission for a certain action to take place without any form of coercion. For example, a supervising psychologist getting her trainee to complete a survey. In this circumstance the trainee may feel obliged or pressured to take part and clearly this cannot be regarded as voluntary consent. Voluntary notifications There is a facility for healthcare practitioners or the public to make notifications regarding problematic behaviour (which does not constitute the threshold for mandatory notifications) to the PsyBA.

Index f denotes figures; t denotes tables 4+2 and 5+1 programs 19, 196 24 hour therapy 64, 159 see also Landy, Dr Eugene ABC radio 138 ABS 105 action phase 38–9 ADHD testing 156 advertising of services 190, 255–6 aged care system and policies that affect ethical service of provision 84–5 AHPRA see Australian Health Practitioners Regulation Agency (AHPRA) American Psychological Association 148, 162 Anderson, R. 60 anonymity and pseudonymity 172 APS see Australian Psychological Society APS Code A.1. Justice 90, 211–13 A.2. Respect 60, 213–15 A.3. Informed consent 31, 32–3, 74, 81, 84, 142, 143, 215–20 A.4. Privacy 220 A.5. Confidentiality 11, 24, 25, 27, 29, 107–8, 124, 175, 221–5 A.6. Release of information to clients 43, 225 A.7. Collection of client information from associated parties 226–30 B.1. Competence 17, 18, 41, 91, 197, 232–4 B.2. Record keeping 170, 176, 234–5 B.3. Professional responsibility 66, 235–7 B.4. Provision of psychological services at the request of a third party 237–8 B.5. Provision of psychological services to multiple clients 164, 238–9 B.6. Delegation of professional tasks 188, 240–1

B.7. Use of interpreters 93, 241–2 B.8. Collaborating with others for the benefit of clients 186, 189, 242 B.9. Accepting clients of other professionals 243–4 B.10. Suspension of psychological services 187, 244 B.11. Termination of psychological services 109, 185, 186, 193, 245–7 B.12. Conflicting demands 42, 159, 161, 247–9 B.13. Psychological assessments 153, 155, 158, 249–51 B.14. Research 137, 141, 251–2 C.1. Reputable behaviour 253–4 C.2. Communication 190, 254–7 C.3. Conflict of interest 64, 257–9 C.4. Non-exploitation 67, 162, 163, 200, 259–60 C.5. Authorship 146, 260–1 C.6. Financial Arrangements 191, 192, 261–2 C.7. Ethics investigations and concerns 262–3 APS Code of Ethics (2007) 4, 6–7, 41, 197 adoption of 206–7 amended standards 207 application of 210 competency standards 17–18 definitions 208–10 interpretation of 210 preamble 207–8 APS Code of Ethics General Principle A: Respect (2007) 6, 136, 211–30 APS Code of Ethics General Principle B: Propriety (2007) 6, 136, 231–52 APS Code of Ethics General Principle C: Integrity (2007) 6, 136, 253–63 APS Ethical Guidelines (2012) 7, 41, 59, 208 APS Evidence-Based Psychological Interventions in the Treatment of Mental Disorders 159

273

274

Index

APS Guidelines for Providing Psychological Services and Products Using the Internet and Telecommunications Technologies 107 APS Guidelines for Psychological Assessment and the Use of Psychological Tests 157 APS Guidelines for Psychological Practice with Lesbian, Gay and Bisexual Clients 98, 212 APS Guidelines for Psychological Practice with Women and Girls 96 APS Guidelines for the Provision of Psychological Services for, and the Conduct of Psychological Research with, Aboriginal and Torres Strait Islander People of Australia 95 APS Guidelines for Working with People who Pose a High Risk of Harm to Others 123 APS Guidelines on Confidentiality 26 APS Guidelines on Record Keeping 176, 182, 184 APS Guidelines on the Prohibition of Sexual Relationship with Clients 69 APS Guidelines on Working with Sex and/or Gender Diverse Clients 97 APS Guidelines Regarding Financial Dealing and Fair Trading 8, 191 APS Guidelines Relating to Suicidal Clients 105, 106 assessment tools clients’ access to information 181 considerations when dealing with younger and older clients 85 determining client harm-risk 125f for Indigenous groups 22, 157 assessments see psychological assessments assisted suicide 108 audits 28, 177 Australian Bureau of Statistics (ABS) 105 Australian Health Practitioners Regulation Agency (AHPRA) 199 adoption of APS Code of Ethics 6 advertising regulations 190 mandatory notification requirements 36, 40 minimum levels of CPD 16 registration process 196 Australian Privacy Principles (APP) 172–5 Australian Psychological Society 4 see also APS Code of Ethics (2007) Australian Psychological Society Limited 206 Australian Psychology Accreditation Council (APAC) 19 Australian Research Council 139 authorship 146, 260–1 autonomy 105, 108, 123, 127 clients with dangerous/risky behaviours 117–18 considerations in emergency situations 108 Baumrind, D. 147, 148 beneficence principle 7 Bhatia, K. 115

Blackwell, Dianne 138 body language 93–4 boundary crossings 58, 63f boundary violations 58, 63–4 case study 59, 68–9 Boyle, Chris 5, 155, 161 breach of confidentiality see confidentiality breaches Breen, K.J. 202 British Psychological Society (BPS) 161 checking phase 38, 45 child abuse and mandatory reporting requirements 40, 80, 123, 129–30 children (0–8 years) and informed consent 74–5 client diversity case study 89–90 communication 91–8 competency in dealing with 91 client files 175 see also client records client records 234–5 access to 180–1 case study 176, 177, 180, 182, 183–4 clients under 18 years 170 confidentiality of 175 content of 176–8 corrections or alterations to 181–2, 235 implementation of two-part 175–9 ownership of 179–80, 222 relevancy of information disclosure 224 storage and security of electronic 23 transportation of 184 see also client service records client reviews 51–2 client service records 175, 176 clients 15, 36 access to client records 178, 180–1, 225 awareness of practice across lifespan 22 confidentiality after death of 25 death of 186 determination of rights of confidentiality of 24 reasons for confidentiality breaches 27–9 release of information obligations 43–4 see also multiple clients clients of other professionals 243–4 clients under 18 years recordkeeping requirements 170, 235 storage of client records 182 clients who cannot give consent informed consent 73–83, 226 other issues that affect 84–5 see also children (0-8 years); INconsenting adults; mature minors (14+ years); older children (8–14 years)

Index

clients who do not consent to services 83–5 case study 83 informed consent 227 clients who pose a risk to others 122–8 case study 122, 127–8 ethical obligations 123–8 evaluation of risk and type of harm 125–6 evaluation of risk of harm 124–8 legal obligations 123–8 use of decision assistance models 123 clients who pose a risk to themselves 104–19 dangerous/risky behaviours 117– 19 provision of PCSP to 111–14 safety of clients and those around them 106–8 self-harm behaviours 114–17 suicide risk assessments 108–11 clients with dangerous/risky behaviours 117–18 clients with English as a second language informed consent and communication considerations 30–2 language skills competency 92 clients with suicidal ideation 105–14 case study 104, 106, 109–11, 111–12 decision-making models 108 ongoing care and support for 111–14 referrals 113–14 Code of Ethics see APS Code of Ethics (2007) Code of Professional Conduct see APS Code of Ethics (2007) coercion 143–4 collaborations with other professionals 189 communication 21, 254–7 management of professional boundaries 62 working with diverse clients 91–8 see also plain language competence 16–24 case study 15–16 core areas of 19–24 dealing with clients with suicidal ideation 106 dealing with diverse client groups 91 maintenance of 24 professional boundaries 232–4 Psychology Board of Australia’s (PsyBA's) areas of 19–24 conducts that require mandatory notification 199–201 confidentiality 6, 24–9, 221–5 after client's death 25 circumstances for disclosure 222–3 client records 175 dealing with minors 74–80 in group therapies 163–4 levels of complexities with 15–16 maintenance of 25 mandatory notification requirements 203 working with clients with illegal behaviour 118–19

confidentiality breaches acceptable cases for 203 case study 10–12 common reasons for 26–9 third parties 123, 124–5 see also Tarasoff v. Regents of the University of California 1976 confidentiality disclosure alternatives to 126 criminal activity 128–9 issues in disclosing information to protect third parties 127–8 state legislation differences 128 conflict of interest 64, 257–9 in research 144–5 conflicting demands 247–9 Connors' Rating Scales 3 156 consultation with other experts and colleagues 44–5 continuing professional development (CPD) 16, 198–9, 212 cooperation in ethics investigations 262–3 Corey, G. 8, 11, 141, 154 court order services 83 CPD 16, 198–9, 212 criminal activity and confidentiality disclosures 128–9 cross-cultural training 21–2 communication considerations 93–4 cultural bias 156–7 cultural norms 94 DA-MAP see Decision Assistance Model for Australian Psychologists (DA-MAP) De Looper, M. 115 debriefing process with interpreters 93 with research participants 147, 148 deception in research 144 Decision Assistance Model for Australian Psychologists (DA-MAP) 39f legal obligation guidance 42 phases within 38–9 practical applications for 53 use in ethical decision-making 38–53 decision assistance models 9, 36, 37 use in evaluation of risk of harm to third parties 123, 126 see also Decision Assistance Model for Australian Psychologists (DA-MAP) decision-making see ethical decision-making decision-making models for clients with suicidal ideation 108 see also emergency decision-making models; time-sensitive decision-making models delegation of tasks 240–1

275

276

Index

deliberate self-injurious behaviour 115–17 case study 117 direct marketing 173 discipline, knowledge competency for 20 dual relationships 60–2, 188 poor management of 62 see also Psychologists Registration Board of Victoria v Pallini (2008) duty of care 129, 185 to research participants 141–2

Gamble, Nick 5 gender-diverse clients see sex and/or gender-diverse clients Gharaibeh, N.M. 4–6 government-related identifiers 174 Great Moments in Academic Fraud 145 group memberships 94–5 group therapy 238–9 client records for 178–9 maintenance of confidentiality in 163–4 Guidelines for Advertising Health Services 190 Guidelines for Mandatory Notifications 199, 202 Guidelines for Providing Psychological Services and Products Using the Internet and Telecommunications Technologies 107 Guidelines for Psychological Assessment and the Use of Psychological Tests 157 Guidelines for Psychological Practice with Lesbian, Gay and Bisexual Clients 98, 212 Guidelines for Psychological Practice with Women and Girls 96 Guidelines for the Provision of Psychological Services for, and the Conduct of Psychological Research with, Aboriginal and Torres Strait Islander People of Australia 95 Guidelines for Working with People who Pose a High Risk of Harm to Others 123 Guidelines on Confidentiality 26 Guidelines on Continuing Professional Development 198 Guidelines on Record Keeping 176, 182, 184 Guidelines on the Prohibition of Sexual Relationship with Clients 69 Guidelines on Working with Sex and/or Gender Diverse Clients 97 Guidelines Regarding Financial Dealing and Fair Trading 8, 191 Guidelines Relating to Suicidal Clients 105, 106

education system and policies that affect ethical service of provision 84–5 eHealth records 23 electroconvulsive therapy (ECT) 162 electronic communication security and storage issues 23 use in decision-making process 46 use in emergency situations 107 Elms, Professor Alan 148–9 EMDR 159, 162, 163 emergency decision-making models 38, 39f, 53, 244 suicidal ideation situations 109–11 Epstein, R.M. 16 ethical code in practice 9–12 ethical conduct 138 Ethical Criticism of Milgram (Baumrind) 147 ethical decision-making 36–7 considerations when dealing with conflicting advice 41–5 development of potential actions and outcomes 45–6 evaluation of options and actions 49–51 evaluation of previous decisions made 46–9 maintenance of objectivity 40 review processes 51–2 situational considerations 48–9 Ethical Guidelines see APS Ethical Guidelines (2012) ethics 4 difference from morality and the law 8 overlap of standards scenarios 8–9 Ethics Appeals Committee 208 evaluation of research 21 evidence-based practice 141 see also intervention eye movement desensitisation reprogramming (EMDR) 159, 162, 163

Hammond, S. 60 health information and state legislations 171 Health Practitioner Regulation National Law Act 2009 42 high-risk patients 112–13 Hundert, E.M. 16 hypnotherapy 161

female clients 96–7 financial payments 261–2 clients who can't afford to pay referrals 192 third party payments 191–2 Fisher, C.B. 11, 144, 156, 164 Ford, G.G. 164

ICP see informed consent procedure (ICP) identifiable third parties see third parties illegal behaviour 118–19 implicit coercion in research 143–4 INconsenting adults 80–3 case study 82 ethical issues surrounding 82–3

193–4

Index

Indigenous groups 95–6 cognitive assessment tools for 22, 157 communication considerations for 93–4 deaths from suicides in 105 issues to be aware of when working with 96 inducements in research 143–4 information see personal information informed consent 142–3, 154, 157, 215–20 checklist for interventions 161–2 informed consent procedure (ICP) 16, 29–33, 81, 215–20 case study 30 changes in service provision 110 clients who cannot give consent 73–83 communication considerations for 31–2 competency in 22–3 confidentiality 25–6 core elements in 31 for interventions 61, 161–2 for mandatory notifications 203 psychological assessments 154 research projects 142–3 InPsych 95 insurance requirements 197–8 integrity principles 136, 208 internship programs 19, 196 interpersonal relationships 21 interpreters 92–3, 241–2 intervention 20, 159–62 group therapies 163–4 high-risk therapies 161, 162 informed consent for 61, 161–2 manualised 22 psychologist-client physical contact 162–3 strength of evidence criteria 160t therapies evaluated for effectiveness 160–1 Jifkins, J. 187 Journal of Abnormal and Social Psychology justice principle 90, 92, 211–12

147

Kämpf, A. 28, 123 Keith-Speigel, P. 154 Khawaja, N.G. 94 Kimberley Indigenous Cognitive Assessment tool Koocher, G.P. 154 La Trobe University 147 research and ethical behaviour 138 Landy, Dr Eugene 64, 159 language see plain language law difference from morality and ethics 8 overlap of standards scenarios 9 learning experiments 138 Lee, A. 94 legal guardians 73

157

INconsenting adults 81 minors 74, 76 legal obligations 40–1, 42, 45 case study 41–52 INconsenting adults 82 legal requirements confidentiality breaches 28 for registration 20 legislative disclosure requirements of states and territories 28–9 lesbian, gay and bisexual clients 98 lifespan, dealing with clients across various 22 low-risk patients 112–13 low-risk projects 139–40 mandatory notification requirements 36, 40, 199–201 difference from mandatory reporting 80 issues with 202 penalties for not making 201 state exclusions from 202 mandatory reporting requirements child abuse 123 child abuse and neglect 129–30 difference from mandatory notifications 80 manualised interventions 22 marginalised groups 94–5 mature minors (14+ years) 75–8 case study 76–7 parental relationship considerations 78–80 McSherry, B. 125 media portrayals of diverse clients 90 portrayals of psychologists 4–6 reports on La Trobe University’s research 138 Medicare 28, 177, 178, 224 Milgram, Stanley 138, 147–8 Milgram obedience experiments 138 criticisms about ethical nature of 147–9 minors and confidentiality considerations 74–80 morality, difference from the law and ethics 8 overlap of standards scenarios 8–9 multi-agency reports 154 multidisciplinary teams 188–90, 242 multiple clients client records 178–9 provision of services to 238–9 multiple relationships 59–62, 257–8 considerations in urban and rural environments 60 see also dual relationships National Health and Medical Research Council (NHMRC) 136, 144, 146 National Statement 136, 139, 142 National Privacy Principles (NPP) 171 see also Australian Privacy Principles (APP)

277

278

Index

National Psychology Exam 19, 196–7 National Registration Scheme 204 National Science Foundation 148 neglect of children, mandatory reporting requirements 129–30 negligible risk projects 139 NHMRC 136, 144, 146 non-exploitation of clients 58, 67–9, 259–60 non-healthcare professionals 189–90 non-maleficence principle 7, 141–2, 160 not low-risk projects 140 NPP 171 NSW Coroner's Court 112, 114 obedience experiments see La Trobe University; Milgram obedience experiments observation 154–5 O'Connor, N. 110, 111 Office of the Australian Information Commissioner (OAIC) 181 Privacy Principles 171–2 office workflow in psychology practice 184 older children (8-14 years) and informed consent 75 older people and reporting requirements 130 parental relationships 78–80 case study 79–80 PCSP 112–14 peer consultation 198, 199, 233 peer supervisions 16–17, 199 peer-reviewed publications 21 Perry, Gina 138 personal information access to 174 collection from third parties 226–30 collection of solicited 172–3, 225 correction of 175 cross-border disclosure 173–4 legislative protection of deceased clients' 187 notification of the collection of 173 quality of 174 release of information obligations 225 security of 174 unsolicited 173 use or disclosure of 173 personal information management 172 Pirkis, J. 5 plagiarism 145 plain language in assessment reporting 158 case study 158–9 in informed consent forms 31–2 Plato 4 Poddar, Prosenjit 11 post-traumatic stress disorder treatment interventions 162

power imbalance 65–6 practice contingency plan (PCP) 186–7, 247 practising while intoxicated standards 199–200 practising with an impairment standards 200–1 practitioners 4 privacy 171–5, 220 developing policies for 171–2 OAIC principles 171–2 Privacy Act 1988 171 professional boundaries 232–4 case study 58, 66 communication and ethical 62 professional development see continuing professional development (CPD) professional requirements for registration 20 professional responsibility 66, 235–7 professional standards and departures from accepted 201 propriety principles 136, 208 protection, care and support plan (PCSP) 112–14 provisional registered psychologists 196, 198 PsyBA see Psychology Board of Australia (PsyBA) psychological assessments 20, 152–5, 249–51 case studies 152–3, 158 clients’ access to information 181 cultural diversity considerations 156–7 informed consent 154 language case study 158–9 referrals for 155 relationship with testing 156f reporting requirements 157–9 psychological harm 140–1 psychological measurements 20 psychological testing 154, 155–7 definition of 155–6 informed consent 157 relationship with assessments 156f psychologist-client physical contact 219 interventions with 162–3 psychologists core competencies for registration 19–24 critical evaluation of practice 18–19 media portrayals of 4–6 practice contingency plan (PCP) 186–7 risk of harm from clients 130–1 self-reviews 52 see also provisional registered psychologists; registered psychologists Psychologists Registration Board of Victoria v Pallini (2008) 62 Psychology Board of Australia (PsyBA) 16, 36, 61, 197, 202 areas of competence 19–24 Decision Guide 200 Guidelines for Advertising Health Services 190

Index

Guidelines for Continuing Professional Development 198 Guidelines for Mandatory Notifications psychometrics 156

199, 202

RANZCOP 69 re: Marrion (1992) 76 record keeping 170–1, 234–5 referrals paid 192 for PCSP 113–14 post termination of service 186 psychological assessments 155 registered psychologists 196 practice endorsements 204 registration, core competency pathways for 19–24 reputable behaviour 253–4 research 21, 251–2 case study 137 coercion, inducements and deception in 143–4 considerations for vulnerable groups 146 cross-border disclosure of information 173–4 duty of care to participants 141–2 ethical checklists for 139 ethical rules for reporting findings 145 forms for informed consent 142–3 fraud and misconduct in 145 La Trobe University experiments 138 levels of risk in 139–40 methodological and ethical issues inherent in 140–1 Milgram obedience experiment 138, 147–9 research participants 136 respect principles 94, 136, 207, 213–15 Retraction Watch 145 review processes client 51–2 self-reviews 52 risk assessment tools for suicide 108–12, 115 Ross, J. 145 Royal Australian and New Zealand College of Psychiatrists (RANZCOP) 69 Rules and Procedures of the Ethics Committee 208 safety of clients who pose a risk to themselves 106–8 workplace design considerations 130–1 Schneider, I. 5 security of electronic client records 23 of personal information 174 workplace design considerations 130–1 self-reporting methods 154 self-harm 114–18 case study 116

self-injurious behaviour see deliberate self-injurious behaviour semi-structured interviews 154 service delegation 188–90 sex and/or gender-diverse clients 97–8 sexual misconduct notification standards 200 sexual relationships with clients 67–9 Shum, D. 155–6 slippery slope phenomenon 63, 68f Smith v Jones (1999) 123 St. Louis Post-Dispatch 147 Standing Orders of the Board of Directors of the Society 208 Stapel, Diederik 145 stereotypes 90, 94–5 Stokes, David 175, 176 storage case study 182, 183–4 of client records 182–4, 235 of electronic client records 23, 183 time frame for 221–2 structured interviews 154 students and mandatory notification standards 201 suicidal ideation 61, 142 suicide 104 deaths from 105 risk assessment tools 108–12, 115 see also assisted suicide supervision requirements 18, 233 support staff 188–9 survey-based research 142 suspension of services 244 Sydney Morning Herald 138 Tarasoff v. Regents of the University of California 1976 11–12, 123 Tarasoff, Tatiana 11 technology see electronic communication television media and portrayals of psychologists 4–6 termination of services 245–7 reasons for 184–7 The Australian Educational and Development Psychologist 144 therapeutic interventions 63 third parties 122 access to confidential information 28 collection of information from 226–30 evaluation of those at risk 124–5 payments by 191–2 provision of services at request of 237–8 reasons for confidentiality breaches 28–9 time-sensitive decision-making models 53

279

280

Index

Victorian Civil and Administrative Tribunal voluntary consent 143 voluntary notifications 202 vulnerable groups 146 reporting requirements 130 Wiger, D.E. 177 Wilson, Brian 64, 159

61

women see female clients Woo, E. 64 Yale University Young, S.D. 4

138, 148

Bringing ethical guidelines and decision-making to life in the helping professions Ethical Practice in Applied Psychology focuses on ethical principles to provide the basis for sound psychological practice of Australian students preparing for registration as psychologists. Written to align with the Australian Psychological Society’s Code of Ethics, the authors offer a clear and accessible explanation of the Code and its subsequent guidelines. Case studies are utilised throughout to help students learn how to apply the Code to real scenarios, provide a theoretical context to ethical situations and provoke discussion of issues relating to ethical dilemmas. With an engaging writing style and clear structure, Ethical Practice in Applied Psychology provides students with a deep and clinically useful education in ethics and empowers them to make ethical decisions in the transition to practice. Key features •• Based on the Australian Psychological Society’s Code of Ethics and Ethical Guidelines. •• Excellent case examples bring the complexities of ethical decisionmaking to life. •• Encourages best practice with a focus on scenarios where good practice is exemplified. •• Key terms, margin notes and questions to consider support student learning. Christopher Boyle is a registered Psychologist and Senior Lecturer in Educational Psychology, School of Education at the University of New England. Nicholas Gamble is a registered Psychologist and lectures in the Faculty of Education at Monash University.

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