The Register Report, Spring 2007 Ethics and Evidence-Based Practice: Are We Asking the Right Questions? by: Richard Ruth, Ph.D. Return to Table of Contents

The intent of this article is to explicate some ethical considerations facing practicing psychologists in the era of evidence-based practices (EBPs) and to frame productive ways of thinking through such questions. At first blush, this may seem like an odd intellectual enterprise: Would not reliance on EBPs imply that a psychologist was practicing ethically, or, at least, that many potential ethical problems were less likely to occur? As I hope to demonstrate, the answer is not so obvious.

THE PSYCHOLOGIST AS A PROFESSIONAL

The Preamble of the American Psychological Association’s (2002) Ethical Principles of Psychologists and Code of Conduct begins, “Psychologists are committed to increasing scientific and professional knowledge of behavior and people’s understanding of themselves and others...” What does the term “professional” mean in this context, and why is there a need for such a term to accompany the characterization of knowledge as scientifically based?

Ethical practice involves not just keeping up with the scientific literature - although that is an essential for all practicing psychologists - but participating in the life of our profession, preferably actively and proactively rather than passively and reactively. As we will go on to see, applying ethical principles to new and evolving real-world dilemmas inevitably forces the profession to think through complexities unforeseen in earlier eras; the precedents and collective experience of the profession go on to shape how we understand and react to future ethical dilemmas. When we face new phenomena, such as changing healthcare reimbursement schemes or previously unfamiliar disorders, and want to identify ethical and effective ways to respond, we are ill-served by trying to think through the ethical implications on our own, and well served by participating in the collective conversations in our profession. Reading articles about ethics in professional publications, attending professional meetings where cutting-edge ethics issues are being discussed, and turning to organizational resources when we face a problem that stumps us are always useful strategies.

UNDERPINNINGS OF THE PSYCHOLOGY ETHICS CODE

The APA Ethics Code is an intentional mix of aspirational principles and enforceable standards (Behnke, 2006) based on the recognition that psychological practice is fluid, evolving, complex, and inherently conflictual. The Code, by its very structure, forces us to recognize that many situations we face in everyday practice are not as straightforward or unambiguous as they may seem on the surface, so that our ethical thinking needs to be oriented not toward searching for the right way, but identifying the most important among the competing ethical values and coming to a reasonable next step.

Dr. A is a scientist-practitioner clinical psychologist in private practice. She completed her internship five years ago. Her training, in graduate school and after, emphasized evidence-based cognitive-behavioral treatments of anxiety, depression, and adjustment disorders, and she has done research on empirically supported behavioral treatment for the acute effects of trauma. She is new to the community where she practices and needs to build a practice that can sustain her family’s economic needs. She receives a referral from a colleague, involving a prospective adult patient with a history of incestuous abuse; the patient also has a history of major depression, past substance abuse, and complex family dysfunction. Dr. A has never treated a patient like this before, but the colleague assures Dr. A that, as a local trauma specialist, Dr. A is well positioned to treat this patient.

In thinking through the ethical questions the referral presents, Dr. A considers the aspirational principles that “[p]sychologists strive to benefit those with whom they work and take care to do no harm” (Principle A) and that “[p]sychologists exercise reasonable judgment and take precautions to ensure that...the boundaries of their competence, and the limitations of their expertise do not lead to or condone unjust practice” (Principle D). However, her ethical thinking begins, but does not stop, there. Taking account of her legitimate needs to develop her range of clinical expertise and earn a living, and her desire to serve the community in which she practices, she might then try to balance these aspirations with the standards that “[p]sychologists provide services...with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience” (Standard 2.01a) and “[p]sychologists take reasonable steps to avoid harming their clients/patients . . . and to minimize harm where it is foreseeable and unavoidable” (Standard 3.04) (American Psychological Association, 2002).

Dr. A is competent in and committed to using only EBPs, but she cannot assume from her research and clinical experience that an approach to chronic and complex trauma would parallel her experience working with acute trauma symptoms. Nor should she automatically preclude herself from taking on a referral where her background and interests situate her to be of valuable service to a patient in need. Possibilities for obtaining relevant additional training, consultation and supervision would need to be weighed.

The current version of the APA ethics code is crafted with practitioners’ realities and needs very much in mind (Behnke, 2004). If Dr. A uses ethical thinking to help orient and structure her self-assessment, including both strengths and limitations in her abilities, to treat the full spectrum of trauma-related and other problems in the patient who has been referred to her, she may find creative and ethical ways of balancing her aspirations to be of service and build a practice with the competing demands of required standards. For instance, if she is working in a region with a wide variety of available psychological resources, she may use the referral as an opportunity to build her network with clinicians in neighboring locales with experience and interest in the spectrum of trauma treatment, and consider either passing on the referral to a colleague more experienced with complex trauma or finding a supervisor to support her work with this patient. If Dr. A is practicing in an area where the prospective patient has few other treatment options, Dr. A may conclude that the requirement to minimize harm is best served by making her services available to the patient, while at the same time enlisting supports that could equip her to do a competent job and taking care to negotiate the patient’s informed consent.

INFORMED CONSENT

The APA ethics code makes at least four different references to the centrality of informed consent to our ethical thinking. Standard 3.10 specifies that the requirement to obtain informed consent extends across the full range of psychologists’ activities, needs to be communicated meaningfully and effectively, and needs to be documented. Standard 9.03 requires that the psychologist present informed consent, in diagnostic and testing situations, in a way that is candid, specific, confidential and thorough-going; in no way is this to be a pro forma procedure. Standard 10.01 requires that, with respect to therapy, psychologists have a proactive responsibility to address with patients in some depth the nature and process of treatment, alternatives to the proposed course of treatment, and potential risks as part of the process of obtaining truly informed consent. Standards 7 and 8 discuss ways informed consent applies to teaching, supervision, and research situations as well (American Psychological Association, 2002).

The APA ethics code makes provision for the inevitable difficulties that arise in applications in everyday professional life. There is guidance for what to do in emergencies, with minors whose parents hold their rights, with those incapable of giving consent, and with procedures that rely on necessary elements of deception and ambiguity. For example, while a practitioner of transference-based treatment would not be expected to “front load” a therapy with detailed information about the workings of this unconscious process, a general discussion of what the patient might anticipate would be indicated.

For EBPs only studied in laboratory settings with carefully controlled patient selection and treatment procedures, informed consent suggests the need to make this known to a patient being seen under different conditions in a community setting. In a professional climate that values the rapid dissemination of new discoveries, limitations on a treatment’s applicability to persons of specific ages, gender, sexual orientation, ethnicity, social class background, or disability status, which may not yet have been determined through adequate research, may also be discussed near the beginning of a proposed course of treatment.

Dr. B, a researcher-clinician, studies short-time psychodynamic psychotherapy for anxiety disorders. His part-time practice specializes in this treatment, and his expertise is known to colleagues and the public in the community in which he practices. The parents of an Asian-American early adolescent, who is dealing with the anxiety of coming out as gay, consult Dr. B. The parents are comfortable with their son’s emerging sexual orientation. They are interested in Dr. B treating their son because they believe that the prospect of treatment that offers a quick resolution of the young man’s anxiety will be most valuable to him. Dr. B does not have specific experience working with Asian-Americans or gay teenagers in the process of coming out, but he has worked with many persons of diverse ethnic and cultural backgrounds and with many adolescents. From what the parents tell him, he believes his approach has good chances of being helpful to the young man.

Dr. B is a member of his state psychological association. After receiving the initial inquiry from the parents, he seeks consultation from the association’s ethics committee to help him think through the issues he may confront in undertaking this treatment. Equipped with what he learns from this consultation, he sets up an initial meeting with the parents. While treating their request with empathy and projecting the confidence he feels in his treatment approach and skills, he is also candid with the parents about the limited research on the use of his method with Asian-Americans, and with gay males. He discusses with them alternative approaches they might consider and identifies local resources experienced in providing gay-affirmative therapy and working with Asian-Americans. He offers information about what can be expected to happen in the treatment approach he practices. He offers the parents a return appointment to discuss any questions or concerns they have, after they have a chance to consider with each other what he has explained to them.

Dr. B’s positive but nuanced approach to the parents’ request is respectful of the ethical considerations likely to present if the parents refer their son to him. He has considered the circumstances provided for in Standard 10.01b: “When obtaining informed consent for treatment for which generally recognized techniques and procedures have not been established, psychologists inform their clients/patients of the developing nature of the treatment, the potential risks involved, alternative treatments that may be available, and the voluntary nature of their participation.” (American Psychological Association, 2002). He is also modeling a considerate, thoughtful attitude that augurs well for his ability to build a productive therapeutic relationship with the young man and his family, and models values of autonomy, reflection, empowerment, and collaboration that will likely contribute to the effectiveness of the course of therapy being considered. continued

 

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