Prudence Cuper, MA, and Erica Wise, PhD
What complex ethical dilemmas can occur in training programs when a student’s personal values conflict with program values?
Leo recently completed his second year in a clinical psychology doctoral program. In his first year, he finished required coursework in psychotherapy and assessment, and since the fall semester he has been providing therapy to clients from the community in his practicum placement at the program’s Psychology Training Clinic. Several months into the practicum year, Leo’s supervisor, Dr. J., observed that Leo’s personal views seemed to be interfering with his approaching client concerns in an open and supportive fashion. This was particularly evident in the critical stance he assumed when discussing non-heterosexual relationships. In reviewing videos of counseling sessions, Dr. J. noted that Leo tended to be less supportive of two of his clients: an 18-year-old male college student who wondered if he might be gay, and a young adult lesbian who was deciding whether to come out to her family. Leo’s peers noticed his judgmental stance as well and they challenged him during group supervision. Leo responded that certain behaviors were simply “never proper” and that it falls to the therapist to point this out to clients.
Early in the year, Dr. J. attempted to discuss his observations directly with Leo, reminding Leo that the program endorsed non-discrimination as an underlying value and that the training clinic explicitly welcomed diverse clients and offered LGBTQ affirmative services. He also warned Leo that, according to the program’s policy, a failure to respect client diversity could result in remedial action. Leo responded that he always strives to behave in accordance with his personal beliefs, which are shared by his family and church. He argued that the training program should not regulate his beliefs and suggested that the largely liberal faculty were discriminating against him. When a written mid-year evaluation reflected concern about the impact of Leo’s conservative value system and rigid beliefs on the treatment of diverse clients in the training clinic, Leo maintained that he felt it important to live and work by his own values. Because he continued to show bias toward certain clients, they were eventually transitioned to other therapists.
At the end of the year, Dr. J. and the training committee met to discuss Leo’s case. They decided that Leo had not fulfilled the requirements of the practicum rotation, and they failed to give him course credit. Further, they decided that Leo would need to undergo remediation in order to remain in the program. The remediation plan stated that Leo must meet with the program’s training director to discuss whether he would be willing to modify his approach to working with diverse clients and to determine specific behavioral changes that he would need to make when conducting therapy. Additionally, the committee suggested that the training director and Leo talk about the possibility of Leo seeking psychotherapy himself to address his discomfort with non-heterosexual relationships. Due to issues of confidentiality and ambiguity about what would constitute successful treatment, psychotherapy would be optional.
The current scenario raises ethical questions on two fronts: (1) Leo’s interactions with clients, and (2) the committee’s failure to give credit for the practicum and their decision to require that Leo make behavioral changes as a condition for remaining in the program.
Does Leo’s Behavior Violate Ethical Principles or Standards?
Leo’s attitudes and behavior can be examined through the lens of the General Principles of the Ethical Principles of Psychologists and Code of Conduct (APA, 2002), the non-enforceable rules meant to guide psychologists’ conduct. Leo’s attitudes and behavior can also be analyzed for their adherence or non-adherence to specific Ethical Standards. All of the general principles hold some relevance for this case, but for the sake of brevity, the current discussion will focus on Principle A, Beneficence and Nonmaleficence, and Principle E, Respect for People’s Rights and Dignity.
As Tjelveit (2006) points out, when client and therapist values conflict, a therapist may need to balance Principle A with Principle E. In striving to help a client attain a “good life,” a well-meaning clinician may find himself imposing his own ideas of “good” on the client. “Paternalism…occurs when a professional’s ideas about what is good for a client (beneficence) trump the client’s choice about the treatment provided or the therapeutic goals to be pursued” (p. 188). We would argue that in this vignette, Leo’s attempt to “benefit” his clients by guiding them away from “improper” behavior (in this case, same-sex relationships) undermines clients’ autonomy and is likely to cause harm to clients who are seeking balanced and non-judgmental assistance. The problem lies not in Leo’s own conservative values, but in his rigidity and lack of respect for and validation of other perspectives.
If Leo were to pursue a career treating clients with values similar to his own and referred clients with dissimilar values to other clinicians (as per Standards 2.01 and 5.01, Boundaries of Competence and Avoidance of False or Deceptive Statements), would Leo’s behavior be consistent with the general principles of the ethics code? Arguably, this “informed consent and referral” solution would provide some protection to potential clients as they make a decision whether or not to seek psychological services from Leo. There are, however, several problems with this potential solution. First, professional psychology has taken a strong stand in support of embracing diversity and affirmative psychotherapy. This position is reflected in the APA Ethics Code and in the accreditation standards for training programs. Second, allowing Leo to practice as a non-affirming psychologist might have a broader impact on society. In the Preamble to the Ethics Code, psychologists are advised to use their scientific and professional knowledge to “improve the condition of individuals, organizations, and society” (p. 3). If Leo were to promulgate prejudiced attitudes or discriminatory behaviors in either public statements or private practice, there would be the potential for a detrimental impact on society. Arguably, what happens in therapy can and should meaningfully impact society by, for example, illuminating and (when possible) reducing power differential- based factors such gender, race, socioeconomic status, ability, or sexual orientation. While many psychologists believe that we have a responsibility to improve society, this position has been most clearly articulated by the feminist psychologists in the maxim that the “personal is political” (Brown, 2006).
Did the Training Committee Behave Ethically in Requiring Remediation?
The program clearly has reservations about Leo’s competence and adherence to ethical standards. For example, the training committee members would have cause for concern about a violation of the standard of Unfair Discrimination (3.01) in Leo’s denigration of same-sex relationships. Similarly, they might cite his noncompliance with Standard 2.04, Bases for Scientific and Professional Judgments. The question, then, is whether the committee’s actions were ethical, or whether they themselves discriminated against Leo. For guidance on this issue, we look to APA’s Guidelines and Principles for Accreditation of Programs in Professional Psychology (APA, 2000), as well as to the Ethical Standards.
The Guidelines state that a program should “indicate respect for and understanding of cultural and individual diversity as reflected in its recruitment and retention policies” for students as well as faculty. The Guidelines also clearly state that accredited programs must train students to respect diversity among their clients and to inform their clinical practice with psychological science and empirically-supported procedures. The training committee found itself in the difficult position of evaluating a student whose values, influenced by culture and religion, impeded the student’s ability to comply with ethical standards as prescribed by the APA. While it is true that if Leo were a client, a therapist treating him would respect his beliefs, it is also true that the role of psychologist as endorsed by the APA carries with it the responsibility to respect the values and choices of individuals of varying backgrounds and to base judgments about client outcomes on science whenever possible.
The Ethical Standards describe how transactions between programs and students are expected to take place. Standard 7.06, Assessing Student and Supervisee Performance, states that: (1) supervisors use a “timely and specific process” for evaluating students, and that students get information about the process at the beginning of supervision; and (2) students are evaluated on “relevant and established program requirements.” Dr. J. adhered to the standards by discussing Leo’s approach to human relations as early as feasible in the training process, so that there was ample opportunity for Leo to remediate unacceptable behavior. Additionally, Dr. J. reminded Leo of the program’s guidelines regarding expectations for working with clients whose values and life choices might be inconsistent with his own, and he informed Leo of the consequences of failing to meet those expectations.
The Guidelines for Accreditation state that training programs are expected to make training values explicit in publicly available information to assist prospective students in their selection of a training program. If the program had failed to do this, Leo could argue that he was not given sufficient notice of the expectations of the program in terms of respect for diversity or adherence to humanitarian values. On the other hand, when program values are clearly explicated in advance and a “timely and specific process” is in place for evaluating and remediating students, programs are on solid ground when they disallow the behavior of students who impose religious or other values on clients.
This article was originally published in the North Carolina Psychologist.
Prudence Cuper, MA, lives in Durham, North Carolina, where she is enrolled in the clinical psychology doctoral program at Duke University. She is currently working on her dissertation research, which examines the relationship between fantasy proneness, attention and mood.
Erica Wise, PhD, is Clinical Associate Professor in the Department of Psychology at the University of North Carolina-Chapel Hill, where she also serves as Director of the Psychology Training Clinic. She has served as a Chair of the APA Ethics Committee and a member of the Committee on Professional Practice and Standards. Dr. Wise is former chair of the NC Psychology Board and currently the NC Representative to the APA Council. She is also a former member of the National Register Board of Directors and former Chair of the National Register Committee on Professional Practice and Ethics (COPPE).
American Psychological Association. (2002). Ethical Principles of Psychologists and code of conduct. American Psychologist, 57, 1060-1073.
American Psychological Association. (2000, January 1). Guidelines and Principles for Accreditation of Programs in Professional Psychology. Retrieved June 8, 2009, from http://www.apa.org/ed/gp2000.html.
Brown, L. S. (2006). Still subversive after all these years: the relevance of feminist therapy in the age of evidence-based practice. Psychology of Women Quarterly, 30, 15-24.
Tjelveit, A. C. (2006). To what ends? Psychotherapy goals and outcomes, the good life, and the principle of beneficence. Psychotherapy: Research, Practice, Training, 43, 186-200.