Ethics Committee Reports/Updates

March 2021

Behind closed doors: Therapeutic alliance and the ethics of political self-disclosure
Alex Keene, BA and Irina Gelman, PsyD

The contentious political climate in the United States has long been a source of distress, particularly for marginalized or oppressed communities. Distress associated with politics has a dramatic role in daily life and, necessarily, therapy. Impacts of political distress touch all areas of health addressed in the biopsychosocial-cultural model and have significant implications for clinical work (Hilty, 2015). Yet, an important question remains for many clinicians: Should politics be explicitly addressed in therapy? The 2016 presidential election triggered a significant emotional response. Fifty-seven percent of Americans surveyed shortly after the election endorsed politics as a major source of stress and roughly 49% tied their increased stress directly to the election, which suggests that there is some clinical value to openly exploring politics in therapy (Solomonov & Barber, 2018). In fact, 46% of participants in the same study described wishing politics were discussed more in therapy (Solomonov & Barber, 2018). However, the intensity of American political divisions has its own potential to affect the therapeutic alliance. News media sympathetic to post election anxiety often characterized therapy as a valid source of support while other outlets demonized therapy as a refuge for “snowflakes” who could not come to terms with the election results (Sointu & Hill, 2020). Therapists also operate within this milieu as cultural, social, and political beings impacted by political structures themselves. In some instances, therapists may feel inclined to self-disclose regarding their own political beliefs as a form of building rapport and joining with their clients, as they support their clients in managing politics-related stress. In the era of ‘Trump anxiety,’ mounting political distress, and division, how can therapists engage in ethical self-disclosure that centers their clients’ needs and improves therapeutic alliance (Gibson, 2012; Solomonov & Barber, 2018)? Shared experiences can be important for clients experiencing marginalization, can shape therapist usage of self-disclosure, and are of particular importance in times of political distress and oppression (Goode-Cross & Grim, 2014). This article seeks to examine the ethical implications of political self-disclosure.

The ethics of self-disclosure are important to consider as they can affect client outcomes and the quality of a working alliance. The strength of therapeutic alliance can be a key indicator of when to employ self-disclosure as stronger alliances have a positive correlation with clients’ experiences of therapist disclosures (Henretty & Levitt, 2010). Most therapists engage in some disclosure and scholars have identified two major subtypes: self-disclosing, or sharing information about therapists’ experiences outside of the therapy context, and self-involving, which includes sharing process-oriented observations or feelings about clients (Gibson, 2012). Though the latter type appears better received by clients, the research literature around political self-disclosure is still in its infancy (Gibson, 2012). With rising political self-disclosure, psychologists may consider reviewing guidance provided by the American Psychological Association’s code of ethics (APA, 2017). Standard 3.04 exhorts psychologists to avoid causing harm to clients, indicating that clinicians should maintain awareness of their own emotions and the risk of harmful disclosure due to political distress (APA, 2017). In addition, standard 3.06 calls on psychologists to consider whether their “objectivity, competence, or effectiveness” are affected by personal or other interests and to refrain from practicing in situations where there is a conflict between those interests and their duty as a psychologist (APA, 2017). This suggests that psychologists should be mindful of countertransference when clients disclose their beliefs and seek other avenues to support them if difference in political views may negatively impact the quality of care.

Solomonov and Barber (2018) provided several insights about these ethical considerations. They found that 64% of people surveyed discussed politics with their therapists. Participants were recruited through online listserves, websites, social media, and community clinics, and completed the survey online. Therapists’ implicit disclosure of political beliefs were perceived most positively, especially when disclosures revealed similarities in political views. Even in the absence of disclosures, the researchers found that clients regularly made assumptions about their therapist’s political views and a majority of Trump and Clinton supporters believed their therapists held similar views. These findings emphasize the significant need for greater psychologist competency when engaging with political topics in therapy. Knowing that many clients have discussed political distress in therapy and naturally make hypotheses about their therapist’s political beliefs, what are therapists’ experiences with this kind of self-disclosure? Psychologists are encouraged to review the ethics code section 2.01, “Boundaries of Competence” when considering engaging in these discussions (APA, 2017).

Solomonov and Barber (2019) found that therapists themselves endorsed engagement with political topics in therapy at a higher rate than clients. Eighty-seven percent of participating therapists, the majority of whom identified as White, reported discussing politics in session during the previous 3 weeks. Despite the frequency of their political discussions, few therapists reported explicitly disclosing political beliefs. Only 21% explicitly disclosed beliefs to clients, 37% did not disclose at all, and roughly 42% stated that clients could easily identify their views. Fifty-three percent of therapists indicated that clients disclosed their political views. However, the rate of mutual self-disclosure between clients and therapists varied significantly based on the perceived similarity or difference in their political affiliations. Barely 16% of therapists who believed their views diverged from their clients’ self-disclosed, compared to 50% of therapists who believed that they shared most of their clients’ political beliefs. Therapists perceived that political agreement in session had either a slightly (52% of responses) or highly (17% of responses) positive impact on the therapeutic alliance. Interestingly, 68% of therapists believed that in-session political disagreements had no influence on their therapeutic alliance. Therapist and client political affiliation were a determining factor of who experienced increased distress. Clinton-supporting therapists saw major increases in political discussions after the 2016 election but therapists who endorsed Trump did not. Clinton supporters with increased stress indicated that these discussions were helpful and Trump supporters, who did not experience an increase in stress, did not want more in-session political conversations.

Solomonov and Barber’s (2019) final sample was significantly less diverse than the US national population, which impacts the applicability of these results for the work of Black Indigenous and people of color (BIPOC) in therapy; 89% of surveyed therapists identified as Caucasian, 5% as Asian, 3% as African American, and 2% as American Indian. The overall psychology workforce in the U.S. is slightly more diverse and rapidly changing as more BIPOC psychologists join the profession. In 2015, 83.6% of psychologists identified as White, 5.3% as African American, 5% as Hispanic, 4.3% as Asian, and 1.7% identified as another ethnicity (APA, 2015). National demographics affect the availability of psychologists who share lived experiences of the mental health impacts of the Black Lives Matter civil rights movement or state discrimination against Latinx communities.

Several principles of the APA ethics code inform providers navigating ethical considerations of political self-disclosure. General principle A, Beneficence and Non-maleficence, calls psychologists to “strive to benefit” their clients and to “do no harm” while also being aware of their professional power and guarding against the misuse of their influence (APA, 2017). Using implicit or explicit political self-disclosure when one’s own views align with those of clients with experiences of political marginalization and increased distress may be a way to uphold this ethical principle. Psychologists must also consider the potential for self-disclosure to unintentionally pressure clients to agree with the therapist’s political views, and take great care to maintain a focus on client’s experiences. Furthermore, principle E, Respect for People’s Rights and Dignity, urges psychologists to limit the impact of bias on their work and to not knowingly participate in or condone activities of others based upon prejudice (APA, 2017). These principles call psychologists to build awareness of their biases and to remain attuned to serving their clients. They further require psychologists to not condone or participate in acts of prejudice during their work. This indicates that psychologists who hold privileged identities compared to clients should continue centering clients instead of justifying their own political beliefs or disclosing the impacts of current events on themselves. Finding balance in applying these principles during moments of self-disclosure also requires psychologists to develop an awareness of sociopolitical constructions of therapy.

Therapy remains a uniquely collaborative healing space that is as private as it is touched by the political climate. But what effect does the increasing polarization of news media have on the political construction of therapy and how clients may choose to engage with these spaces? Many in the US experienced the 2016 election as a political trauma and turned to therapy to address subsequent distress. The influx of first-time participants in therapy and progressive calls to examine national and personal values in post-electoral periods of crisis contributed to a shift for many in therapy from a space of individual introspection to a process of understanding connections with others and their purpose (Sointu & Hill, 2020). Through this process, individual therapeutic spaces grow into larger therapeutic communities that at their best can encourage transferring the lessons of individual attempts to enhance wellbeing to activism and shared political action. In contrast, conservative media and movements painted this political trauma as overblown and viewed seeking therapy as engaging in self-pity and indulging over-sensitivity or castigated it as weak and effeminate (Sointu & Hill, 2020). Psychologists and other clinicians must maintain an awareness of this context as they consider political conversations in therapy and ethical self-disclosure. Principles A, Beneficence and Non-maleficence, and E, Respect for People’s Rights and Dignity, offer the beginnings of a response to attempts to demonize seeking support. Principle A suggests that psychologists should seek to maintain therapy as a shared healing space and to work to reduce politicized mental health stigma. Principle E encourages psychologists to respond to rhetoric that dehumanizes communities by instead upholding their commitment to the dignity of their clients with particular attention to how this rhetoric and general political distress affect marginalized communities.

Ultimately, therapeutic practice has always been politicized as it connects clients and therapists who are both entangled in political systems. Psychologists must consider ethical obligations when responding to political polarization and distress in therapy. Changes in the trends of political distress or whether conservative clients may report greater distress in response to the 2020 election remains to be seen. However, political self-disclosure rooted in ethical practice appears to largely benefit clients and may be a critical area for increased practitioner competency.  

References

American Psychological Association. (2015).
          Demographics of the U.S. psychology workforce: Findings from the American Community Survey.
          https://www.apa.org/workforce/publications/13-demographics/report.pdf

American Psychological Association. (2017).
          Ethical principles of psychologists and code of conduct.
          https://www.apa.org/ethics/code/

Gibson, M. F. (2012). Opening up: Therapist self-disclosure in theory, research, and practice.
          Clinical Social Work Journal, 40, 287-296. https://doi.org/10.1007/s10615-012-0391-4

Goode-Cross, D. T., & Grim, K. A. (2014).
          “An unspoken level of comfort”: Black therapists’ experiences working with black clients.
          Journal of Black Psychology, 42(1), 29-43. https://doi.org/10.1177/0095798414552103

Henretty, J. R., & Levitt, H. M (2010).
          The role of therapist self-disclosure in psychotherapy: A qualitative review.
          Clinical Psychology Review, 30(1), 63-77. https://doi.org/10.1016/j.cpr.2009.09.004

Hilty, D. M. (2015). Advancing science, clinical care and education:
          Shall we update Engel’s biopsychosocial model to a bio-psycho-socio-cultural model?
          Psychology and Cognitive Sciences, 1(1), e1-e6. https://doi.org/10.17140/PCSOJ-1-e001

Sointu, E., & Hill, D. W. (2020).
          Trump therapy: Personal identity, political trauma and the contradictions of therapeutic practice.
          European Journal of Cultural Studies, 1-17. https://doi.org/10.1177/1367549420980007

Solomonov, N., & Barber, J. P. (2018).
          Patients’ perspectives on political self-disclosure, the therapeutic alliance,
          and the infiltration of politics into the therapy room in the Trump era.
          The Journal of Clinical Psychology, 74 (5), 779-787. https://doi.org/10.1002/jclp.22609

Solomonov, N., & Barber, J. P. (2019).
          Conducting psychotherapy in the Trump era: Therapists’ perspectives on political self-disclosure,
          the therapeutic alliance, and politics in the therapy room. https://doi.org/10.1002/jclp.22801


January 2021

Ethical Considerations in Clinical Psychology Graduate Admissions
Sophia Sbi, B.S., Len Kaufman, Ph.D., and the OPA Ethics Committee

Students have an undeniable impact on the culture, growth, and legacy of their professional graduate programs, the professional field, and the communities they ultimately serve (Fauber, 2006). Subsequently, admissions procedures are foundational in determining who will have such an impact, requiring judicious ethical attention and consideration. As the field of psychology currently stands, there is a significant underrepresentation of Black, Indigenous, and People of Color (BIPOC) and lower socioeconomic status (SES) groups in psychology graduate programs. Despite 13.4% of the U.S. population identifying as Black and 18.5% identifying as Latinx (Latino/Latina gender neutral), only 9.1% and 9.3% of graduate psychology students identify as Black and LatinX, respectively (Hamp et al., 2016; U.S. Census Bureau, n.d). The psychology workforce shows even greater disparity, with Black professionals representing only 3% and LatinX professionals only 7% of individuals employed as psychologists who have professional or doctoral degrees (American Psychological Association [APA], 2020). While racial/ethnic, cultural, and socio-economic diversity within academia is important for nurturing academic, moral, and interpersonal growth within the student body and training program as a whole (Gurin et al., 2002; Parker et al., 2016), Grapin et al. (2016) asserted that representation of diversity in the psychology workforce increases the likelihood that underrepresented groups will have their experiences appropriately recognized and attended to, and that a more inclusive body of mental health providers and researchers will tap into new perspectives and talent in a historically White-dominated field. This article aims to highlight important ethical issues to consider in the clinical psychology graduate admissions process so as to diversify the pool of clinical psychology graduate students and, ultimately, the field of clinical psychology.

Findings that low-income and BIPOC students face significant barriers and deterrents to enrollment in graduate programs come into conflict with Principle D: Justice of the APA Ethical Principles of Psychologists and Code of Conduct (hereafter referred to as the APA Ethics Code) (APA, 2017). The student loan debt crisis disproportionately burdening students of color, especially Black students (Houle & Addo, 2019), and the expectation of experience in the field prior to graduate school, such as volunteer research and clinical positions, or costly extracurricular activities, may not be reasonable for financially self-reliant students (Roberts & Ostreko, 2018). Such factors may not only undermine the applications of BIPOC and lower SES students, but also discourage these prospective students from applying to graduate psychology programs in the first place. Principle D: Justice of the APA Ethics Code states that psychologists will provide equal access to the contributions of psychology and equal allocation of processes, procedures, and services enacted by psychologists (APA, 2017);however, prospective students need to weigh their ability to meet costly admission criteria, as well as the cost of the program, against their financial circumstances. Pruitt and Isaac (1985) suggested that programs offering BIPOC and lower SES students teaching or research assistantships, fellowships, or work-study financial aid may mitigate financial barriers to enrollment while providing such students with valuable experience in the field. Roberts and Ostreko (2018) suggested that training programs should consider skills acquired through less directly-related experiences. Additionally, a program that can demonstrate cultural humility through diverse faculty, classes, and clinical opportunities that are aligned with issues relevant to their experiences (i.e., human diversity, racism, culture) are more likely to attract and retain underrepresented populations (Muñoz-Dunbar & Stanton, 1999). In service of Principle D: Justice, psychology programs should adopt a holistic admissions process, during which the emphasis on pre-screeners such as test scores and relevant experience is reduced, all applicants are reviewed, and factors such as applicants’ skill sets and character are prioritized to identify prospective students who are most likely to succeed in a clinical psychology training program (Roberts & Ostreko, 2018).

Historically, applicants to clinical psychology training programs need to submit letters of recommendation, a curriculum vitae, a personal essay, and their Graduate Record Examinations (GRE) scores as part of their applications. While performance on the GRE has been used to determine admission to clinical psychology training programs, the research on the usefulness of the GRE for predicting graduate school success is mixed (Dollinger, 1989; Goldberg & Alliger, 1992; Hall et al., 2017; Kuncel et al., 2001; Pruitt & Isaac, 1985), and standardized tests such as the GRE have been found to be biased against students from underrepresented groups (Dollinger, 1989; Miller & Stassun, 2014).This suggests that heavy reliance on the GRE in admissions may be misguided. The use of the GRE as an assessment measure, given its potential bias and questionable predictive validity, appears to conflict with Standard 9.02: Use of Assessments of the APA Ethics Code (2017), which states:

    1. Psychologists administer, adapt, score, interpret, or use assessment techniques, interviews, tests, or instruments in a manner and for purposes that are appropriate in light of the research on or evidence of the usefulness and proper application of the techniques.
    2. Psychologists use assessment instruments whose validity and reliability have been established for use with members of the population tested. When such validity or reliability has not been established, psychologists describe the strengths and limitations of test results and interpretation.

Additionally, the use of an assessment measure that may be biased against specific populations and may not suit its intended purpose, predicting graduate school success, may also conflict with Standard 9.08: Obsolete Tests and Outdated Test Results of the APA Ethics Code (2017), which states:

Psychologists do not base their assessment or intervention decisions or recommendations on data or test results that are outdated for the current purpose.

Use of GRE scores as a pre-screener for admission to clinical psychology graduate training programs despite potential bias, as well as possibly limited predictive validity poses ethical concerns, as admissions decisions rooted in psychometrically questionable assessment data are likely to limit access to education and career opportunities of capable BIPOC and lower SES applicants.

The interview stage of the graduate admissions process can also be a source of disproportionate burden and deterrence to underrepresented populations. Applicants from lower income backgrounds may not be able to take time off work or afford travel costs and possibly childcare, among other financial barriers, to feasibly attend an interview in-person (Roberts & Ostreko, 2018). Due to the current COVID-19 pandemic, there has been a dramatic shift in the field’s use of telecommunication resources. Carrying the accessibility benefits of online platforms forward through offering interviews in video formats could reduce admissions barriers. for students from lower SES backgrounds (Roberts & Ostreko, 2018).

The field of clinical psychology works to strike a balance between an emphasis on individual factors and the use of empirically supported measures, and all admissions policies and procedures need to exemplify this balance. An entirely scientific approach to admissions and enrollment procedures will continue to perpetuate systemic racism, classism, and oppression. An entirely humanistic, individualistic approach will likely be impractical and expensive. However, a balanced, holistic admissions model is consistent with the APA Ethics Code. In order to create more inclusion in psychology training programs, admissions committees need to consider application costs, skills acquired through less directly related experiences and overall skill sets, character, and personality characteristics.  Training programs may choose to offer a broader range of opportunities for financial support, greater diversity in clinical experiences, and faculty more representative of the student population they seek to attract. The OPA Ethics Committee may be helpful in helping a program consider these complicated ethical issues and move toward a more ethical, inclusive admissions process. We encourage readers to consult with the OPA Ethics Committee for support in considering these, and other, difficult ethical issues.

References

American Psychological Association. (2016, December 1).
          Summary Report, Graduate Study in Psychology 2017: Student Demographics.
          http://www.apa.org/education/grad/survey-data/2017-student-demographics

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct.
          http://www.apa.org/ethics/code/

American Psychological Association. (2020). Demographics of U.S. psychology workforce
          [Interactive Data Tool].
          https://www.apa.org/workforce/data-tools/demographics.aspx

Dollinger, S. J. (1989). Predictive validity of the Graduate Record Examination in a
          clinical psychology program. 
          Professional Psychology: Research and Practice20(1), 56.

Fauber, R. L. (2006). Graduate admissions in clinical psychology: Observations on the present and
          thoughts on the future. Clinical Psychology: Science and Practice13(3), 227-234.
          https://psycnet.apa.org/doi/10.1111/j.1468-2850.2006.00029.x

Goldberg, E. L., & Alliger, G. M. (1992). Assessing the validity of the GRE for students in psychology:
          A validity generalization approach. Educational and Psychological Measurement, 52(4), 1019-1027. 
          https://psycnet.apa.org/doi/10.1177/0013164492052004026

Grapin, S. L., Bocanegra, J. O., Green, T. D., Lee, E. T., & Jaafar, D. (2016).
          Increasing diversity in school psychology: Uniting the efforts of institutions, faculty, students,
          and practitioners. Contemporary School Psychology, 20(4), 345-355.
          https://doi.org/10.1007/s40688-016-0092-z

Gurin, P., Dey, E., Hurtado, S., & Gurin, G. (2002). Diversity and higher education:
          Theory and impact on educational outcomes. Harvard Educational Review, 72(3), 330-367.
          https://doi.org/10.17763/haer.72.3.01151786u134n051

Hall, J. D., O’Connell, A. B., & Cook, J. G. (2017).
          Predictors of student productivity in biomedical graduate school applications.
          PLoS ONE, 12(1), e0169121.
          http://dx.doi.org/10.1371/journal.pone.0169121

Hamp, A., Stamm, K., Lin, L., & Christidis, P. (2016). 
          2015 APA survey of psychology health service providers. American Psychological Association.
          http://www.apa.org/workforce/publications/15-health-service-providers/index

Houle, J. N., & Addo, F. R. (2019). Racial disparities in student debt and the reproduction of the 
          fragile black middle class. Sociology of Race and Ethnicity, 5(4), 562-577.
          https://doi.org/10.1177%2F2332649218790989

Kuncel, N. R., Hezlett, S. A., & Ones, D. S. (2001).
          A comprehensive meta-analysis of the predictive validity of the Graduate Record Examinations:
          Implications for graduate student selection and performance. 
          Psychological Bulletin127(1), 162-181.
          https://doi.org/10.1037/0033-2909.127.1.162

Miller, C., & Stassun, K. (2014). A test that fails. Nature, 510(7504), 303-304.
          https://doi.org/10.1038/nj7504-303a

Muñoz-Dunbar, R., & Stanton, A. L. (1999). Ethnic diversity in clinical psychology: 
          Recruitment and admission practices among doctoral programs. 
          Teaching of Psychology26(4), 259-263. 
          https://psycnet.apa.org/doi/10.1207/S15328023TOP260403

Parker III, E. T., Barnhardt, C. L., Pascarella, E. T., & McCowin, J. A. (2016).
          The impact of diversity courses on college students' moral development.
          Journal of College Student Development, 57(4), 395-410.
          https://psycnet.apa.org/doi/10.1353/csd.2016.0050

Pruitt, A., & Isaac, P. (1985). Discrimination in recruitment, admission, and retention of minority 
          graduate students. 
          The Journal of Negro Education, 54(4), 526-536. doi:10.2307/2294713

Roberts, M. C., & Ostreko, A. (2018). GREs, public posting, and holistic admissions for diversity in
          professional psychology: Commentary on Callahan et al. (2018). 
          Training and Education in Professional Psychology, 12(4), 286–290. 
          https://doi.org/10.1037/tep0000219

U.S. Census Bureau. (n.d.).U.S. Census Bureau QuickFacts: United States.  U.S. Department of Commerce.
          https://www.census.gov/quickfacts/fact/table/US/RHI125219#RHI125218


November 2020

Reviewing Limits to Confidentiality in Telepsychology Practice
Nichole Sage, PsyD, and the OPA Ethics Committee

The COVID-19 pandemic prompted a rapid shift to telepsychology practices for psychologists. This allowed for continuity of care and flexibility in treatment services amid the crisis. Nationwide, approximately 76% of psychologists were providing telepsychology services by late spring of this year in response to stay-home orders (American Psychological Association, 2020a). Telepsychology was fairly rare as a practice mode pre-pandemic, with just 7% of psychologists reporting virtual service delivery (Pierce et al., 2020). Considering the relatively low rates of active telepsychology practices prior to the pandemic, this new practice format was perhaps unfamiliar and initially unintuitive. Resources, time, and energy were likely required to learn new software and procedures. In the chaos of this transition, important elements of clinical practice may have been overlooked or forgotten as psychologists adjusted to new routines. One such element may have been the review and discussion of the limits to confidentiality typically conducted at the outset of treatment. This article is intended as a reminder of this important step and to highlight relevant issues when discussing the limits to confidentiality in telepsychology practice.

Reviewing informed consent at the start of the therapeutic relationship is an essential action that sets the stage for the clinical relationship and reduces legal and ethical risks. This process is highlighted in the American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct (hereafter referred to as the APA Ethics Code) Section 4.02 (Discussing the Limits of Confidentiality) as an ethical imperative. The code reads as follows:

(a) Psychologists discuss with persons (including, to the extent feasible, persons who are legally incapable of giving informed consent and their legal representatives) and organizations with whom they establish a scientific or professional relationship (1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities. (See also Standard 3.10, Informed Consent.)
(b) Unless it is not feasible or is contraindicated, the discussion of confidentiality occurs at the outset of the relationship and thereafter as new circumstances may warrant.
(c) Psychologists who offer services, products, or information via electronic transmission inform clients/patients of the risks to privacy and limits of confidentiality.(American Psychological Association, 2017, Standard 4.02)

Whereas the safeguarding of client confidentiality may be obvious to clinicians, the expectation of reviewing confidentiality with clients at the outset of therapy might be less recognized. According to the APA Ethics Code, in addition to the duty to protect client confidentiality (APA Ethics Code Section 4.01; American Psychological Association, 2017), it is the ethical obligation of each psychologist to review the limits to confidentiality at the outset of treatment (and thereafter whenever it is indicated). This must occur whether the service occurs in-person or virtually. Included below are considerations and actions clinicians may take to address limits to confidentiality in telepsychology practice.

First, it is important for psychologists to be knowledgeable about how telepsychology services are ethically unique relative to traditional office appointments. Although the majority of clinicians offering telepsychology services report feeling knowledgeable and confident (75% and 78%, respectively) about the use of telepsychology software (American Psychological Association, 2020a), the level of awareness regarding security issues affecting confidentiality and privacy is less clear. It is essential for clinicians to recognize and understand security vulnerabilities, patient data storage and maintenance issues, therapist-client electronic communication challenges, and potential differences in billing procedures or documentation (American Psychological Association, 2013). A solid understanding of any laws pertinent to telepsychology, such as limitations to service provision only within one’s state of licensure, is also necessary to reduce liability and ensure ethical practice (for more information see the Oregon’s Board of Psychology’s 2015 article on Telepsychology [Oregon Board of Psychology, 2015]). This foundational knowledge of the potential ethical issues associated with telepsychology practice will allow practitioners to thoroughly outline these considerations for clients and respond to questions that arise.


Further complicating matters is the fact that many psychologists are currently working remotely from their own homes for social distancing purposes, perhaps without having a well-planned space for telepsychology. Working from one’s home may pose challenges with boundaries as well as privacy for both client and psychologists. According to Drum and Littleton (2014), careful consideration of potential boundary issues in telepsychology is important, as clients and therapists may not have a well-developed schema for navigating virtual boundaries. Additional considerations with respect to boundary issues may manifest in unexpected or new ways relative to traditional in-person therapeutic work. Reviewing expectations for privacy and limits to confidentiality at the outset of the therapeutic relationship sets the tone for therapy, while scaffolding appropriate boundaries minimizes potential boundary crossings or violations. Moreover, highlighting these ethical considerations with clients at the initial meeting can foster a sense of trust and enhanced therapeutic sharing on the part of the client.

Aside from reviewing the traditional elements of limits to confidentiality, psychologists may address telepsychology-specific confidentiality concerns with clients. Clinicians may consider providing appropriate information to the client about the level of privacy in the therapist’s home office. For example, is the therapist working behind closed doors? Does the therapist use headphones to prevent transfer of noise through the computer, or is there a white noise machine to drown out the therapist’s comments and questions? Because clients cannot view beyond the space captured by the camera, they are unable to feel assured that the space is private. As such, the psychologist should consider describing these aspects of the therapeutic environment to reassure clients and offer the opportunity for questions about privacy and confidentiality.

Clinicians may also consider initiating a discussion about protecting a client’s privacy within the client’s home. Education about the importance of confidentiality for effective clinical work and concerns about compromised confidentiality from within the client’s personal space or elsewhere may be useful. If clients engage in sessions in multiple places (e.g., home, office, vacation house), it may be helpful to inquire about the privacy of the client’s physical location at the start of each virtual session to confirm a confidential space. A discussion about how to respond if service is disrupted, how long to wait before making a re-attempt at connection if service is interrupted, and planning for whether the psychologist or client will initiate the call, may also be prudent. Additionally, the concept of confidentiality is rooted in values of the Western world and may be regarded differently across cultures. A culturally sensitive conversation about the client’s views related to privacy may foster better understanding and ethical decision-making about creating and maintaining confidentiality in telepsychology sessions.

It is never too late to improve one’s ethicality in any facet of clinical practice, particularly for telepsychology, should rates of telehealth practices maintain. For a comprehensive guide on telepsychology practice, readers are referred to the American Psychological Association Guidelines for the Practice of Telepsychology (American Psychological Association, 2013). The American Psychological Association (2020b) has also released an informed consent checklist for telepsychology services for practitioner reference.

Finally, psychologists should develop a telepsychology-specific informed consent document and utilize this form as the blueprint for the verbal review of the limits to confidentiality in the initial appointment with new telepsychology clients (Jacobs, 2018). Consultation with a mental health attorney or other qualified professional may be necessary for ensuring that the consent form is comprehensive and legally sound. Since the start of the pandemic, the OPA Ethics Committee has received multiple calls regarding telepsychology and we are proud to serve our psychological community in these stressful and confusing times. We encourage readers to reach out for consultation about ethical dilemmas concerning telepsychology or beyond.

References

American Psychological Association. (2013). Guidelines for the practice of telepsychology. 
          https://www.apa.org/practice/guidelines/telepsychology

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct
          (2002, amended effective June 1, 2010, and January 1, 2017). 
          https://www.apa.org/ethics/code/

American Psychological Association. (2020a).
          Psychologists embrace telehealth to prevent the spread of COVID-19.
         
https://www.apaservices.org/practice/legal/technology/psychologists-embrace-telehealth

American Psychological Association. (2020b). Informed consent checklist for telepsychological services.
          https://www.apa.org/practice/programs/dmhi/research-information/informed-consent-checklist

Drum, K. B., & Littleton, H. L. (2014). Unique issues and best practice recommendations. 
           Professional Psychology, Research, and Practice, 45 (5), 309-315.

Jacobs, J. (2018). Managing risks of telepsychology. The National Psychologist.
          https://nationalpsychologist.com/2018/08/managing-risks-of-telepsychology/104807.html

Oregon Board of Psychology. (2015). Telepsychology
           https://www.oregon.gov/psychology/Documents/Newsletter_Summer_15.pdf

Pierce, B. S., Perrin, P. B., Tyler, C. M., McKee, G. B., & Watson, J. D. (2020).
           The COVID-19  telepsychology revolution:
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September 2020

Navigating Client Racial Prejudice in the Assessment and Therapy Room
Brandt, A. S. & Hill, E.

Racism is pervasive in our society and antithetical to the American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct (2017), hereafter referred to as the APA Ethics Code. While our field emphasizes the importance of addressing our own racial biases to ensure ethical professional work, little discussion exists in the literature regarding how to respond to client racial bias. In this article, we discuss ethical considerations for navigating client racial prejudice that arises in the context of psychological care as well as review the scant literature on this topic.

The General Principles of the APA Ethics Code (2017), which “guide and inspire psychologists toward the very highest ethical ideals of the profession,” state that psychologists have a duty to be “aware of and respect” individual differences, including ethnicity/race, and “do not knowingly participate in or condone activities of others based upon such prejudices” (Principle E: Respect for People’s Rights and Dignity, p. 3). However, determining the most ethical course of action when a client makes a prejudiced statement—racial or otherwise—is not addressed in the APA Ethics Code. In these instances, our duty to uphold a client’s right to “self-determination” (Principle E: Respect for People’s Rights and Dignity, p. 4) and respect their worldview may be in conflict with our “professional and scientific responsibilities to society” (Principle B: Fidelity and Responsibility, p. 3) and the Principle of Justice (Principle D). As Principle A, Beneficence and Nonmaleficence, states, “psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons” (p. 3). Meta-analytic research has established that experiencing racial prejudice is associated with a myriad of negative psychological outcomes, including increased distress, depression, anxiety, substance use, and suicide risk, as well as decreased life satisfaction (Lui & Quezada, 2019), among other negative sequalae; thus, racial prejudice is not innocuous. As psychologists, how do we weigh our obligations to an individual client against society, and “resolve these conflicts in a responsible fashion that avoids or minimizes harm” (Principle A, p. 3)?

In general, there is a dearth of published literature on whether and how psychologists should address client prejudice—racial or otherwise. Commonly discussed clinical considerations in the literature include:

  • Quality of and threat to the therapeutic relationship (Bartoli & Pyati, 2009; King, 2014; Mbroh, Najjab, Knapp, & Gottlieb, 2020)
  • Relevance to a client’s presenting concerns (Bartoli & Pyati, 2009; King, 2014)
  • Clinical context (e.g., short-term stabilization of a suicidal or psychotic client in an inpatient facility versus a long-term outpatient therapy client; Mbroh et al., 2020)
  • Likeliness of intervention success/client’s readiness to change (Bartoli & Pyati, 2009; King, 2014; Mbroh et al., 2020)
  • Psychologists’ motivations for intervening or not intervening (e.g., potential therapeutic benefits, desire for retaliation; Bartoli & Pyati, 2009; King, 2014)

A psychologist’s own racial identity may be another important consideration. To date, published literature on the experiences of client racism among BIPOC (Black, Indigenous, and People of Color) mental health providers is lacking. To the authors’ knowledge, only two such publications exist, a book chapter titled, “When Racism Is Reversed: Therapists of Color Speak about their Experiences with Racism from Clients, Supervisees, and Supervisors,” and a qualitative study of eight BIPOC counselors (seven Black, one Southeast Asian). In the former, one author described their experience of being “thrown off” their “professional balance” and feeling vulnerable when clients made racist comments, as well as being unsure how to respond (Ali et al., 2005). In the latter publication, Branco and Bane (2020) identified qualitative themes related to BIPOC counselor experiences of “bracing and buffering” in response to or anticipation of racist client statements as well as “intrusions” of microaggressions on treatment and the therapeutic relationship, with covert bias being more common that overt racist statements.

In the face of client racial prejudice, depending on the nature of the comments and the psychologist’s own racial identity and life experiences, it may be difficult for them to remain unbiased towards the client, which could impair competence (Code 2, “Competence”). In many cases, consultation, while maintaining client confidentiality (Codes 4.01, 4.05, 4.06), may be warranted for weighing conflicting ethical obligations, exploring personal reactions to the client’s specific statements, and determining a course of action that avoids and minimizes harm to the client (Code 3.04, “Avoiding Harm”) and others. While having a reaction to racist statements is hardly a “personal problem,” but, rather, an understandable and normal response to prejudice, Code 2.06 “Personal Problems and Conflicts” may still be relevant. This Code states, “When psychologists become aware of personal problems that may interfere with their performing duties adequately, they take appropriate measures, such as obtaining professional consultation.”

In rare cases, if continued services could be expected to cause the client or others harm (Code 3.04, “Avoiding Harm”), the psychologist might determine the most ethical course of action is to terminate services (Code 10.10a) and “suggest alternative service providers” (10.10c). The psychologist might also decide to terminate services if, based on the nature of the comments and their own identity, they feel “threatened or otherwise endangered by the client” (Code 10.10b). However, while termination of services might be in the best interest of a client at times, or warranted if a psychologist feels threatened, it might also be considered discrimination related to the client’s beliefs (Code 3.01 “Unfair Discrimination”), and cessation of services could result in harm to the client (Code 3.04).

Moreover, addressing a client’s racial prejudice in the context of psychological care— rather than ignoring biased comments or choosing to not work with the client—may not only have benefits for society, but benefits for the individual client. In psychological treatment, we often explore and challenge a client’s false beliefs that may be harming the client or contributing to their personal and interpersonal challenges. Racial prejudice, being generalized preconceived notions of an entire racial/ethnic group that is not based upon reason, represent faulty beliefs. Thus, intervening when a client makes racially prejudiced statements may be therapeutically indicated in many cases.

Whether and how mental health professionals respond to client racial bias is understudied. To the authors’ knowledge, only two studies have been conducted on this topic. Most recently, in Branco and Bane’s (2020) secondary qualitative analysis of interviews with eight BIPOC counselors, three main responses were identified: reframing or redirecting the client, trying to understand the client within the context of their worldview, or directly responding to the racist statement. Counselors considered likelihood of success and relevance to presenting problems, given client’s racial identity and awareness, when determining whether to address racism comments. Relatedly, in a small, mixed-methods study among 17 primarily White clinical and counseling psychologists, King (2014) found that reactions to racist comments by White clients in the context of therapy ranged widely and were motivated by various client, relational, and psychologist factors. When a client made a racist comment in therapy, some psychologists reported challenging or disagreeing with the statement, while others described exploring the comment further; still others described ignoring the comment completely or changing the subject. With regards to motivations for addressing or not addressing prejudiced statements, psychologists described several client factors, including client vulnerability or readiness to change and relationship contextual factors, such as level of rapport and power and identity differences within the relationship, as well as psychologist factors, including personal values related to client autonomy or anti-racism, theoretical orientation, and self-doubt regarding one’s abilities to effectively address the issue.

While there remains a lack of research on best practices when faced with client racism, a recent theoretical article on this topic presents five useful general guidelines to assist in navigating ethical dilemmas, which they apply to determining whether and how to address all types of client prejudice that arise in psychological treatment (Mbroh et al., 2020). First, they recommended that psychologists generally remain up-to-date on psychological literature as a means of being “proactive in their ethical decision making and approaches to navigating ethical dilemmas” (p. 288; “Education”). They also advised weighing the costs and benefits of various decisions by “considering all the potential consequences” of an intervention (“Application of Knowledge”). In the case of client prejudice, one might consider, “Could addressing these beliefs bring about any positive changes in the patient’s life or for society?” (p. 289). Mbroh and colleagues also encouraged “Self-Reflection,” or examining one’s motives. They asserted that psychologists should consider whether the goals of an intervention “are both realistic and directly related to the benefit of the patient and society and not merely for the psychologist’s own benefit,” such as an “unconscious goal of retaliation” (p. 289). “Consultation” is another recommendation, which they highlighted as particularly important if a psychologist’s emotional response to a client’s prejudiced comment could impair their work with the client. Finally, the authors described a three-pronged “Intervention,” emphasizing the importance of a collaborative, non-confrontational approach. First, they recommended that psychologists empathize with the emotions behind the client’s comment. This serves to promote the client’s ability to remain open when the psychologist next challenges the belief by creating dissonance between a client’s beliefs and their goals, or highlights how a client’s beliefs may negatively impact their relationships. In the final step, psychologists invite the client to explore the origins, accuracy, or emotions related to their beliefs. Through this process, psychologists can challenge a client’s problematic beliefs and validate their emotions without supporting the prejudice, and “provide an open environment to explore these beliefs if the patient is willing” (p. 289).

Ultimately, as psychologists, we are tasked with minimizing harm when “conflicts occur among psychologists’ obligations” (Principle A: Beneficence and Nonmaleficence; p. 3), as may be the case when a client makes a racially prejudiced comment in the course of assessment or treatment. There are many considerations regarding whether and how to address client racial prejudice based on client, psychologist, and therapeutic relationship factors. However, with thoughtful consideration of relevant ethical and clinical issues, and use of the clinical tools at our disposal for helping clients examine unhelpful thoughts and behaviors, encountering client racial prejudice in treatment is also an opportunity to foster positive change for individual clients as well as society.

References 

Ali, S. R., Flojo, J. R., Chronister, K. M., Hayashino, D., Smiling, Q. R., Torrest, D. & McWhirter, E. H. (2005). When racism is reversed. In M. Rastogi & E. Wieling (Eds.), Voices of color: First-person accounts of ethnic minority therapists (pp. 117-134). Thousand Oaks, CA: Sage Publications.

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2001, amended effective June 1, 2010 and January 1, 2017). www.apa.org/ethics/code/

Bartoli, E., & Pyati, A. (2009). Addressing clients’ racism and racial prejudice in individual psychotherapy: Therapeutic considerations. Psychotherapy: Theory, Research, Practice, Training, 46(2), 145-157.  https://psycnet.apa.org/doi/10.1037/a0016023

Branco, S. F., & Bayne, H. B. (2020). Carrying the burden: Counselors of color’s experiences of microaggressions in counseling. Journal of Counseling & Development98(3), 272-282. https://doi.org/10.1002/jcad.12322

King, M. (2014). What do clinicians do? Addressing white clients' racist comments in the therapy room (Unpublished doctoral dissertation).Southern Illinois University at Carbondale.

Lui, P. P., & Quezada, L. (2019). Associations between microaggression and adjustment outcomes: A meta-analytic and narrative review. Psychological Bulletin145(1), 45-78. https://psycnet.apa.org/doi/10.1037/bul0000172

Mbroh, H., Najjab, A., Knapp, S., & Gottlieb, M. C. (2019). Prejudiced patients: Ethical considerations for addressing patients’ prejudicial comments in psychotherapy. Professional Psychology: Research and Practice, 51(3), 284–290. https://psycnet.apa.org/doi/10.1037/pro0000280