November 2022

New Frontiers in Mental Health Treatment: Ethical Implications
of Oregon’s Psilocybin Services Act and Its Emerging Implementation

Darcy Gist Zornes, MA, MEd; Len Kaufman, PhD; & OPA Ethics Committee

Each year, Mental Health America publishes a report with rankings based on prevalence of mental illness and rates of access to care across all 50 states and the District of Columbia. The most recent 2023 report presented sobering statistics for the state of Oregon, which ranked #51 for youth and #48 for adults, highlighting that many people in our state are struggling with unmet mental health needs (Ranking Guidelines 2023, n.d.). Undoubtedly, these challenges have been exacerbated by the COVID-19 pandemic over the past 2.5 years. Oregon faces a dire need to find improved solutions to address this crisis, alleviate suffering, and support improved well-being. One such proposed solution is psychedelic-assisted therapy, specifically psilocybin-assisted therapy. 

Psilocybin: A Brief Overview
The term psychedelic, with Greek origins that roughly translate to “mind” (psyche) “manifesting” (delos),was coined in 1956 by English psychiatrist Humphrey Osmond, a pioneer of drug-assisted therapies who conducted research on hallucinogenic drugs as treatment for alcohol dependence (Lowe et al., 2021). Broadly, hallucinogens are psychoactive substances–natural or synthetic–that induce alterations of consciousness, perceptions, cognitions, and emotions, profoundly affecting one’s internal processes and perception of the world around them (Martinotti et al., 2018). Psilocybin, a hallucinogen derived from “magic” mushrooms found in certain regions of South America, Mexico, and the United States, produces an experience characterized by a “sense of new, ineffable knowledge, feelings of unity and connection and encounters with ‘deep’ reality or God” (Smith & Sisti, 2020, p. 807). 

Psilocybin has been used for thousands of years for sacred and ancient traditions among indigenous Mesoamerican cultures to treat both spiritual and physical illness (Van Court et al., 2022). In modern times, psilocybin is illegal in most countries and, since the early 1970s, has been categorized by the United Nations and the United States as a Schedule 1 illegal substance, defined as “drugs with no currently accepted medical use and a high potential for abuse” (Barcenas, 2003; Drug Enforcement Agency, 2021). Recently, psilocybin has gained increased interest for its potential as a mental health treatment and was granted the status of “breakthrough therapy” by the Food and Drug Administration in 2018 and 2019 following promising results from preliminary trials on psilocybin treatment for major depressive disorder and treatment-resistant depression (Lowe et al., 2021). Currently, psilocybin is being researched in association with treatment of a number of conditions, ranging from substance abuse, anxiety, depression, and suicidality to chronic pain, epilepsy, headaches, and cancer-related symptoms (Lowe et al., 2021). 

Oregon Psilocybin Services Act: Knowns and Unknowns
In November 2020, Oregonians voted into law Ballot Measure 109, also known as the Oregon Psilocybin Services Act, making Oregon the first state to establish a regulatory framework for psilocybin services, which are defined as “preparation, administration, and integration sessions with a licensed facilitator” (Oregon Health Authority, n.d.). This legislation directs the Oregon Health Authority (OHA) to license and regulate psilocybin products and services and led to the formation of the Oregon Psilocybin Services (OPS) section, housed under OHA’s Public Health Division’s Center for Health Protection. The ballot measure also established the Oregon Psilocybin Advisory Board, a group of multidisciplinary experts who make recommendations to OHA across five primary domains: Training, Research, Products, Licensing, and Equity. Service centers are expected to open their doors in 2023, depending on the timeline of the four types of new licenses (manufacturing, testing, service centers, and facilitators) that are required to offer services. OPS began receiving applications for training program curriculum approval in June 2022. The first subset of administrative rules relevant to psilocybin products, testing, and training programs was adopted in September 2022, and the remaining rules are scheduled to be adopted later in fall 2022. As December 31st marks the official end of the 2-year development phase, on January 2, 2023, OHA will begin accepting applications for facilitator, service center, manufacturer, and laboratory licenses.

Ethical Considerations: Unique Potential Benefit versus Novel and Unknown Risks
While psilocybin is one of the most widely studied psychedelics, is considered to have one of the most favorable safety profiles of all psychedelics, and boasts promising preliminary clinical evidence for improving certain health outcomes, many unknowns remain about its clinical application (Lowe et al., 2021; Martinotti et al., 2018; Smith & Sisti, 2020; Van Court et al., 2022). These gaps, both at the broader level of scientific research and at the narrower level of statewide rules and regulations, raise important ethical questions. Such questions are relevant to mental health professionals in Oregon, whether viewed from the perspective of a future licensed psilocybin facilitator or as a provider who may be recommending psilocybin services and coordinating care for clients. Broadly, health care providers face questions about what is known about the risks and benefits, what is yet to be learned, and what the implications are for how the state moves forward with implementing legislation. 

Services versus Therapy. The Oregon Psilocybin Act permits OHA to license and regulate psilocybin products and services, and while the measure cites mental health treatment as a primary purpose of this act, the distinction between “service” and “therapy” is significant. This legislation effectively creates a new type of licensed professional (i.e., psilocybin facilitator) that does not fall under a mental health model. Anyone who is over the age of 21; has a high school diploma; is a resident of Oregon; completes the training, exam, background check; and pays the fees can become a licensed psilocybin facilitator. Given that the facilitator training requirements have not been fully outlined or officially adopted, questions remain about how the state will ensure the safety of both the provider and client, and will avoid and minimize harm. Furthermore, additional methods that would have implications for facilitators, such as group administration and microdosing, have not been explicitly addressed but are also not prohibited. What are the minimum skill and training requirements to safely and successfully support a client through a psychedelic experience, and what measures need to be in place to ensure those requirements are consistently met? With the details of Oregon’s Facilitator Code of Ethics ostensibly still being drafted, what ethical training will facilitators receive and in what ethical framework will they be expected to operate? If someone is also a licensed professional in another field (e.g., psychologist, counselor, physician), how would that person navigate identifying and resolving ethical issues that arise during the course of providing psilocybin services if there are conflicting points in the various codes they are legally obligated to uphold? Potential conflicts could include areas such as informed consent, avoiding harm, and boundaries of competence.

Informed Consent. Given the unique nature of a psychedelic experience, informed consent will be a critical part of delivering services in an ethical manner. Smith and Sisti (2020) noted three areas particularly relevant to enhancing informed consent for administering psilocybin in a therapeutic context. First, psilocybin brings about shifts in values and personality that a client may find unwelcoming, and the intensity and extent of these changes is difficult to convey in advance. For example,  a spiritual experience, which is commonly reported with psilocybin use, may present significant challenges for a client who identifies as atheist, and may be impossible to fully imagine beforehand. Second, with novel benefits also come novel risks, some of which are not yet understood. Psilocybin has been found to pose rare but potentially severe mental health risks, including severe anxiety, psychosis, and trauma re-exposure. Clients need to be well-informed about the possibility of experiencing such adverse events. Third, therapeutic touch during the client’s psychedelic experience may be indicated to ensure safety (e.g., holding hands for comfort or guiding an individual to the restroom), and thus presents potential issues with boundaries. Consider the following scenarios: A patient initially consents to be touched but then in the psychedelic state, due to anxiety, rejects being touched. Or a patient initially does not consent to be touched but then becomes agitated and is a safety risk, or becomes distressed and asks to be physically comforted. How does a facilitator navigate determining informed consent and decision-making capacity, and how is that weighed alongside client safety and well-being? What content and process does informed consent need to have to respect, as fully as possible, a client’s right to self-determination throughout participation in psilocybin services?

Client Screening and Outcome Tracking. As Smith and Sisti (2020) aptly stated, “psilocybin is like other novel therapeutic modalities in that ethical challenges arise because knowledge of mechanisms, safety and further benefits is limited and norms about standard practice outside of the research context have yet to emerge” (p. 813). Clinical trials carefully select participants and set stringent eligibility requirements to minimize risk of harm, such as excluding individuals with a history of schizophrenia or heart conditions. In opening psilocybin services to anyone over the age of 21 without the need for referral from a client’s mental health provider, a number of important questions are raised about the screening process for vulnerabilities (i.e., spiritual/religious, trauma, medical) and who will be responsible if a client experiences a harmful or even life-threatening event during a psilocybin session. What kinds of information will be collected in a screener prior to psilocybin administration, and how will facilitators utilize that information given the limited scope of their capacity and access to clients’ medical information? What if a client provides false or incomplete information on a screener, especially since medical personnel will not necessarily be on site? How will client baseline functioning be assessed, and outcomes measured, in order to ensure that we are making well-informed decisions based on evidence, and improving service delivery as we learn more?

Cultural Context. Psilocybin has long played a role in spiritual and religious ceremonies dating back thousands of years across cultures throughout Mesoamerica and continuing contemporarily in Mexican indigenous cultural communities. While practices vary, these ceremonies have typically been carried out at night in a quiet place with the support of an experienced guide or shaman. Additionally, limitations on food, alcohol, medication, and travel are common (Lowe et al., 2021). Given this context, one wonders about the implications of attempting to disentangle the cultural components from the psychedelic components of the psilocybin experience. Can we truly separate the benefits of psilocybin from the cultural fabric of these rituals? What, if anything, is potentially lost or changed by adapting these practices to medicalized applications, and what might be done to avert or mitigate these losses or changes?

Uncharted Territory: Paving the Way Forward
The topics explored above offer only a sampling of the ethical questions raised at this point in the emerging process of implementing the Oregon Psilocybin Services Act. As OHA continues to codify rules and regulations, in tandem with the advisory board, administrative committee, and input from citizens in public listening sessions, we will likely gain clarity from answers and face uncertainty with new questions. Oregon is in the midst of a mental health crisis, and our state desperately needs to find effective, accessible solutions that can help each person live meaningfully and thrive in health. Novel treatments offer unique promise, and they also offer unique challenges. As Oregon paves the way in this uncharted territory, successfully holding and balancing this tension would seem to be a key factor in determining whether ours is a model to follow.


Barcenas, G. (2003). Final act of the United Nations Conference for the adoption of a protocol on psychotropic substances.

Drug Enforcement Administration. (2021). Drug scheduling

Lowe, H., Toyang, N., Steele, B., Valentine, H., Grant, J., Ali, A., Ngwa, W., & Gordon, L. (2021). The therapeutic potential of psilocybin. Molecules, 26(10), 2948.

Martinotti, G., Santacroce, R., Pettorruso, M., Montemitro, C., Spano, M. C., Lorusso, M., Di Giannantonio, M., Lerner, A. G. (2018). Hallucinogen persisting perception disorder: Etiology, clinical features, and therapeutic perspectives. Brain Sciences 8(3), 47.

Oregon Health Authority. (n.d.). Oregon psilocybin: What are psilocybin services?

Ranking Guidelines 2023. (n.d.). Mental health America

Smith, W. R., & Sisti, D. (2020). Ethics and ego dissolution: The case of psilocybin. Journal of Medical Ethics. Advance online publication.

Van Court, R. C., Wiseman, M. S., Meyer, K. W., Ballhorn, D. J., Amses, K. R., Slot, J. C., Dentinger, B. T. M., Garibay-Orijel, R. & Uehling, J. K. (2022). Diversity, biology, and history of psilocybin-containing fungi: Suggestions for research and technological development. Fungal Biology, 126(4), 308-319.

For more information about the Oregon Psilocybin Services Act, including the adopted rules and details about upcoming meetings and public listening sessions, visit

 August 2022

The OPA Ethics Committee: What we do and who we are

Hello OPA community! The OPA Ethics Committee (EC) would like to take this opportunity to introduce you to what we do and who we are.
We are a volunteer committee, currently made up of 9 OPA psychologists, who serve 5-year terms, and 3 OPA student members who serve 2-year terms. Our main function is to serve as a consultative body, primarily for OPA members, but also for students, and even the mental health community at large. In this role, we take calls from psychologists and other providers who are dealing with a range of ethical issues. We field calls about issues you would expect, such as multiple relationships, confidentiality, and informed consent; we also field calls about more unique or unusual issues, such as therapists feeling threatened by their clients, termination issues, or supervisor/supervisee relationships. We consider the confidentiality of these consultations to be of primary importance and we take multiple steps to address this. First, we document consultation calls with ID numbers rather than identifying information and when discussing the calls in EC meetings do not include any identifying information. Second, any EC member who may have a conflict of interest recuses themselves from all activity related to the call. Third, we do not share any information outside of the EC. Specifically, we do not report any information to the Oregon Board of Psychologists. There has been some confusion in the past, based on ORS 676.150, which mandates that psychologists report prohibited or unprofessional conduct of their peers. EC members are not required to report to the licensing board under this rule.
Because ethical and legal issues often overlap, we work closely with OPA’s general counsel, Paul Cooney, referring many callers to him to answer legal questions that arise during our consultations. We also coordinate with OPA’s Confidential Peer Support Committee in an effort to support OPA members who are experiencing conflict with colleagues, clinical concerns, family conflicts, or any other distressing situations which might affect the capacity for work. If you are experiencing a problem and you are not sure who to contact first, please call us, and we will help you find the appropriate resource(s).
The EC typically receives approximately four to six consultation calls per month, which is a surprisingly low number given that there are over 3000 active licensed psychologists listed on the Oregon Board of Psychology’s website! We have a highly effective triage system in place to streamline the referral process. The first step starts with you sending an email to [email protected] that includes a description of your specific concerns, contact information, and convenient contact times. The EC member who serves as the Consultation Coordinator retrieves the message and contacts the rest of the EC members to determine who can best address your specific concerns. That member then contacts you within 1 week to set up a consultation phone call. The actual consultation takes place by phone or Zoom and may take up to 1 hour. The reason for the lengthy call is because we don’t provide an answer to your specific question; instead, we work with you to develop a plan that will best address your unique situation. An important step in this process is for you to review the APA Ethics Code prior to the consultation call in order to identify the sections of the code most relevant to your situation; the EC member assigned to your call will do the same. Following the consultation call, the EC member provides a summary of the call at the next EC meeting and contacts you via a follow-up phone call with any comments or feedback.
In addition to our consultative role, the EC participates in many other activities. First, to make sure that graduate students are aware of our services, we offer presentations annually in ethics courses at the doctoral programs in clinical psychology in Oregon. Second, we also assist OPA with their continuing education offerings, coordinating with a nationally-recognized psychologist to speak at OPA’s annual ethics workshop in the spring. In recent years, we’ve enjoyed presentations from ethics experts such as Drs. Roy Huggins, Sam Knapp, and Vanessa Hintz. Third, we write quarterly articles for the OPA Bulletin on ethics topics that might interest OPA members. Recent topics have addressed navigating political engagement, the ethics of self-care, addressing client racism, ethical considerations in clinical psychology graduate admissions, suicide risk management via telehealth, and forensic psychology via telehealth. Finally, we present a workshop at the annual OPA conference. Recent workshops have focused on addressing colleagues’ ethical transgressions and ethical hybrid practice.
In September 2022, we have a number of comings and goings on the EC. We regretfully say goodbye to three dedicated student members, Elijah Hill, Sophia Sbi, and Alex Keene, and are happy to welcome three new student members, Alexandra Fisher, Zachary Kramer, and Darcy Gist, all from the PsyD program at Pacific University. We are also excited to add three new psychologist members to the EC in September: Cindy Marino, PsyD (Training Director at Lewis & Clark Counseling Services); Kalin Clark, PsyD (a behavioral health provider at Providence Center for Weight Management); and Dina Wirick, PhD (in private practice providing individual adult psychotherapy and psychological assessment). As these three new members come on board, we say goodbye to Irina Gelman, PsyD; Petra Zdenkova, PsyD; and Justin Lee, PhD. Thank you to our outgoing members for your invaluable service!Other current members of the EC include Allison Brandt, PhD (Director of Youth and Family Services and Director of Community Outreach and Training at Portland Anxiety Clinic); Len Kaufman, PhD (Clinical Director at Portland Mental Health & Wellness); Heather Sheafer, PhD (in private practice conducting forensic evaluations); Erica Aten, PsyD (Director of Child and Adolescent Services at Collective Care Clinic); Erin Steen, PhD (in private practice focused on therapy with adults); and Jennifer Clark, PsyD (Clinical Director at Aspire Psychology).
Although the EC has members with expertise in multiple settings, with multiple age ranges, and with multiple populations, we are continually looking for members who can help us diversify our geographical representation of Oregon. Shifting our meetings to Zoom in 2020 has created greater accessibility for psychologists across the state as meetings no longer require attendance in Portland. If you are interested in joining this dynamic, engaged group of psychologists and students, please reach out to Jennifer Clark at [email protected].
In summary, the EC has been active over the past year, and we look forward to another year of ethics consultations and educative opportunities. We hope you all will reach out to us at OPA’s conferences and workshops to learn more about us as professionals and EC members. As psychologists, we are privileged to work with people who need our help, which includes all of us at some point! Please don’t hesitate to contact us with any ethics questions or concerns you have; we are here to help.

May 2022

Training Equity: Labor and the Ethics of Unpaid Psychology Practicums 
Alex Keene, MAand the OPA Ethics Committee 

The 4,139 psychology doctoral students who participated in 2021’s APPIC match accumulated a mean debt of $99,488 during their training (Keilin, 2021b; Keilin, 2021a). U.S. applicants reported a mean debt of $103,198 and a median debt of $80,000 associated with graduate school, while Canadian students accumulated virtually no debt (Keilin, 2021b). In the United States, average pre-internship debt increased 8.4% in 3 years and 14% over 13 years (Association of Psychology Postdoctoral and Internship Centers, 2008; Keilin, 2021b) 

Hatcher et al. (2012) estimated that in the U.S. approximately 12,000 psychology graduate students are engaged in practicum training each year. As these numbers indicate, practicum training is as ubiquitous as it is vital. The American Psychological Association (APA) requires programs to include practicum training of various levels and duration as criteria for accreditation, yet makes no provisions regarding compensation for graduate student labor (APA, 2015). Many programs allow their students to be paid, but only 4% require it, and some programs prohibit trainee compensation (Hatcher et al., 2011). Many of these policies have remained constant in recent decades and have not been revisited with consideration of the student debt crisis, the COVID-19 pandemic, or the rise in the cost of living nationwide.  

In addition to increased cost of living and stagnant early career wages, graduate psychology trainees endorse high levels of stress throughout their education and often describe persistent financial stress and taking on additional debt to afford living expenses (Doran et al., 2016). While increasing debt burdens affect all trainees, Black, Indigenous, and People of Color (BIPOC) trainees are disproportionately affected by debt accumulation (Malcom & Dowd, 2012). Unpaid trainee labor is also highly gendered and racialized. Professions that are construed as male-dominated and traditionally White often pay trainees, while professions traditionally held by marginalized people or construed as female-dominated regularly require hundreds or thousands of hours of unpaid labor prior to employability (Caldararu, 2019).  

As Doran et al. (2016) noted, the debt trainees accumulate likely exacerbates barriers to increasing the representativeness and diversity of the field. These new concerns and challenges require significant adaptation from the profession. This article attempts to explore the issue of unpaid graduate labor and equity in the profession from a perspective grounded in the APA Ethics Code (2017). 

The 1938 Fair Labor Standards Act (FLSA) is the legal basis for unpaid practicums, permitting employers to pay a lower wage to apprentices and learners, and was followed by a series of legal battles which distinguished between training and employment (Burke & Carton, 2013). The U.S. legal system uses the “primary beneficiary test” to assess the quality of a trainee-employer relationship by reviewing several factors to determine whether the trainee gains more from their placement than the employer (United States Department of Labor, 2018). In a psychological context, the test would measure the clarity of practicum expectations established by sites and the cost to provide training in comparison to the monetary value of services provided by trainees. Graduate programs and practicum coordinators routinely define expectations and rules for trainees, which must be agreed upon prior to the start of these placements, thus meeting the legal system’s standard for clarity of expectations (Burke & Carton, 2013; Hatcher et al., 2011, 2012).  While trainee informed consent to unpaid training is required, trainees participate in larger systems that constrict their choices. In addition, unpaid trainees are also likely to have fewer legal protections than they would in an educational context or as an employee (Burke & Carton, 2013). Scholars noted that this arrangement creates a difficulty to meet the need for standardization of the quality of practicum training and university monitoring of trainee experiences (Burke & Carton, 2013; Hatcher et al., 2011, 2012). Practicum coordinators who are charged with these duties value their work and seek to provide quality training (Hatcher et al., 2012). Yet they also endorse varying degrees of institutional support. Most coordinators indicate that their organizations emphasize training as part of their mission statements while only 39% reported the inclusion of practicum expenses in organizational budgets (Hatcher et al., 2012). Coordinators endorsed concerns about trainees being adequately prepared prior to begin their placements (Hatcher et al., 2012). The authors also identified supervision as a concern indicating that prior to the COVID-19 related shift to telehealth, less than 20% of practicum sites conducted direct observation of students (Hatcher et al., 2012). In addition, most practicum placements are unpaid and student services may not be eligible for insurance reimbursement (Hatcher et al., 2012)Seventy-two percent of responding coordinators indicated that they do not pay students and that stipends are of little importance for training quality; 81% of sites also had no travel stipends which were also regarded as minimally important (Hatcher et al., 2012). These data accentuate the misalignment between institutional priorities and trainee financial strain as current social, economic, and political conditions make the situation increasingly untenable. This misalignment further highlights the value of upholding the profession’s ethical principles through action.  

The Ethics Code does not require compensation for trainees’ labor, but its general principles and sections offer space for ethical consideration of the current system (APA, 2017). Principle A, Beneficence and Nonmaleficence, guides psychologists to “safeguard the welfare and rights” of people in professional contexts and to cultivate an awareness of how their health affects their ability to serve others. Principle B, Fidelity and Responsibility, encourages psychologists to work with professionals and organizations as necessary to serve the best interests of those within their sphere of influence. Principle E, Respect for People’s Rights and Dignity, highlights the importance of psychologists’ recognition of individuals’ right to self-determination and dignity. Section 3.04, Avoiding Harm, advises psychologists to take reasonable steps to prevent harm to their students and supervisees. In combination, these guidelines suggest that psychologists strive to respond to a wide range of situations that represent a threat to trainee welfare and the diversity and equity of the profession. While trainee welfare and equity are broad concerns, scholars recently identified financial strain as a factor for specific concern. Doran and colleagues’ (2016) work exploring the numerous impacts of financial strain and the rapid surge of APPIC applicant total debt highlights financial stress and debt burden as significant impediments to trainee welfare and the potential impact of this strain on their work and career outlook. 

Trainees in both PhD and PsyD programs often take on additional debt to afford living expensesalthough many receive a combination of tuition remission, research assistantships, teaching assistantships, grants, and other financial support (Doran et al., 2016). Starting salaries for new psychologists have not grown as quickly as these costs (Doran et al., 2016). Rising costs of living and education without practicum stipends or equivalent increases in early career salaries negatively affect the health of trainees, newly licensed psychologists, and potentially the profession (Doran et al., 2016). 

Psychologists in training, like other healthcare workers, regularly face significant anxiety, stress, depression, burnout, and chronic physical health difficulties prior to their internships, graduation, and licensure (Bhurtun et al., 2019; Kaeding et al., 2017; Richardson et al., 2018; Rummell, 2015; Zhou et al., 2020). Researchers have often investigated personality-level characteristics to understand and predict burnout (Kaeding et al., 2017; Richardson et al., 2018). However, systems level approaches can provide a helpful departure point for additional ethical observations. Zhou et al. (2020) found that trainee physicians facing workplace stress, like negative work-life balance or negative work environments, were twice as likely to endorse burnout compared to trainees struggling with non-work-related factors like self-efficacy or physical health. They also demonstrated that perceived poor salary, debt, or financial problems contributed to burnout stress to a lesser extent than work stress and emphasized the importance of organization-level intervention.  

These systemic, organization-level interventions require consideration of the material conditions from which they originate. Caldararu (2019) urged examination of the sociopolitical construction of graduate training as a site of conflict between policies emphasizing individual responsibility and those prioritizing the common good. Practica offer trainees opportunities to develop competencies, obtain gradually increasing responsibility, and receive supervision to enhance their work while attempting to prevent unprepared professionals from causing harm in the communities they serve. Yet trainee labor and growing competency occur within a market-oriented economic system. Trainee labor thus produces increasing value across their studies, which can allow organizations to bill for services or, in some contexts or professions, shift labor from paid workers to trainees (Caldararu, 2019). Caldararu’s “hidden curriculum” refers specifically to the social construction of mandatory unpaid practicums operating within a neoliberal framework that privileges service-delivery, and capital generation, over trainee development or questioning established power hierarchies of class. In his formulation, educational institutions nationwide contribute unpaid labor to private sector or non-profit organizations, teaching students the hidden lesson that they must pay for career opportunities by accumulating debt, sacrificing their personal lives, or seeking paid employment after hours.  

While trainee psychologists experience exponential growth in their abilities during practicum training, the profession’s “hidden curriculum” creates innumerable barriers to entry for trainees facing the most systemic discrimination. Principle D, Justice, (APA, 2017) asks psychologists to ensure equitable access and benefit from the field’s advances, which is threatened when systemic barriers limit equitable access to membership in the profession. Furthermore, differing priorities of training coordinators, their organizations, and practicum trainees often lead to unintended conflicts and organizational standards that are out of alignment with the Ethics Code.  

Pietrantonio and Garriott (2017) offered valuable steps the profession can take to address this issue in their response to Doran et al.’s (2016) article on the graduate psychology debt crisis. Their plan emphasizes:   

(a) transparency and guidance for undergraduate psychology students, (b) financial-informed consent in graduate training, (c) ensuring financial literacy and creating a culture of safety around discussing student debt, (d) post-graduation financial resources, (e) increasing funding opportunities for clinical training, (f) federal advocacy for student debt concerns, and (g) APA advocacy for higher wages for entry-level positions (Pietrantonio & Garriott, 2017, p. 94). 

These steps provide a holistic approach to addressing the structural inequality inherent in the current practicum model by addressing the potential harms of the system at the level of their causes while also increasing the equity of the profession.  

An ethics-oriented approach to the dramatic increases in graduate psychology trainee debt, financial stress, and tension between the profession’s ethical principles and common institutional and organizational constraints can provide helpful suggestions for future action. Psychologists must critically assess the “hidden curriculum” of unpaid trainee labor and determine whether it aligns with the profession’s ethical aims. The full impacts of the COVID-19 pandemic’s influence on living costs and the long-term course of the student debt crisis remain uncertain. Yet, the financial burden of joining the profession clearly requires a broad response guided by its ethical principles. Page Break 


American Psychological Association. (2015, February). Standards of accreditation for health service psychology 

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct.  

Association of Psychology Postdoctoral and Internship Centers. (2008, July 27). 2008 APPIC Match: Survey of internship applicants part 1: Summary of survey results  

Bhurtun, H. D., Azimirad, M., Saaranen, T., & Turunen, H. (2019). Stress and coping among nursing students during clinical training: An integrative review. Journal of Nursing Education, 58(5), 266-272  

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Doran, J. M., Kraha, A., Reid Marks, L., Ameen, J. E., & Hassan El-Ghoroury, N. (2016). Graduate debt in psychology: A quantitative analysis. Training and Education in Professional Psychology, 10, 3-13.

Hatcher, R. L., Grus, C. L., & Wise, E. H. (2011). Administering practicum training: A survey of graduate programs’ policies and procedures. Training and Education in Professional Psychology, 5(4), 244-252

Hatcher, R. L., Wise, E. H., Grus, C. L., Mangione, L., & Emmons, L. (2012). Inside the practicum in professional psychology: A survey of practicum site coordinators. Training and Education in Professional Psychology, 6(4), 220-228.  

Kaeding, A., Sougleris, C., Reid, C., van Vreeswijk, M. F., Hayes, C., Dorrian, J., & Simpson, S. (2017). Professional burnout, early maladaptive schemas, and physical health in clinical and counselling psychology trainees. Journal of Clinical Psychology, 73(12), 1782-1796.  

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 February 2022

Moving forward with a telehealth model: What can go wrong?
Sophia Sbi, MA, Erin Steen, PhD, and OPA Ethics Committee

The COVID-19 pandemic triggered a massive shift from in-person clinical practice to telehealth. Telehealth broadly encompasses the utilization of “telecommunications and information technology to provide access to health assessment, diagnosis, intervention, and information across a distance, rather than face to face” (American Psychological Association, n.d.).   The use of telehealth reached its peak in April of 2020 but has since stabilized to a rate 38 times higher than the pre-COVID-19 baseline, with psychiatry surpassing all other healthcare disciplines (Bestsennyy et al., 2021). In 2021, the American Psychological Association (APA) distributed a national survey to doctoral-level licensed clinical psychologists and found that 96% utilized telehealth in their clinical practice throughout the pandemic, and 93% plan to continue using telehealth post-pandemic. Given the flexibility, accessibility, and comfort that telehealth affords patients and providers, it is no surprise that telehealth is here to stay. 

Despite the clear benefits of telehealth, potential limitations include work-life boundary diffusion, limited professional oversight and collaboration, and challenges with managing patient risk and safety (Mosley et al., 2021). In 2013, APA established a list of recommendations and guidelines for addressing risks of telehealth practice (APA, 2013); however, these guidelines do not fully address present-day context. More recent guidelines (Cooper et al., 2019; Smith et al., 2020) are limited in their ability to account for the long-term implications and risks of telehealth practice, as they are still largely unknown. As the field of clinical psychology adapts to reliance on technology in practice, future uses of telehealth are likely to evolve (Kuziemsky et al., 2019; Smith et al., 2020). Telehealth guidelines need to be adapted to modern contexts and project out future risks and solutions. This article aims to clarify future directions for ethical practice guidelines and considerations. 

One consideration is that use of telehealth may place psychologists at higher risk of burnout. Since the widespread implementation of telehealth, a new phenomenon of “Zoom fatigue” has emerged, which suggests that telecommunications require additional or different sources of social energy than in-person communication (Sasangohar et al., 2020). Throughout the COVID-19 pandemic, mental health providers are in greater demand than before. Many providers have reported longer waitlists and more referrals compared to pre-pandemic practice (APA, 2021). Zoom fatigue, paired with increased clinical demands, is not a sustainable situation for mental health providers. Long-term use of telehealth for mental health treatment increases provider vulnerability for compassion fatigue and vicarious trauma (Botaitis & Southern, 2020). In 2021, 46% of psychologists reported feeling burned out (APA, 2021). Principal A of the APA Ethical Principles of Psychologists and Code of Conduct (hereafter referred to as APA Ethics Code) states, “Psychologists strive to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work” (APA, 2017). Research suggests that mental health provider burnout can also impact client care (Rupert et al., 2015). Guideline 3.04 (a) Avoiding Harm states, “Psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm where it is foreseeable and unavoidable” (APA, 2017). Increased engagement in self-care, whether it be providers seeing their own therapist, scheduling in breaks, and/or leaning on social and work supports, are recommended strategies for mitigating the effects of burnout and compassion fatigue on patient care and well-being (Miu et al., 2022; Sasangohar et al., 2020), and might be of particular importance among those practicing via telehealth. 

Prior to the widespread use of telehealth, providers who worked in group practices or shared clinical offices benefited from impromptu consultation with colleagues and supervisors (Sasangohar et al., 2020). Being in a shared physical office space naturally offers the reality and perception of oversight in a way that is not afforded with remote work. Despite the fact that telehealth communication channels are just as accessible for most, teleconsultation appears to be underutilized (Miu et al., 2022; Ramli & Ali, 2018). With the transition to a new treatment delivery model increasing caseloads and the ongoing collective stress and hardships associated with the pandemic, providers arguably need more consultation and peer support. 

Principle B: Fidelity and Responsibility of the APA Ethics Code states, “psychologists consult with, refer to, or cooperate with other professionals and institutions to the extent needed to serve the best interests of those with whom they work” (APA, 2017). For many, knowing one should consult does not translate into consulting or provide any solutions, and does not overcome the previously mentioned barriers and contextual factors that make consultation difficult. To improve the likelihood that providers regularly engage in consultation, Miu and colleagues (2022) recommended that providers shift their model to one that is non-judgmental, positive, and supportive rather than one that feels surveilling or punitive. An additional recommendation for overcoming consultation barriers and resistance includes setting up static and protected supervision/consultation time within work hours (Mosley et al., 2021; Rothwell et al., 2021). Implementing a system that allows for intentional, meaningful, and consistent engagement in supervision/consultation may reduce predictable and unforeseeable ethical risks long term. 

Telehealth may not be suitable for all patient populations and there is a lack of treatment manuals to address needed adaptations for specific populations (Smith et al., 2020). The development of manuals and guidelines typically lags behind the necessitating clinical contexts (Alqahtani et al., 2021). Although specific adaptations for the use of telehealth across a variety of populations may not yet be available, APA’s Guidelines for the Practice of Telepsychology recommends that mental health providers “evaluate and assess the appropriateness of utilizing these technologies prior to engaging in, and throughout the duration of, telepsychology practice to determine if the modality of service is appropriate, efficacious and safe” (APA, 2013). Careful examination of telehealth fitness for a patient should incorporate cultural considerations related to a family’s comfort with telehealth, client technological competence and resources, ability status, and treatment needs (APA, 2013; Pollard et al., 2017). It is also worth noting how these risks may compromise fidelity to Principle E: Respect for People's Rights and Dignity, which states, “Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status, and consider these factors when working with members of such groups” (APA, 2017). Proper consideration of clients’ identity factors includes a thorough assessment at the onset of treatment, incorporation of necessary adaptations, and care coordination, or referring out if clients’ needs are not within one’s bounds of competence (Chenneville & Schwartz-Mette, 2020). 

New technology platforms, applications, and services are being implemented in clinical practice despite having limited tools and understanding for continued data maintenance and security. These discrepancies pose ethical risks pertaining to privacy and confidentiality issues. With the use of video conferencing technology, patients could potentially record therapists without therapists' consent, third parties may interrupt sessions, and Personal Health Information (PHI) could be compromised (Chenneville & Schwartz-Mette, 2020; Mosley et al., 2021). Guideline 4.01 Maintaining Confidentiality of the APA Ethics Code states, “Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium” (APA, 2017).  Recommendations for improved security include the use of a secure trusted platform, headphones, a wired network connection instead of Wi-Fi, as well as adherence to Health Insurance Portability and Accountability (HIPAA) data security policies and procedures (Smith et al., 2020). However, when considering the trajectory of technology advancement and accessibility within clinical practice (e.g., artificial intelligence, virtual reality, incorporation of symptom trackers and health apps) the digital risks are unpredictable and solutions to mitigating risks may not be readily available or feasible to implement. Considering these issues, perhaps future ethical guidelines for telehealth practice should urge mental health providers to refrain from incorporating new technology into their practice until there is an abundant source of risk protection procedures available. 

Conclusions and Recommendations
The challenges associated with telehealth are only accumulating as mental health providers continue to rely on a telehealth model. However, there are a number of safeguards psychologists can implement to help ensure they protect against unethical practice while striving for excellence in professionalism and competence. Maintaining improved connection and consultation is necessary to uphold ethical and professional competence and can be done through establishing peer consultation groups and regular supervision in a way that feels supportive and nonjudgmental (Miu et al., 2022; Mosley et al., 2021; Sasangohar et al., 2020). To comply with ethical standards associated with practicing telehealth and respecting clients’ rights and dignity, providers should assess client fit for telehealth, adapt treatment to meet clients’ needs, and establish safety and technology failure plans (Chenneville & Schwartz-Mette, 2020; Pollard et al., 2017; Sasangohar et al., 2020). To minimize risks associated with the contributors of burnout, mental health providers could prioritize their own mental health (e.g., seeking and maintaining personal counseling services, reducing caseloads, and/or incorporating breaks to account for Zoom fatigue and burnout; Chenneville & Schwartz-Mette, 2020; Sasangohar et al., 2020). Lastly, providers should refrain from implementing new technology in their clinical practice until clear policies and procedures around data security become available. In an ever-evolving world, psychologists must actively evaluate the applicability of available standards and guidelines and adapt clinical practice appropriately. 


Alqahtani, M. M. J., Alkhamees, H. A., Alkhalaf, A. M., Alarjan, S. S., Alzahrani, H. S., AlSaad, G. F., Alhrbi, F. H., Wahass, S.H., Khayat, A. H., & Alqahtani, K. M. M. (2021). Toward establishing telepsychology guideline. Turning the challenges of COVID-19 into opportunity. Ethics, Medicine and Public Health, 16. 

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November/December 2021

Psychologist Considerations for Telehealth with Forensic Populations
Elijah Hill, MA and Erica Aten, PsyD

Since March 2020, COVID-19 has spread throughout the world, causing an ongoing global health pandemic. In-person healthcare services, including mental health, have been limited, leading to the rise in popularity for telehealth services. The American Psychological Association (APA, 2013, Definition of Telepsychology para 1) defines telehealth as the “preparation, transmission, communication or related processing of information by electrical, electromagnetic, electromechanical, electro-optical or electronic means. As the initial impact of COVID-19 begins to dissipate and in-person services resume, psychologists must determine the impact of in-person services versus telehealth, with regard to mental health recourse and the quality of services (i.e., information gathering; Carroll, 2020). This decision is perhaps even more critical when working with special populations, as is the case for clients seeking forensic assessment services, due to the complexity of alleged offenses of their clientele and the scrutiny psychologists face when justifying their findings (Carroll, 2020).

When considering administration of assessments via telehealth, there are several provisions in the Ethical Principles of Psychologists and Code of Conduct (APA, 2017) that are pertinent to the process. General principles address the following: do no harm (Principle A: Beneficence and Nonmaleficence), professional responsibilities (Principle B: Fidelity and Responsibility), promoting accuracy and honest practices (Principle C: Integrity), fairness and justice in access and benefits (Principle D: Justice), and respecting the dignity and worth of all people (Principle E: Respect for People’s Rights and Dignity). Given that “forensic evaluation reports are heavily contested or subjected to intense cross-examinations” (Adjorlolo & Chan, 2015, p. 4), it is imperative that psychologists prioritize beneficence, fidelity, integrity, justice, and respect for people’s rights and dignity when choosing to conduct virtual forensic assessments.

With these principles in mind, we continue to explore ethical guidelines and literature particular to assessments. The first standard (9.01, Bases for Assessment) states that psychologists should “base the opinions, contained in their recommendations, reports and diagnostic or evaluative statements including forensic testimony, on information and techniques sufficient to substantiate their findings.” The standard continues by stating that, if a psychologist is unable to substantiate their findings, they should “document the efforts they made and the results of those efforts, clarify the probable impact of their limited information…and appropriately limit the nature and extent of their conclusions or recommendations.” According to Adjorlolo and Chan (2015, p.14), “the report should explicitly state whether, in the opinion of the evaluator, the use of the virtual conference medium negatively influenced the result obtained, especially the reports produced for court utility.” Further, psychologists should have a clear rationale for the selection of telehealth services and the chosen assessments they administer based on “established scientific and professional knowledge of the discipline” (Standard 2.04: Bases for Scientific and Professional Judgements). Because of the lack of research examining the effectiveness of virtual assessment for forensic purposes (Adjorlolo & Chan, 2015), psychologists must consider all relevant ethical codes when determining their forensic assessment modality.

The second standard (9.02, Use of Assessments) states that psychologists should “administer, adapt, score, interpret, or use assessment techniques, interviews, tests or instruments in a manner and for purposes that are appropriate.” In addition, the standard continues by stating that “psychologists describe the strengths and limitations of test results and interpretation.” For example, psychologists should be mindful of the differences that in-person versus telehealth-based assessments provide (i.e., cost, convenience, comfort, privacy and confidentiality; Adjorlolo & Chan, 2015; Carroll, 2020). Telehealth assessments may improve access to services; however, the quality of nonverbal assessment regarding eye contact, use of senses, motor movement, and micro-expressions may be compromised or removed entirely (Carroll, 2020).

Finally, Standard 9.06, Interpreting Assessment Results states that a psychologist should “take into account the purpose of the assessment as well as the various test factors, test-taking abilities, and other characteristics…such as situational, personal, linguistic and cultural differences.” For example, modifications a psychologist takes while conducting telehealth services should be addressed in any documentation or results. This includes the topics of accuracy, validity and the reliability of the assessments used (Adjorlolo & Chan, 2015).

In conclusion, it is important that forensic psychologists consider the assessments they provide, the setting in which assessments are administered, and the ability of the psychologist to interpret the assessment data in response to the referral question. Forensic psychologists should be mindful of the population with whom they are working and the cost and access to resources for both in-person and telehealth-based assessment. In addition, psychologists should not only maintain competence for the assessments being used but also for the modality in which assessments are being given. Maintaining these areas of competence is the “best practice standard required for assessments” when complicated and complex challenges may arise with the use of telehealth (Adjorlolo, 2015, p. 185). 


Adjorlolo, S., & Chan, H. C. (2015). Forensic assessment via videoconferencing: Issues and practice considerations. Journal of Forensic Psychology Practice, 15(3), 185-204.

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Carroll, A. (2020). Forensic mental-health assessments after coronavirus disease 2019: Will telehealth lead us to trade psychological depth for convenience. Medicine, Science and the Law, 60(3), 169-171.

November/December 2021

Remote Suicide Risk Assessment and Ethical Practice
Alex Keene, MA, Heather Sheafer, PhD, and the OPA Ethics Committee

While telehealth has long been generally regarded as equivalent to in-person care (Godleski et al., 2008; Pruitt et al., 2021), legal and ethical concerns related to suicide screening and prevention, combined with limited research (McGinn et al., 2019), restricted its use among high-acuity populations (Gilmore & Ward-Ciesielski, 2019; Godleski et al., 2008). By 2020, the rapid spread of COVID-19 necessitated the use of telehealth across populations. At the beginning of the pandemic, researchers and health organizations cautioned that a global outbreak of COVID-19 was likely to have a profound influence on mental health outcomes and increase many factors that are predictive of suicide attempts and deaths (Gunnell et al., 2020; Khan et al., 2020; World Health Organization, 2020). Lockdowns, fear of infection, social isolation, political turmoil, and individual, familial, and communal losses throughout 2020 and 2021 produced critical increases in mental health symptoms alongside accompanying decreases in quality of life (Creswell et al., 2021; Jenkins et al., 2021; Rains et al., 2020). People and communities facing political and/or economic marginalization, mental and/or physical health difficulties, ableism, racism, sexism and/or heterosexism, and other structural inequalities were particularly impacted (Jenkins et al., 2021; Ruprecht et al., 2021; Santos et al., 2020; Shakespeare et al., 2021).

The increase in mental and behavioral health difficulties associated with the COVID-19 pandemic necessitates high quality, ethically informed suicide risk assessment and prevention strategies. Still, suicide risk assessment remains one of the most complicated tasks in psychology and other allied healthcare disciplines. Researchers have identified few suicide risk measures with strong predictive validity or diagnostic accuracy rates above 50%, and research related to suicide prevention overall appears to have a high level of methodological limitations (O’Shea & Dickens, 2014; Roos et al., 2013; Runeson et al., 2017). In addition, some treatment and preventive measures, such as involuntary hospitalization, are traumatic, costly, and potentially associated with post-intervention increased risk of suicide (Coyle et al. 2018; Luxton et al., 2013; Ward-Ciesielski & Rizvi, 2021). These dynamics are further complicated by the necessary adoption of telehealth practice due to the COVID-19 pandemic. Despite wide acceptance of telehealth, ethical concerns related to suicide assessment and prevention remain (Jobes et al., 2020).

Remote assessment is perhaps chief among telehealth related ethical issues. Prior to the pandemic, mental health care providers reported reticence in working with patients experiencing suicidal ideation (SI) due to doubts around assessing non-verbal indicators of risk, as well as lack of control over their patients’ environments (Gilmore & Ward-Ciesielski, 2019; Jobes et al., 2020). Furthermore, patients who live with others and receive care at home may have less privacy than in traditional behavioral and mental health settings, which could influence their likelihood of reporting self-harming or suicidal behaviors and SI. In addition, even when providers carefully assess for SI, it is not always possible to account for SI that develops throughout the course of treatment. Given the difficulty involved in telehealth-based suicide risk assessment, psychologists may benefit from reviewing the following ethical considerations (American Psychological Association [APA], 2017).

Providing telehealth services in emergencies. In response to an influx of mental health crises, psychologists without specialized telehealth training quickly transitioned their patients to telehealth, while also developing their competencies in this area (Standard 2.02, Providing Services in Emergencies). However, as the pandemic will likely continue for some time, psychologists should place additional emphasis on, assessing their own skills (Standard 2.01, Boundaries of Competence), expanding and maintaining their competencies (Standard 2.03, Maintaining Competence), and rooting their practice in science (Standard 2.04, Bases for Scientific and Professional Judgments). Consistent with these standards, psychologists practicing telehealth are expected to be critical consumers of research on remote suicide prevention and apply new standards appropriately.

Knowledge of suicide risk measures. Psychologists should be aware of validity issues in suicide risk assessment, utilize appropriately validated instruments (Standard 9.02, Use of Assessments) and be mindful of anxieties around about telehealth risk assessment, including uncertainty based on the medium of the assessment instead of on a patient’s endorsement of severe risk, which may increase the likelihood of unnecessary interventions.

Involuntary hospitalization. Before the COVID-19 pandemic, involuntary hospitalization carried significant risks, such as insufficient treatment, trauma from the loss of personal autonomy, and frequent lack of post-hospitalization follow-up (Luxton et al., 2013). In addition, police officers are frequently involved in responding to mental health crises. Data indicate that in 1999, 10% of all police encounters were with people with significant mental health difficulties (Watson & Fulambarker, 2012). Researchers have found that police are involved in the journey to mental health services for 12% of people with psychiatric diagnoses (Livingstone, 2016). Many police officers are not adequately trained to intervene in behavioral health crises and existing evidence on the quality and effectiveness of police training programs indicates that such trainings do not reduce police use of force (Rogers et al., 2019). Police involvement in such crises, particularly when Black, Indigenous, or other people of color (BIPOC) are those in crisis, can lead to violence, traumatization, and even death (Rogers et al., 2019; Shadravan et al., 2021).

Encounters with police officers and emergency service workers, and exposure to medical settings with high levels of COVID-19 positive individuals, increase the risk of viral transmission to patients already in crisis. Therefore, psychologists should consider not only the general risk of harm and infection for their patients, but also the risk of transmission from inpatient treatment settings to other individuals in their patients’ lives or communities (Principle A, Beneficence and Nonmaleficence). Healthcare workers and researchers must contend with the impact of these risks on the ethics of involuntary hospitalization. In fact, many involuntary treatment settings have been sites for high COVID-19 infection rates, prompting some health systems to cease civil commitments early in the pandemic (Morris & Kleinman, 2020).

Given the increased risk of infection for people who are hospitalized or in contact with emergency services, some researchers suggest more stringent criteria to justify restricting a person’s rights (Gather et al., 2020; Morris & Kleinman, 2020). Psychologists should be particularly conscious of their ethical obligations when making clinical decisions which may involve restriction of a patient’s liberty and increase their risk of contracting COVID-19 (Principle A, Beneficence and Nonmaleficence; Principle E, Respect for People’s Rights and Dignity).

In addition to being aware of potential risks of involuntary commitment, psychologists must also consider the influence of their own biases and emotional reactions, including anxiety and uncertainty about telehealth risk assessment and suicide prevention. As always, psychologists may benefit from consultation with other professionals to further consider whether a patient will benefit from involuntary hospitalization (Standard 4.06, Consultations).

Informed consent related to telehealth suicide prevention policies. The informed consent process around risk of harm assessments may have increased importance due to these concerns. Psychologists can reduce potential harm to patients, as well as minimize potential ruptures in the therapeutic relationship, by being open and honest with patients about the ways in which they remotely assess and respond to SI (Standard 3.10, Informed Consent; Standard 9.03, Informed Consent in Assessments; Standard 10.01, Informed Consent to Therapy). Along these lines, psychologists can better serve their patients by maintaining awareness of COVID-19 policies, procedures, and precautions at nearby psychiatric units and by monitoring the potential infection risk to patients. Psychologists who provide telehealth services outside their localities are also ethically responsible for knowing the relevant resources local to their patients (Jobes et al., 2020).

Pandemic-related increases in mental health distress, coupled with the rapid adaptation and habituation to telehealth for many health professionals and patients, has significantly changed the ways in which psychologists approach suicide risk assessment and prevention efforts. Psychologists working via telehealth should be prepared to develop and maintain competency in telehealth, while also striving to meet the standard of care in their assessment procedures. They must also assess the increased risk of harm inherent in crisis interventions by police or emergency services workers and inpatient hospitalization, while being particularly mindful of their own emotions regarding suicide risk assessment and prevention. Psychologists should also be prepared for open and ongoing informed consent discussions with patients that include consideration of the ongoing spread of COVID-19 variants and new waves of infections. Finally, psychologists can respond to the ongoing COVID-19 pandemic and minimize harm to patients experiencing SI by continuing to align their practice with the APA’s Ethical Principles and Code of Conduct (APA, 2017).


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Watson, A., & Fulambarker, A. (2012). The Crisis Intervention Team model of police response to mental health crises: A primer for mental health practitioners. Best Practices in Mental Health, 8(2), 71. 

World Health Organization. (2020). Mental health and psychosocial considerations during the COVID-19 outbreak.


July 2021

Practicing In a Pandemic: Navigating Boundary Diffusion as a Psychologist
Sophia Sbi and Jennifer R. Clark, PsyD - OPA Ethics Committee 

In March, 2020 the spread of COVID-19 quickly turned into a global public health pandemic. With enclosed public spaces no longer safe to occupy, the majority of psychologists’ work shifted to virtual, from private homes and spaces with video conferencing, phone calls, emails, and text messaging becoming the main means of communication. In contrast to in-person work, remote work can lead to a lack of clearly defined boundaries (e.g., physical, temporal, role, etc.), which can have implications on work, family or personal life, health, and well-being (Cho, 2020). Since the onset of the COVID-19 pandemic, psychologists have had to embrace flexibility in how they conduct their work, whether in the role of practitioner, supervisor, administrator, etc. With this increased flexibility comes the need to ensure that psychologists’ practice remains consistent with The American Psychological Association’s (APA) Ethical Principles of Psychologists and Code of Conduct (hereafter referred to as the Ethics Code; APA, 2017). Despite the spread of COVID-19 slowing, a complete return to “normal” practice is unlikely and psychologists need to prepare for remote work continuing in some capacity long-term. As such, a shift in thinking about boundaries and related ethical principles is needed. 

The physical boundaries of a work location (e.g., within a building or office) serve to signal where one’s work tasks are to be fulfilled. Remote work is typically completed in the home, though if network connections are obtained elsewhere, one may choose alternative spaces. Location flexibility can allow for greater dissemination of services to previously hard-to-reach populations (Zukor, 2021); however, complications can arise if individuals are “remotely” transported (such as while in a video conference) into spaces other than agreed upon locations. Specific to conducting a remote therapy session, clinical psychologist Zukor (2021) remarked, "I have ‘reminded’ more than one student that I am unwilling to conduct a therapy session while they are in line at the dining hall or local coffee shop, even if they have no personal reservations about their (very public) setting (pp. 3-4)." Standard 4.01 of the Ethics Code (Maintaining Confidentiality) states, “Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium” (APA, 2017). Thus, regardless of a client’s willingness to attend therapy in a given setting, the responsibility lies on the psychologist to protect a client’s confidentiality. 

Physical boundaries also serve to protect the sharing of information. When communication occurs within a defined location, parties are aware of who is present and, thus, privy to the information being shared. Remote work has led to greater risk for psychologists and those with whom they work gaining and sharing personal information that would not have been shared or revealed otherwise. This information can be obtained or revealed through unwelcomed interruptions by third-parties, digital risks, and visual cues. Third-parties, such as roommates, family members, or even strangers in ear-shot of a call may interrupt sessions or meetings. Whether done knowingly or accidentally, this puts those present at greater risk for unintended disclosures or interference with session protocols and interventions (Zukor, 2021). The full nature of digital risks to privacy as well as the protection against those risks are complicated and may not always be fully understood by practitioners and clients. As Chenneville and Schwartz-Mette (2020) pointed out, “Psychologists should be aware that clients, themselves, may be able to record sessions without psychologists’ knowledge or consent” (p. 647). The Ethics Code provides guidelines on protecting client’s privacy and use of digital recordings (see Standard 4.01, Maintaining Confidentiality, and Standard 4.03, Recording; APA, 2017); however, the code lacks guidance around protecting a clinician’s privacy across digital platforms. Visual cues present in the background of a video session or meeting (e.g., clutter, a political flag or poster) could result in unintended sharing of personal or private information. 

Temporal boundaries have also become more diffuse with this shift in practice. For some psychologists, “demands on [their] time have increased, not decreased, during the pandemic” due to employers being “less mindful about scheduling meetings back-to-back or requiring work attendance and participation far beyond the once-valued boundaries of 8am to 5pm, Monday through Friday. Emails arrive at all hours of the day and often require some sort of response or acknowledgement" (Zukor, 2021, p. 2). Blurred temporal boundaries allow for greater flexibility in scheduling (Allen et al., 2021); however, with this benefit also comes risks. With remote work, there is no clear indication of the work-day ending and the risk for work time “bleeding” into personal time and vice versa is increased (Zukor, 2021). This may impact student trainees, employees, and others in relationships in which a power differential exists. Standard 3.08 of the Ethics Code (Exploitative Relationships) states, “Psychologists do not exploit persons over whom they have supervisory, evaluative or other authority such as clients/patients, students, supervisees, research participants, and employees” (APA, 2017). Students and trainees especially may struggle to say “no” to off hours requests given the power differential and concerns of being evaluated negatively, despite Standard 7.06 of the Ethics Code (Assessing Student and Supervisee Experience) stating, “Psychologists evaluate students and supervisees on the basis of their actual performance on relevant and established program requirements” (APA, 2017). 

Role boundaries determine what roles we allot our attention and efforts towards at a given time. Boundary diffusion due to remote work may positively impact the development of skills in role negotiations (Cho, 2020); however, it also establishes opportunity for multitasking (e.g., cooking dinner while in a meeting) which can have negative implications on performance. Studies have found that multitasking negatively impairs productivity and performance (Buser & Peter, 2012; Singh, 2014). Standard 2.03 of the Ethics Code (Maintaining Competence) states, “Psychologists undertake ongoing efforts to develop and maintain their competence” (APA, 2017). Adequate care and attention should be provided to mitigate risk of role boundary diffusion on competence. Allen et al. (2021) argued that it is one’s preference for segmentation (rigid boundaries between roles) and integration (loose boundaries between roles) that impacts work-life outcomes. If there is a misalignment in integration/segmentation preference and degree to which those preferences are met, work and family outcomes will suffer. 

Blurred psychological or work-life boundaries can have negative implications on mental health and well-being, especially in the context of a global pandemic. Boundary diffusion impairs work-life balance, which can be defined as the optimal levelness between achievement in work and enjoyment in personal life (Kumar & Chakraborty, 2013). With greater work-life balance comes increased satisfaction, effectiveness, efficiency, and morale in the workplace as well as reduced stress in home and work domains (Kumar & Chakraborty, 2013). Pluut and Wonders (2020) found that reduced work-life balance is associated with deterioration in healthy lifestyle behaviors (e.g., reduced physical activity, sleep quality, relaxation, and healthy eating) and, as a result of compromised health behaviors, happiness suffers. The stress of the COVID-19 pandemic as well as the racial trauma and political conflict throughout 2020 has increased the United States’ need for mental health providers (APA, 2020; Restauri & Sheridan, 2020). However, as Clay (2020) noted, “[Psychologists] have all of these concerns ourselves, and then we have to also provide support as our patients struggle with them, too” (p. 1). The negative mental health and professional outcomes associated with blurred work-life boundaries directly impacting psychologists have the potential to indirectly harm clients. Standard 3.04 of the Ethics Code (Avoiding Harm) states, “Psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm where it is foreseeable and unavoidable.” 

Lastly, property boundaries have been blurred as a result of the pandemic (Desai et al., 2020; Zukor, 2021). Typically, when going into a physical work location, a work space and necessary materials and devices are provided. However, with remote work the responsibility and expectation has fallen on individuals to extend the use of their personal property to work purposes. This may pose a disproportionate strain on low-income or disadvantaged individuals who may not have the capacity or resources available to shift in this way. Student trainees may be impacted as well when training clinics have to loosen policies that formerly limited students’ use of their personal devices (e.g., cell phones) for clinical work (Desai et al., 2020). 

With the inevitability of future public crises and continued remote work, professional psychology would benefit from adapting its practices. Given the changing way psychologists work, there may be room for expanding the Ethics Code to include avoiding risk and harm specifically pertaining to work-life boundaries. For instance, Standard 4 of the Ethics Code (Privacy and Confidentiality) addresses the importance of protecting clients’ and research participants’ privacy, but not that of psychologists and trainees in remote settings. Future research should evaluate the long-term implications of boundary diffusion (Allen et al., 2021). This research could inform preventative interventions and practices for maintaining optimal work-life balance (Allen et al., 2021). 

To close, here are several tips for psychologists navigating boundary diffusion associated with remote work: 

  • When working with clients:
    • Discuss the impact of remote work on confidentiality with clients as part of the informed consent process (Chenneville & Schwartz-Mette, 2020). Include discussion of third-parties, digital risks, and visual cues.
    • Explicitly review expectations for location boundaries with clients and how difficulties with this will be addressed (Chenneville & Schwartz-Mette, 2020).
  • When working with employees and trainees:
    • Limit expectations for work outside of the established work-day despite ease of contact outside of these hours (Desai et al., 2020).
    • Discuss boundary expectations as part of an onboarding or orientation process.
    • Be mindful of the power differential in relationships and consider the impact of working and communicating outside of temporal boundaries and limits (Desai et al., 2020).
    • Provide additional support resources for those struggling with remote challenges (Pluut & Wonders, 2020)).
    • Consider adjusting work expectations to be responsive to integration/ segmentation preferences (Allen et al., 2021).
    • Attend to employee and trainee work-life balance through establishing clear work shifts and containing communications, expectations for responses, and deadlines within those shifts (Kumar & Chakraborty, 2013)
    • Consider expanding the availability of loanable devices to reduce financial and resource burden for those who need them. 


Allen, T. D., Merlo, K., Lawrence, R. C., Slutsky, J., & Gray, C. E. (2021). Boundary management and work‐nonwork balance while working from home. Applied Psychology.

American Psychological Association. (2020, November 17). Psychologists report large increase in demand for anxiety, depression treatment [Press release].

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct.

Buser, T., & Peter, N. (2012). Multitasking. Experimental Economics, 15(4), 641-655.

Chenneville, T., & Schwartz-Mette, R. (2020). Ethical considerations for psychologists in the time of COVID-19. American Psychologist, 75(5), 644.

Cho, E. (2020). Examining boundaries to understand the impact of COVID-19 on vocational behaviors.

Clay, R. A. (2020, July). Self-care has never been more important. Monitor on Psychology51(5).

Desai, A., Lankford, C., & Schwartz, J. (2020). With crisis comes opportunity: Building ethical competencies in light of COVID-19. Ethics & Behavior, 30(6), 401-413.

Kumar, H., & Chakraborty, S. K. (2013). Work Life Balance (WLB): A key to organizational efficacy. Aweshkar Research Journal, 15(1).

Pluut, H., & Wonders, J. (2020). Not able to lead a healthy life when you need it the most: Dual role of lifestyle behaviors in the association of blurred work-life boundaries with well-being. Frontiers in Psychology11.

Restauri, N., & Sheridan, A. D. (2020). Burnout and posttraumatic stress disorder in the coronavirus disease 2019 (COVID-19) pandemic: Intersection, impact, and interventions. Journal of the American College of Radiology, 17(7), 921-926.

Singh, D. K. C. (2014). Does multitasking improve performance? Evidence from the emergency department. Manufacturing & Service Operations Management, 16(2), 168-183.


May 2021

Ethical Considerations for Transition Back to Live Services
Elijah Hill, MA and Justin B. Lee, PhD, OPA Ethics Committee

On March 11th, 2020 the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic (American Journal of Managed Care Staff, 2021). During this time, like many states across this country, Governor Kate Brown also issued Executive Order 20-12, which was a mandatory stay-at-home order, challenging mental health care providers to continue care for their clients (State of Oregon, 2020). In response, mental health care providers quickly integrated varying degrees of teletherapy (also referred to as telemental health, telepsychology, telemedicine, telehealth, or telepsychiatry) into their practices. Over the last year, the rise in teletherapy served as a catalyst for organizations such as the American Psychological Association (APA), Board Certified-teleMental Health Provider, and Zur Institute Certificate Program in teleMental Health & Digital Ethics to emerge and provide guidelines, training, and certification for the practice of teletherapy (Burgoyne & Cohn, 2020).

With progress slowly being made in regards to the COVID-19 pandemic, mental health care providers now need to prepare for the transition back to in-person therapeutic services. Many factors need to be considered for each provider, clinic, and organization during this transition. While factors related to clinical issues or public health matters are beyond the scope of this article, we will an ethical decision-making model to address the ethical dilemmas that mental health care providers may face during this transition period.

Several provisions in the American Psychological Association’s (APA) Ethical Principles of Psychologists and Code of Conduct (2017; hereafter referred to as the APA Ethics Code) are relevant to this discussion.  First, the General Principles of the APA Ethics Code “guide and inspire psychologists towards the very highest ethical ideals of the profession.” Specifically, Principle A (Beneficence and Nonmaleficence) states that a psychologist has the duty to “benefit those with whom they work and take care to do no harm.” Principle E (Respect for People’s Rights and Dignity) asks that psychologists “respect the dignity and worth of all people.”  Finally, Principle D (Justice) states that all persons have “access to and benefit from the contributions of psychology.”  Additionally, practitioners should be aware of relevant standards in the APA Ethics Code regarding the resolution of conflicts between the Ethics Code and governing bodies (Standard 1.02: Conflicts Between Ethics and Law, Regulations, or other Governing Legal Authority) and organizations (Standard 1.03: Conflicts Between Ethics and Organizational Demands).  It is with these aspirations and standards in mind that we explore the ethical-decision-making model.

The first step within an ethical decision-making model is to identify the problem and which principle(s) and standard(s) may be potentially violated. For example, a potential dilemma for clients who are house-bound, live in remote communities, or have disabilities, is the change in accessibility to care when considering in-person psychotherapy as compared to teletherapy. In this situation, Standard 3.12: Interruption of Psychological Services states that psychologists should “make reasonable efforts to plan for facilitating services in the event that psychological services are interrupted.” The APA Guidelines for the Practice of Telepsychology (2013) state that psychologists “carefully examine the unique benefits of delivering telepsychology services” (Standard 2: Standards of Care in the Delivery of Telepsychology Services), which include considerations pertaining to access of care based on geographic location, convenience for the client, and accommodations for client needs.

The second step of the ethical decision-making model is to develop alternatives and hypothesize solutions for the identified dilemma(s). Collaboration and consultation with mental health professionals may be useful in this process. The APA Ethics Code explicitly encourages psychologists to cooperate with other professionals “in order to serve their clients/patients” in an effective and appropriate manner (3.09: Cooperation with Other Professionals), reach out to local or state psychological groups such as an ethics committee (1.06: Cooperating with Ethics Committees), or reach out to colleagues for consultation (4.06: Consultations) to aid and support in the identification of ethical dilemmas and seek ways to respond and serve client needs. For clients with a change in accessibility, collaboration and consultation may allow psychologists to discuss referral sources that are geographically closer to the client.

After all potential solutions have been generated, the third step is to evaluate and analyze all identified options. In this step, psychologists are encouraged to incorporate the solutions that provide the most benefits and advantages while minimizing disadvantages. When prioritizing, solutions that honor the guiding principles to do the most good and least harm, particularly in regard to the client (3.04: Avoiding Harm) should be considered most ideal. In addition, solutions should remain within the competency of the psychologist providing services based on “their education, training, supervised experience, consultation, study or professional experience” (2.01: Boundaries of Competence). This can be particularly important for psychologists who have recently entered the field or for psychologists in training who have not yet had the opportunity or training to work with clients in a face-to-face modality. Identified referral sources should be accessible for the client, and the psychologist should be knowledgeable in the current treatment modality the client is receiving or wishes to receive.

The fourth step in the ethical decision-making model is to implement a course of action. For example, implementing a course of action may include informing the client “as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy” (10.01: Informed Consent to Therapy). During this informed consent session or any other session, a psychologist should provide “sufficient opportunity for the client/patient to ask questions and receive answers” as it pertains to the transition to in-person services. As with most work of a psychologist, documentation of the selected course of action should be created and appropriately stored (6.01: Documentation of Professional and Scientific Work and Maintenance of Records). If termination is the selected course of action, the psychologist should “provide pretermination counseling and suggest alternative service providers as appropriate” (10.10 Terminating Therapy). As part of that counseling meeting, plans for confidential transfer of client records should be collaboratively identified (6.02 Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work). If applicable, a meeting with the new psychologist in the client’s area may be held in order to provide an opportunity for a warm hand-off. The current psychologist, the transfer psychologist, and the client can all meet to allow the client to become comfortable with the transfer psychologist and the transfer process.

The final step in the decision-making model is to evaluate the effectiveness of the solution that was identified and implemented. One needs to consider whether the ethical dilemma has fully and appropriately been resolved. If the dilemma continues, such as limited or no mental health professionals in the client’s area, an alternative approach may be warranted .  To identify this alternative approach, the psychologist may need to work through the decision-making model again, identifying additional options and weighing pros and cons of each option.       In conclusion, as the practice of psychology continues to evolve in Oregon during this pandemic, mental health care providers are encouraged to utilize the APA Code of Ethics as a guide to assist them during the transition to in-person services.


American Journal of Managed Care Staff. (2021). A timeline of COVID-19 developments in 2020.

American Psychological Association. (2013). Guidelines for the practice of telepsychology.

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

Burgoyne, N., & Cohn, A. S. (2020). Lessons from the transition to relational teletherapy during COVID-19.
          Family Process, 59(3), 974-988. 

State of Oregon. (2020). Executive order No. 20-12.

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.  


American Psychological Association. (2015).
          Demographics of the U.S. psychology workforce: Findings from the American Community Survey.

American Psychological Association. (2017).
          Ethical principles of psychologists and code of conduct.

Gibson, M. F. (2012). Opening up: Therapist self-disclosure in theory, research, and practice.
          Clinical Social Work Journal, 40, 287-296.

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.

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.

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.

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.

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.

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.

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.


American Psychological Association. (2016, December 1).
          Summary Report, Graduate Study in Psychology 2017: Student Demographics.

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct.

American Psychological Association. (2020). Demographics of U.S. psychology workforce
          [Interactive Data Tool].

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.

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. 

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.

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.

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.

Hamp, A., Stamm, K., Lin, L., & Christidis, P. (2016). 
          2015 APA survey of psychology health service providers. American Psychological Association.

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.

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.

Miller, C., & Stassun, K. (2014). A test that fails. Nature, 510(7504), 303-304.

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. 

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.

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. 

U.S. Census Bureau. (n.d.).U.S. Census Bureau QuickFacts: United States.  U.S. Department of Commerce.

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.


American Psychological Association. (2013). Guidelines for the practice of telepsychology. 

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct
          (2002, amended effective June 1, 2010, and January 1, 2017). 

American Psychological Association. (2020a).
          Psychologists embrace telehealth to prevent the spread of COVID-19.

American Psychological Association. (2020b). Informed consent checklist for telepsychological services.

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.

Oregon Board of Psychology. (2015). Telepsychology

Pierce, B. S., Perrin, P. B., Tyler, C. M., McKee, G. B., & Watson, J. D. (2020).
           The COVID-19  telepsychology revolution:
           A national study of pandemic-based changes in U.S. mental health care delivery.
           American Psychologist. Advance online publication.

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.


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

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.

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.

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.

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.