Psychological Reports, 1991, 69, 1215-1223.
O Psychological Reports 1991
TEACHING PROFESSIONAL ETHICS TO UNDERGRADUATE COUNSELING STUDENTS ' C. SUE LAMB University of North Carolina at Wilmington Summary.-Teaching ethics to undergraduates is a topic of increasing interest among mental health professionals; knowledge of ethics is particularly important to students who seek employment in agencles afrer graduation. This article describes methods of presenting ethics of practice both in a separate ethics course and as part of an undergraduate counseling practicum. Sources of materials used for course readings are presented.
According to Vasquez (1988), mental health professionals need to have a course in ethics as part of their academic training. The teaching of ethics to counselors at both the graduate and undergraduate levels is essential to the twofold responsibility of training programs to teach and to protect. Such training in professional ethics ensures protection for the consumers and enhances the necessary competence of the professionals or paraprofessionals who are in training. The explicit teaching of ethics at both the graduate and undergraduate levels has recently become a matter of considerable interest. McGovern (1988) indicated that, although articles on some aspects of ethics were fairly common, he could find only one (Abeles, 1980) on the actual teaching of ethics. He went on to describe a required graduate-level course that has three main objectives for students: (a) To understand APA's (1981) "Ethical Principles of Psychologists"; (b) To apply those principles to specific cases in terms of analysis and formulation and evaluation of alternatives; and (c) To "develop, clarify, or refine a personal philosophy of moral behavior and ethical decision making" (McGovern, 1988, p. 22). More recently, Matthews' (1991) article discusses psychological ethics from two perspectives: the teaching of ethics and the ethics of teaching. Haemmerlie and Matthews (1988) pointed out that many bachelor's degree majors in psychology are employed in a variety of paraprofessional and direct human service positions. The authors suggest that in preparing undergraduate students for such careers, we need to ask, "What, where, when, and how are ethical issues taught?" (p. 192). They also suggest that undergraduates at the very least need to know that, when in professional-type positions, "they cannot ethically do whatever they want or whatever they alone think is right" (p. 192). This unethical reasoning and resulting behavior is a problem for practicing psychologists as well as for other mental 'Address requests for reprints to C. Sue Lamb, Ph.D., University of North Carolina at Wilmington, South College Road, Wilmington, NC 28403-3297.
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health professionals and paraprofessionals. For example, in Pope and Bajt's (1988) survey, one question was: "In the most serious, significant, or agonizing instance, if any, what law or formal ethical principle have you broken intentionally in light of a client's welfare or other deeper value?" (p. 828). Twenty-one percent of those responding indicated that they had withheld information regarding child abuse from authorities. The justification was that to report the child abuse would damage and even destroy the therapeutic goals. As Van Eenwyk (1990) argued in a comment about the article, "To spare the [abusing] parents was to be guilty by association of the same justifications used by those responsible for the problem-being beyond the law" (p. 400). However, a survey conducted by the Johns Hopkins Sexual Disorders Clinic and reported in Psychotherapy Today (Child Abuse, 1991) found that self-disclosure of child sexual abuse dropped from 21 per year to O after a Maryland state law, similar to those in all 50 states, was passed in 1989 which ordered mental health professionals to report suspected child abuse. As was pointed out in the article, society may be asked to decide in particular situations which is more important, prosecuting an offender or emphasizing a public health approach by giving priority to the identification and treatment of abused chddren. According to Swenson (1983), students who work in human service positions need to understand the variety of legal issues as well as moral principles involved in a professional code of ethics. In addition, as Mills (1984) stated, students must learn procedures to follow if they find themselves with an ethical violation. For example, students aspiring to careers as psychologists need to know how the APA Ethics Committee conducts its affairs. They also need to learn not to hesitate in bringing ethical concerns to the attention of their colleagues, supervisors, and teachers. The APA has long emphasized that education is the best way to foster ethical behavior (Hobbs, 1948). At least two presentations at the 1989 APA convention dealt with increased awareness of the need to teach ethics to undergraduates. Matthews (1989) titled her Division Two address, "Teaching of Ethics and Ethics of Teaching." In it she said that she hoped ". . . to stimulate some of you to think and write about these issues" and went on to point out that undergraduates who will be future professionals may not be getting sufficient experience with ethical issues. In an invited address, Brewer (1989) predicted that ethics wdl be one of "[tlhree topics [that] will become more visible in our undergraduate curricula. . . ." Interest in ethics is further indicated by the establishment of a Task Force on Ethical Issues in Teaching and Academic Life by Division Two of APA. At the University of North Carolina at Wilmington for the last 15 years, ethics of practice has been presented formally in a course, Ethical
TEACHING PROFESSIONAL ETHICS
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Issues in Psychology, and as an integral component of our undergraduate Supervised Counseling Practicum, as suggested by Haemmerlie and Matthews (1988). This article briefly describes both methods of presentation. AN UNDERGRADUATE ETHICSCOURSE Ethcal Principles in Psychology is a one-credit course directed toward consideration of ethical issues in practice that was initially designed to complement our undergraduate supervised counseling practicum. Practicum students are strongly encouraged to take this course either before or with their counseling practicum. Perhaps reflecting an increasing concern with ethics among students, it has in recent years begun to attract nonpracticum students and other undergraduates preparing for human service positions, such as social work majors. As an indication of increased interest, enrollment has grown over the last five years from six or eight students to more than 30. Many students have suggested that course be required of all psychology majors. Goals of the Course The goals are very similar to those of McGovern (1988): Students are expected to know the APA "Ethical Principles of Psychologists" and to be able to apply them to hypothetical and real cases. Of over-ridmg importance is the goal of helping students to accept responsibility for the consequences of their actions as paraprofessionals or as members of the mental health professions (Lamb, 1980-81). Structure and Content of the Course The course is structured around the APA "Ethical Principles of Psychologists" (American Psychological Association, 1990); the APA Ethical Principles of Psychologists serves as a required text. As indicated above, emphasized throughout is Principle 1, Responsibility. Also covered in detail are Principles 2, Competence; 3, Moral and Legal Standards; 4, Public Statement; 5 , Confidentiality; 6, Welfare of the Consumer; and 7, Professional Relations. Principles 9 and 10, which deal with ethics in research with humans and nonhumans, were previously covered in the course. They were omitted because of increased consideration of other topics. Both are covered to some extent in required research-based courses. One topic that now receives increased coverage is dual-role relationships, as described later. As each principle is presented, it is discussed in detail with examples of violations obtained from the Casebook on Ethical Principles of Psychologists (American Psychological Association, 1987) or from my own or colleagues' experiences. Important legal issues such as the requirement of reporting child abuse and the Tarasoff v. Regents of the University of California, et al. court ruling are discussed in class (mentioned in detail later in this article). For example, I use my own (disguised) experience with an acutely psychotic cli-
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ent who heard voices from God demanding that he shoot an on-campus acquaintance as an example of the application of the Tarasoff ruling. Sharing with the students my own struggles as a counselor with legal and ethical issues helps emphasize the fact that these problems do happen to "people like us.'' Several class periods are spent discussing when therapists are legally or ethically obligated to break confidence and when they must remain silent. Illegal drug use, suicide threats, dual-roles, and counseling children and adolescents with and without parental consent are a few of the topics discussed. An ethical issue that is frequently omitted or given minimal coverage, even in graduate-level texts, is that of dual-role relationships. This issue (Kitchener, 1988) is of great importance and should be discussed at length with students and counselors-in-training. Most mental health professionals are guided by their organization's ethical code prohibiting dual-role relationships, especially sexual relationships between counselors or therapists and their clients. The American Association for Counseling and Development (AACD) Code of Ethics (1983, as reprinted by Corey, Corey, and Callanan, 1988) states: "Dual relationships with clients that might impair the member's objectivity and professional judgement . . . must be avoided and/or the counseling relationship terminated through referral to another competent professional" (Corey, et al., 1988, p. 388). The Statement of Ethical and Professional Standards of the American College Personnel Association (ACPA, 1980) goes farther than relationships with clients. It requires its members to refrain from relationships that impinge on the dignity, moral code, selfworth, professional functioning, and/or personal growth of these individuals. It declares unethical any sexual relationships with staff members or students who are under the supervision of, or who are evaluated by, the professional. The Ethical Principles for Psychologists (American Psychological Association, 1990) mandates that psychologists avoid any dual relationships that "could impair their professional judgment or increase the risk of exploitation" (p. 393). Examples of dual-roles cited in the code of ethics include dual-role relationships involving research and/or treatment of students, supervisees, employees, friends, and relatives. As Kitchener (1988) argued, the ~otentialfor harm in dual-role relationships increases when "the conflict between interests is great, the power differential large, and the role expectations incompatible" (p. 220). Kitchener further suggested that when the potential for harm is great, those relationships should be considered "a priori unethical." At the other extreme, when the conflict is small, the difference in power narrow, and the expectation of roles compatible, then the danger of possible harm is limited. As pointed out by Matthews (1991), the professional relationship between students and faculty is frequently blurred. This behavior may result in harm to students who find themselves in dual-role relationships with faculty. For ex-
TEACHING PROFESSIONAL ETHICS
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ample, Glaser and Thorpe (1986) did an anonymous survey of women in Division 12 of APA (Clinical Psychology) which suggests that harm can result from faculty-student sexual relations. They learned that 31% of the women who responded reported that faculty had made sexual advances toward them when they were students. Most distressing was the judgement of these women that the results of this behavior had been harmful to them. Students are taught that the single most commonly violated ethical code is the prohibition of sexual contact with clients (Pope, Keith-Spiegel, & Tabachnick, 1986). According to Vasquez (1988), this topic is frequently deemphasized in training programs because of the reluctance to discuss the topic of sexuality. Students are encouraged to develop self-awareness regarding their own sexuality, needs, and wants. Vasquez (1988) suggested that the following topics are relevant to this discussion: the psychology of women, the changing roles of men and women in society, the limiting effects of gender socialization, and most important, the power difference between women and men and how it can affect the counseling and student-teacher relationship. Students are also made aware of the judicial and legal consequences of sexual behavior with clients and teachers. They are informed that this ethical violation can be grounds for malpractice suits and dismissal of staff or faculty. Pope, et al. (1986) noted that 1 in 10 male therapists and 1 in 50 female therapists become sexually involved with their clients. Less frequently examined, according to Pope, et al. (1986), are the harmful effects even small sexual advances from the counselor can have on a client. Therapy can be halted prematurely, and hospitalizations, due to suicide attempts, are not uncommon. Vasquez (1988) says that students need to be introduced to the idea of boundaries. Such boundaries include limiting the kind and amount of touching, limiting the relationship with the client to a professional one (not social or sexual), and consulting with a more experienced colleague/supervisor if counselors find themselves becoming attracted to the client or if the client appears to have a sexual interest in them. STATUTORY CONFUSION OVERDUTIESTO WARNAND TO PROTECT USINGTHE DIDACTICMETHOD The decision of the California Supreme Court in Tarasoff v. Regents of the University of California (mentioned earlier) mandated that therapists have a duty to protect potential victims from their outpatients' violent acts (A legal primer for mental health professionals, 1991). However, among various states' statutes a clear and consistent standard has not emerged. Only Ohio has done away with the common-law duty to protect. The result has been considerable confusion and blur of the mental health professional's obligations.
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The court r d n g states that the duty to protect begins when the mental health professional determines that the patient or client presents a serious danger of violence to another person. The didactic forum is an excellent method for teaching students about the occasional lack of clarity as to what their moral, ethical, and legal obligations are in certain situations. Students are asked to discuss and debate such questions as: When does the legal duty to protect come into play? and Does the duty to protect begin when patients or clients have communicated actual threats of violence or merely implied them? In addition, is the therapist obligated to "know" a patient or client is violent? Can violence be predicted? Real as well as hypothetical cases are presented to students who are then challenged to clarify what their obligations are morally, ethically, and legally. These duties are not always identical. Vagueness of aspects of duty-to-protect legislation can be brought into the lesson by having students discuss and debate among themselves with the professor what they would do if a client threatens to spray the campus with an automatic rifle. Who are the victims that should be warned? Would a mental health professional be obligated to warn only specified victims? How about random victims? Does the duty to protect involve only warnings to potential victims or should the therapist also be obligated to notify police? Should the mental health professional initiate involuntary commitment proceedings? Is there a conflict between the duty to protect and other legal obligations to protect clients' confidentiality? Lively and informative discussions often result from this teaching method. ETHICSIN THE UNDERGRADUATE COUNSELING PRACTICUM According to Haemmerlie and Matthews (1988), the undergraduate practicum is an ideal forum for dealing with ethical issues. Because students may forget what they hear, but remember what they do, I routinely bring up ethical issues in our weekly counseling practicum supervision sessions. As students discuss what is happening at their practicum settings, I take care to find, point out, and explore potential ethical problems as well as why and how supervisors behave as they do for ethical reasons. For example, one counseling practicum student was justly distressed that a group of professionals at one agency discussed a client at lunch in a crowded public restaurant using not only the client's name but other identifying details. We then discussed how the student should deal with this situation. Counseling practicum students working at a local psychiatric facility are asked how they would react if I were to inquire about an hypothetical student, John Doe, who I heard had been hospitalized there. What might be the ethical consequences of responding, "He's fine."? Counseling practicum students working at the Student Development Center on our campus are asked what they would do if the Chair of the Psychology Department were to ask them if Suzie Smith, whom he referred earlier that day on an emergency basis, "made it over there."
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For those students working with inmates, a relevant issue concerns the ethical and legal dilemma of what to do upon learning in a counseling session that an inmate or client is selling drugs he smuggles into the honor grade prison facility. For those working with troubled teenagers, one question is: How would they respond if their 14-year-old client were to share with them that she was pregnant and planning to have an abortion without her parents' knowledge or consent? These ethical (and sometimes legal) dilemmas often occur during the course of the counseling practicum and are no longer simply "academic" exercises. Counseling practicum is an excellent forum in which to teach ethics; it is during this hands-on experience that students' counseling courses as well as what they have formally learned about ethical professional practices first become relevant and meaningful. As McMinn (1988) has demonstrated, such use of the counseling student's own case studies from real life can facilitate students in acquiring an understanding as well as an appreciation of the application of general professional concepts to real life. -
-
SOMESOURCESOF MATERLALSON ETHICS Over the years, I have collected numerous APA Monitor and American Psychologist articles on ethical issues as well as newspaper clippings of therapists and counselors who have been found guilty of such offenses as sexual relations with clients. These readings are assigned and discussed in both the ethics course and the practicum. Other readings are assigned from sources such as: Macklin (1982), Bayles (1981), Corey, et al. (1988), and KeithSpiegel and Koocher (1985). Particularly useful are books by Jensen (1985) and Thompson (1983). Jensen's book is comprised of professional articles from journals such as Professional Psychology, The Clinical Psychologist, and American Psychologist. Thompson's book addresses ethical concerns in psychotherapy as well as their legal ramifications. Other sources useful for occasional articles on current ethical concerns and cases are the Harvard Newsletter and Psychiatric News: Newspaper of the American Psychiatric Association. One article in the latter had students eagerly discussing the consequences of the U.S. Supreme Court rejecting an appeal from the American Psychiatric Association and its California and Hawaii district branches that places confidentiality at risk in federal criminal cases (1989, November). EVALUATION OF THE PRESENTATIONS Written and oral ratings have consistently been positive. In formal evaluations, the ethics course averages about 1.5 on a 5-point scale (with 1 being highest). Recently, three alumni stated to the current counseling practicum class that the ethics and practicum courses were two of the three courses taught in the department which had best prepared them for their graduate education and graduate practicum experience. Another recent graduate, employed by the Department of Social Services, told me that the ethics course
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had been invaluable to her. She said that her knowledge about confidentiality and competence had come entirely from the ethics course.
CONCLUSION Teaching ethics to undergraduate counseling students is desirable and ethically mandated. Most students upon graduation do not attend graduate school. Many seek employment in mental health centers, psychiatric hospitals, residential treatment centers and homes, social agencies, schools, and personnel offices. As paraprofessionals, they need to be aware of the legal and ethical issues, concerns, and obligations they will be confronting. The question might be asked, Where, if not as part of their undergraduate program, wiU such students become sensitive to and knowledgeable about ethics and ethical issues? REFERENCES ABELES,N. (1980) Teaching ethical principles by means of value confrontations. Psychotherapy: Theory, Research, and Practice, 17, 384-391. AMERICAN ASSOCIATIONFOR COUNSELING A N D DEVELOPMENT. (1983) Ethical standards. In G . Corey, M. S. Corey, & l? Callanan (Eds.), Issues and ethics in the be(ping professions. (3rd ed.) Pacific Grove, CA: Brooks/Cole. Pp. 386-392. AMERICANCOLLEGEPERSONNEL ASSOCIA~ON. (1980) Statement of ethical and professional standards. Alexandria, VA: Author. AMWCANPSYCHOLOGICAL ASSOCIATION. (1987) Casebook on ethical principles ofpsycbologists. Washington, DC: American Psychological Association. AMERICANPSYCHOLOGIC~L ASSOCIA~ON. (1990) Ethical principles of psychologists. American Psychologist, 36, 390-395. BAYLES,M. (1981) Professionalethics. Belmonr, CA: Wadsworth. BREWER,C. L. (1989) Dodoes and caucus-races: the wonderland of psychology. Paper presented at the annual convention of the American Psychological Association, New Orleans, LA. Child abuse: mandated reporting claimed to perpetuate abuse. (1991) Psychotherapy Today: The Independent Psychotherapy Newsletter, 2, 7-8. Confidentiality at risk in federal criminal cases. (1989, November) Psychiatric News: Newspapm of the American Psychiatric Association, p. 10. COREY,G., COREY,M. S., & CALLANAN, P. (1988) Issues and ethics in the helping professions. (3rd ed.) Pacific Grove, CA: Brooks/Cole. GLASER,R. D., & THORPE, J. S. (1986) A survey of sexual contact and advances between psychology educators and female graduate students. American Psychologist, 41, 43-51. HAEMMERLIE, F. M., & MAITHEMS,J. R. (1988) Preparing undergraduates for para rofessional positions: what, where, when, and how are ethical issues taught? Teaching o A c h o l o g y , 15. 192-194. Hawaii rejects psychologist script privileges. (1989) Psychiatric News: Newspaper of the American Psychiatric Association, pp. 1, 19, 31. Hosss, N . (1948) The development of a code of ethical standards for psychology. American Psychologist, 3, 80-84. JENSEN,R. E. (1985) Ethical issues in clinical psychology. Lanham, MD: Univer. Press of America. KEITH-SPIEGEL,P,& KOOCHER, G. (1985) Ethics in psychologv: standards and cases. New York: Random House. KITCHENER,K. S. (1988) Dual role relationships: what makes them so problematic? Journal of Counseling and Development, 67, 217-220. LAMB, C . S. (1980-81) The fourth R: responsibility, American Secondary Education, 10, 9-14.
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MACKUN,R. (1982) Man, mind and morality: the ethics of behavior control. Englewood Cliffs, NJ: Prentice-Hall. M A ~ E W SJ., R. (1991) The teaching of ethics and the ethics of teaching. Teaching o/ Prychology, 18, 80-85. MCGOVERN, T. V. (1988) Teaching the ethical principles of psychology. Teaching of Psychology, 15. 22-26. McMuw, M. R. (1988) Ethics case-study simulation: a generic tool for psychology teachers. Teaching of Psychology, 15, 100-101. W s , D. H. (1984) Ethics education and adjudication within psychology. American Psychologist, 39, 669-675. POPE, K.-s., & BAJT, T. (1988) When laws and values con€lict: a dilemma for psychologists. American Psychologist, 43, 828-829. POPE,K. S., KEITH-SPIEGEL,P., & TABACHNICK, B. G. (1986) Sexual attraction to clients: the human therapist and the (sometimes) inhuman training system. American Psychologist, 41, 147-158. SWENSON, E. V. (1983) Incorporating law into the undergraduate psychology curriculum. Teaching of Psychology, 10, 119-120. THOMPSON, A. (1983) Ethical concerns in psychotherapy and their legal ramifications. Lanham, MD: Univer. Press of America. VAN EENWYK,J. R. (1990) When laws and values conflict: comment on Pope and Bajt. American Prychologist, 45, 399-400. VASQUEZ,M. J. T. (1988) Counselor-client sexual contact: implications for ethics training. Jozrrnal of Counseling and Development, 67, 238-241.
Accepted December 3, 1991.
O Psychological Reports 1991
TEACHING PROFESSIONAL ETHICS TO UNDERGRADUATE COUNSELING STUDENTS ' C. SUE LAMB University of North Carolina at Wilmington Summary.-Teaching ethics to undergraduates is a topic of increasing interest among mental health professionals; knowledge of ethics is particularly important to students who seek employment in agencles afrer graduation. This article describes methods of presenting ethics of practice both in a separate ethics course and as part of an undergraduate counseling practicum. Sources of materials used for course readings are presented.
According to Vasquez (1988), mental health professionals need to have a course in ethics as part of their academic training. The teaching of ethics to counselors at both the graduate and undergraduate levels is essential to the twofold responsibility of training programs to teach and to protect. Such training in professional ethics ensures protection for the consumers and enhances the necessary competence of the professionals or paraprofessionals who are in training. The explicit teaching of ethics at both the graduate and undergraduate levels has recently become a matter of considerable interest. McGovern (1988) indicated that, although articles on some aspects of ethics were fairly common, he could find only one (Abeles, 1980) on the actual teaching of ethics. He went on to describe a required graduate-level course that has three main objectives for students: (a) To understand APA's (1981) "Ethical Principles of Psychologists"; (b) To apply those principles to specific cases in terms of analysis and formulation and evaluation of alternatives; and (c) To "develop, clarify, or refine a personal philosophy of moral behavior and ethical decision making" (McGovern, 1988, p. 22). More recently, Matthews' (1991) article discusses psychological ethics from two perspectives: the teaching of ethics and the ethics of teaching. Haemmerlie and Matthews (1988) pointed out that many bachelor's degree majors in psychology are employed in a variety of paraprofessional and direct human service positions. The authors suggest that in preparing undergraduate students for such careers, we need to ask, "What, where, when, and how are ethical issues taught?" (p. 192). They also suggest that undergraduates at the very least need to know that, when in professional-type positions, "they cannot ethically do whatever they want or whatever they alone think is right" (p. 192). This unethical reasoning and resulting behavior is a problem for practicing psychologists as well as for other mental 'Address requests for reprints to C. Sue Lamb, Ph.D., University of North Carolina at Wilmington, South College Road, Wilmington, NC 28403-3297.
1216
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health professionals and paraprofessionals. For example, in Pope and Bajt's (1988) survey, one question was: "In the most serious, significant, or agonizing instance, if any, what law or formal ethical principle have you broken intentionally in light of a client's welfare or other deeper value?" (p. 828). Twenty-one percent of those responding indicated that they had withheld information regarding child abuse from authorities. The justification was that to report the child abuse would damage and even destroy the therapeutic goals. As Van Eenwyk (1990) argued in a comment about the article, "To spare the [abusing] parents was to be guilty by association of the same justifications used by those responsible for the problem-being beyond the law" (p. 400). However, a survey conducted by the Johns Hopkins Sexual Disorders Clinic and reported in Psychotherapy Today (Child Abuse, 1991) found that self-disclosure of child sexual abuse dropped from 21 per year to O after a Maryland state law, similar to those in all 50 states, was passed in 1989 which ordered mental health professionals to report suspected child abuse. As was pointed out in the article, society may be asked to decide in particular situations which is more important, prosecuting an offender or emphasizing a public health approach by giving priority to the identification and treatment of abused chddren. According to Swenson (1983), students who work in human service positions need to understand the variety of legal issues as well as moral principles involved in a professional code of ethics. In addition, as Mills (1984) stated, students must learn procedures to follow if they find themselves with an ethical violation. For example, students aspiring to careers as psychologists need to know how the APA Ethics Committee conducts its affairs. They also need to learn not to hesitate in bringing ethical concerns to the attention of their colleagues, supervisors, and teachers. The APA has long emphasized that education is the best way to foster ethical behavior (Hobbs, 1948). At least two presentations at the 1989 APA convention dealt with increased awareness of the need to teach ethics to undergraduates. Matthews (1989) titled her Division Two address, "Teaching of Ethics and Ethics of Teaching." In it she said that she hoped ". . . to stimulate some of you to think and write about these issues" and went on to point out that undergraduates who will be future professionals may not be getting sufficient experience with ethical issues. In an invited address, Brewer (1989) predicted that ethics wdl be one of "[tlhree topics [that] will become more visible in our undergraduate curricula. . . ." Interest in ethics is further indicated by the establishment of a Task Force on Ethical Issues in Teaching and Academic Life by Division Two of APA. At the University of North Carolina at Wilmington for the last 15 years, ethics of practice has been presented formally in a course, Ethical
TEACHING PROFESSIONAL ETHICS
1217
Issues in Psychology, and as an integral component of our undergraduate Supervised Counseling Practicum, as suggested by Haemmerlie and Matthews (1988). This article briefly describes both methods of presentation. AN UNDERGRADUATE ETHICSCOURSE Ethcal Principles in Psychology is a one-credit course directed toward consideration of ethical issues in practice that was initially designed to complement our undergraduate supervised counseling practicum. Practicum students are strongly encouraged to take this course either before or with their counseling practicum. Perhaps reflecting an increasing concern with ethics among students, it has in recent years begun to attract nonpracticum students and other undergraduates preparing for human service positions, such as social work majors. As an indication of increased interest, enrollment has grown over the last five years from six or eight students to more than 30. Many students have suggested that course be required of all psychology majors. Goals of the Course The goals are very similar to those of McGovern (1988): Students are expected to know the APA "Ethical Principles of Psychologists" and to be able to apply them to hypothetical and real cases. Of over-ridmg importance is the goal of helping students to accept responsibility for the consequences of their actions as paraprofessionals or as members of the mental health professions (Lamb, 1980-81). Structure and Content of the Course The course is structured around the APA "Ethical Principles of Psychologists" (American Psychological Association, 1990); the APA Ethical Principles of Psychologists serves as a required text. As indicated above, emphasized throughout is Principle 1, Responsibility. Also covered in detail are Principles 2, Competence; 3, Moral and Legal Standards; 4, Public Statement; 5 , Confidentiality; 6, Welfare of the Consumer; and 7, Professional Relations. Principles 9 and 10, which deal with ethics in research with humans and nonhumans, were previously covered in the course. They were omitted because of increased consideration of other topics. Both are covered to some extent in required research-based courses. One topic that now receives increased coverage is dual-role relationships, as described later. As each principle is presented, it is discussed in detail with examples of violations obtained from the Casebook on Ethical Principles of Psychologists (American Psychological Association, 1987) or from my own or colleagues' experiences. Important legal issues such as the requirement of reporting child abuse and the Tarasoff v. Regents of the University of California, et al. court ruling are discussed in class (mentioned in detail later in this article). For example, I use my own (disguised) experience with an acutely psychotic cli-
1218
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ent who heard voices from God demanding that he shoot an on-campus acquaintance as an example of the application of the Tarasoff ruling. Sharing with the students my own struggles as a counselor with legal and ethical issues helps emphasize the fact that these problems do happen to "people like us.'' Several class periods are spent discussing when therapists are legally or ethically obligated to break confidence and when they must remain silent. Illegal drug use, suicide threats, dual-roles, and counseling children and adolescents with and without parental consent are a few of the topics discussed. An ethical issue that is frequently omitted or given minimal coverage, even in graduate-level texts, is that of dual-role relationships. This issue (Kitchener, 1988) is of great importance and should be discussed at length with students and counselors-in-training. Most mental health professionals are guided by their organization's ethical code prohibiting dual-role relationships, especially sexual relationships between counselors or therapists and their clients. The American Association for Counseling and Development (AACD) Code of Ethics (1983, as reprinted by Corey, Corey, and Callanan, 1988) states: "Dual relationships with clients that might impair the member's objectivity and professional judgement . . . must be avoided and/or the counseling relationship terminated through referral to another competent professional" (Corey, et al., 1988, p. 388). The Statement of Ethical and Professional Standards of the American College Personnel Association (ACPA, 1980) goes farther than relationships with clients. It requires its members to refrain from relationships that impinge on the dignity, moral code, selfworth, professional functioning, and/or personal growth of these individuals. It declares unethical any sexual relationships with staff members or students who are under the supervision of, or who are evaluated by, the professional. The Ethical Principles for Psychologists (American Psychological Association, 1990) mandates that psychologists avoid any dual relationships that "could impair their professional judgment or increase the risk of exploitation" (p. 393). Examples of dual-roles cited in the code of ethics include dual-role relationships involving research and/or treatment of students, supervisees, employees, friends, and relatives. As Kitchener (1988) argued, the ~otentialfor harm in dual-role relationships increases when "the conflict between interests is great, the power differential large, and the role expectations incompatible" (p. 220). Kitchener further suggested that when the potential for harm is great, those relationships should be considered "a priori unethical." At the other extreme, when the conflict is small, the difference in power narrow, and the expectation of roles compatible, then the danger of possible harm is limited. As pointed out by Matthews (1991), the professional relationship between students and faculty is frequently blurred. This behavior may result in harm to students who find themselves in dual-role relationships with faculty. For ex-
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ample, Glaser and Thorpe (1986) did an anonymous survey of women in Division 12 of APA (Clinical Psychology) which suggests that harm can result from faculty-student sexual relations. They learned that 31% of the women who responded reported that faculty had made sexual advances toward them when they were students. Most distressing was the judgement of these women that the results of this behavior had been harmful to them. Students are taught that the single most commonly violated ethical code is the prohibition of sexual contact with clients (Pope, Keith-Spiegel, & Tabachnick, 1986). According to Vasquez (1988), this topic is frequently deemphasized in training programs because of the reluctance to discuss the topic of sexuality. Students are encouraged to develop self-awareness regarding their own sexuality, needs, and wants. Vasquez (1988) suggested that the following topics are relevant to this discussion: the psychology of women, the changing roles of men and women in society, the limiting effects of gender socialization, and most important, the power difference between women and men and how it can affect the counseling and student-teacher relationship. Students are also made aware of the judicial and legal consequences of sexual behavior with clients and teachers. They are informed that this ethical violation can be grounds for malpractice suits and dismissal of staff or faculty. Pope, et al. (1986) noted that 1 in 10 male therapists and 1 in 50 female therapists become sexually involved with their clients. Less frequently examined, according to Pope, et al. (1986), are the harmful effects even small sexual advances from the counselor can have on a client. Therapy can be halted prematurely, and hospitalizations, due to suicide attempts, are not uncommon. Vasquez (1988) says that students need to be introduced to the idea of boundaries. Such boundaries include limiting the kind and amount of touching, limiting the relationship with the client to a professional one (not social or sexual), and consulting with a more experienced colleague/supervisor if counselors find themselves becoming attracted to the client or if the client appears to have a sexual interest in them. STATUTORY CONFUSION OVERDUTIESTO WARNAND TO PROTECT USINGTHE DIDACTICMETHOD The decision of the California Supreme Court in Tarasoff v. Regents of the University of California (mentioned earlier) mandated that therapists have a duty to protect potential victims from their outpatients' violent acts (A legal primer for mental health professionals, 1991). However, among various states' statutes a clear and consistent standard has not emerged. Only Ohio has done away with the common-law duty to protect. The result has been considerable confusion and blur of the mental health professional's obligations.
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The court r d n g states that the duty to protect begins when the mental health professional determines that the patient or client presents a serious danger of violence to another person. The didactic forum is an excellent method for teaching students about the occasional lack of clarity as to what their moral, ethical, and legal obligations are in certain situations. Students are asked to discuss and debate such questions as: When does the legal duty to protect come into play? and Does the duty to protect begin when patients or clients have communicated actual threats of violence or merely implied them? In addition, is the therapist obligated to "know" a patient or client is violent? Can violence be predicted? Real as well as hypothetical cases are presented to students who are then challenged to clarify what their obligations are morally, ethically, and legally. These duties are not always identical. Vagueness of aspects of duty-to-protect legislation can be brought into the lesson by having students discuss and debate among themselves with the professor what they would do if a client threatens to spray the campus with an automatic rifle. Who are the victims that should be warned? Would a mental health professional be obligated to warn only specified victims? How about random victims? Does the duty to protect involve only warnings to potential victims or should the therapist also be obligated to notify police? Should the mental health professional initiate involuntary commitment proceedings? Is there a conflict between the duty to protect and other legal obligations to protect clients' confidentiality? Lively and informative discussions often result from this teaching method. ETHICSIN THE UNDERGRADUATE COUNSELING PRACTICUM According to Haemmerlie and Matthews (1988), the undergraduate practicum is an ideal forum for dealing with ethical issues. Because students may forget what they hear, but remember what they do, I routinely bring up ethical issues in our weekly counseling practicum supervision sessions. As students discuss what is happening at their practicum settings, I take care to find, point out, and explore potential ethical problems as well as why and how supervisors behave as they do for ethical reasons. For example, one counseling practicum student was justly distressed that a group of professionals at one agency discussed a client at lunch in a crowded public restaurant using not only the client's name but other identifying details. We then discussed how the student should deal with this situation. Counseling practicum students working at a local psychiatric facility are asked how they would react if I were to inquire about an hypothetical student, John Doe, who I heard had been hospitalized there. What might be the ethical consequences of responding, "He's fine."? Counseling practicum students working at the Student Development Center on our campus are asked what they would do if the Chair of the Psychology Department were to ask them if Suzie Smith, whom he referred earlier that day on an emergency basis, "made it over there."
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For those students working with inmates, a relevant issue concerns the ethical and legal dilemma of what to do upon learning in a counseling session that an inmate or client is selling drugs he smuggles into the honor grade prison facility. For those working with troubled teenagers, one question is: How would they respond if their 14-year-old client were to share with them that she was pregnant and planning to have an abortion without her parents' knowledge or consent? These ethical (and sometimes legal) dilemmas often occur during the course of the counseling practicum and are no longer simply "academic" exercises. Counseling practicum is an excellent forum in which to teach ethics; it is during this hands-on experience that students' counseling courses as well as what they have formally learned about ethical professional practices first become relevant and meaningful. As McMinn (1988) has demonstrated, such use of the counseling student's own case studies from real life can facilitate students in acquiring an understanding as well as an appreciation of the application of general professional concepts to real life. -
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SOMESOURCESOF MATERLALSON ETHICS Over the years, I have collected numerous APA Monitor and American Psychologist articles on ethical issues as well as newspaper clippings of therapists and counselors who have been found guilty of such offenses as sexual relations with clients. These readings are assigned and discussed in both the ethics course and the practicum. Other readings are assigned from sources such as: Macklin (1982), Bayles (1981), Corey, et al. (1988), and KeithSpiegel and Koocher (1985). Particularly useful are books by Jensen (1985) and Thompson (1983). Jensen's book is comprised of professional articles from journals such as Professional Psychology, The Clinical Psychologist, and American Psychologist. Thompson's book addresses ethical concerns in psychotherapy as well as their legal ramifications. Other sources useful for occasional articles on current ethical concerns and cases are the Harvard Newsletter and Psychiatric News: Newspaper of the American Psychiatric Association. One article in the latter had students eagerly discussing the consequences of the U.S. Supreme Court rejecting an appeal from the American Psychiatric Association and its California and Hawaii district branches that places confidentiality at risk in federal criminal cases (1989, November). EVALUATION OF THE PRESENTATIONS Written and oral ratings have consistently been positive. In formal evaluations, the ethics course averages about 1.5 on a 5-point scale (with 1 being highest). Recently, three alumni stated to the current counseling practicum class that the ethics and practicum courses were two of the three courses taught in the department which had best prepared them for their graduate education and graduate practicum experience. Another recent graduate, employed by the Department of Social Services, told me that the ethics course
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had been invaluable to her. She said that her knowledge about confidentiality and competence had come entirely from the ethics course.
CONCLUSION Teaching ethics to undergraduate counseling students is desirable and ethically mandated. Most students upon graduation do not attend graduate school. Many seek employment in mental health centers, psychiatric hospitals, residential treatment centers and homes, social agencies, schools, and personnel offices. As paraprofessionals, they need to be aware of the legal and ethical issues, concerns, and obligations they will be confronting. The question might be asked, Where, if not as part of their undergraduate program, wiU such students become sensitive to and knowledgeable about ethics and ethical issues? REFERENCES ABELES,N. (1980) Teaching ethical principles by means of value confrontations. Psychotherapy: Theory, Research, and Practice, 17, 384-391. AMERICAN ASSOCIATIONFOR COUNSELING A N D DEVELOPMENT. (1983) Ethical standards. In G . Corey, M. S. Corey, & l? Callanan (Eds.), Issues and ethics in the be(ping professions. (3rd ed.) Pacific Grove, CA: Brooks/Cole. Pp. 386-392. AMERICANCOLLEGEPERSONNEL ASSOCIA~ON. (1980) Statement of ethical and professional standards. Alexandria, VA: Author. AMWCANPSYCHOLOGICAL ASSOCIATION. (1987) Casebook on ethical principles ofpsycbologists. Washington, DC: American Psychological Association. AMERICANPSYCHOLOGIC~L ASSOCIA~ON. (1990) Ethical principles of psychologists. American Psychologist, 36, 390-395. BAYLES,M. (1981) Professionalethics. Belmonr, CA: Wadsworth. BREWER,C. L. (1989) Dodoes and caucus-races: the wonderland of psychology. Paper presented at the annual convention of the American Psychological Association, New Orleans, LA. Child abuse: mandated reporting claimed to perpetuate abuse. (1991) Psychotherapy Today: The Independent Psychotherapy Newsletter, 2, 7-8. Confidentiality at risk in federal criminal cases. (1989, November) Psychiatric News: Newspapm of the American Psychiatric Association, p. 10. COREY,G., COREY,M. S., & CALLANAN, P. (1988) Issues and ethics in the helping professions. (3rd ed.) Pacific Grove, CA: Brooks/Cole. GLASER,R. D., & THORPE, J. S. (1986) A survey of sexual contact and advances between psychology educators and female graduate students. American Psychologist, 41, 43-51. HAEMMERLIE, F. M., & MAITHEMS,J. R. (1988) Preparing undergraduates for para rofessional positions: what, where, when, and how are ethical issues taught? Teaching o A c h o l o g y , 15. 192-194. Hawaii rejects psychologist script privileges. (1989) Psychiatric News: Newspaper of the American Psychiatric Association, pp. 1, 19, 31. Hosss, N . (1948) The development of a code of ethical standards for psychology. American Psychologist, 3, 80-84. JENSEN,R. E. (1985) Ethical issues in clinical psychology. Lanham, MD: Univer. Press of America. KEITH-SPIEGEL,P,& KOOCHER, G. (1985) Ethics in psychologv: standards and cases. New York: Random House. KITCHENER,K. S. (1988) Dual role relationships: what makes them so problematic? Journal of Counseling and Development, 67, 217-220. LAMB, C . S. (1980-81) The fourth R: responsibility, American Secondary Education, 10, 9-14.
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MACKUN,R. (1982) Man, mind and morality: the ethics of behavior control. Englewood Cliffs, NJ: Prentice-Hall. M A ~ E W SJ., R. (1991) The teaching of ethics and the ethics of teaching. Teaching o/ Prychology, 18, 80-85. MCGOVERN, T. V. (1988) Teaching the ethical principles of psychology. Teaching of Psychology, 15. 22-26. McMuw, M. R. (1988) Ethics case-study simulation: a generic tool for psychology teachers. Teaching of Psychology, 15, 100-101. W s , D. H. (1984) Ethics education and adjudication within psychology. American Psychologist, 39, 669-675. POPE, K.-s., & BAJT, T. (1988) When laws and values con€lict: a dilemma for psychologists. American Psychologist, 43, 828-829. POPE,K. S., KEITH-SPIEGEL,P., & TABACHNICK, B. G. (1986) Sexual attraction to clients: the human therapist and the (sometimes) inhuman training system. American Psychologist, 41, 147-158. SWENSON, E. V. (1983) Incorporating law into the undergraduate psychology curriculum. Teaching of Psychology, 10, 119-120. THOMPSON, A. (1983) Ethical concerns in psychotherapy and their legal ramifications. Lanham, MD: Univer. Press of America. VAN EENWYK,J. R. (1990) When laws and values conflict: comment on Pope and Bajt. American Prychologist, 45, 399-400. VASQUEZ,M. J. T. (1988) Counselor-client sexual contact: implications for ethics training. Jozrrnal of Counseling and Development, 67, 238-241.
Accepted December 3, 1991.
