Competence: Thomas F. Nagy

CHAPTER 6

COMPETENCE Thomas F. Nagy

The work of psychologists embraces an increasingly diverse range of settings requiring education and training to achieve proficiency. These areas include psychotherapy, school psychology, research, teaching, clinical supervision, forensics, and industrial and organizational consulting, to name a few. Competence in any of these professional areas may be seen as an elastic concept, ranging from a minimal level of capability to the expert level, and including mastery of both knowledge and skills (Abeles, 1998). Defining, achieving, and maintaining competence is the subject of this chapter.1 Epstein and Hundert (2002) provided a comprehensive definition of competence as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served” (p. 226). And Epstein (2007) explained an important developmental aspect of competence as being “gained through deliberate practice and reflection on experience” (p. 388). By maintaining their competence, psychologists maximize the odds of making positive changes in the lives of those with whom they interact and minimize the chances for harm (Nagy, 2011). An example of minimizing harm would be the psychotherapist who fails to recognize the seriousness of a potentially dangerous situation and to take some preemptive action—such as when her depressed

patient discloses his intent to harm his former manager at work who has recently terminated his employment. In such situations, the psychologist normally would be required to break confidentiality and notify the intended victim or the local police department to protect the patient from acting on his hostile impulses. Failure to do so might constitute incompetence on the part of the treating therapist and could result in harm or injury to the identified third party and the patient as well.2 The concept of competence not only includes therapists or clinical supervisors, who provide services to clients and patients or consult with organizations, but also extends to those who do research and publish their results. The reporting and interpreting of data has major implications for psychologists as well as the general public. Incompetent research resulting in errors or fabrications in published materials not only harms the knowledge base by imbuing it with inaccuracies, but also could have negative effects on others—for example, psychologists who rely on current research in their daily work and the individuals and groups whom they serve. This chapter focuses on the concept of competence and how it applies in at least a fundamental way to the various roles played by psychologists. Other chapters in this book go into greater depth in many of the specific areas and roles that are introduced in this chapter. This chapter covers the moral

1

Some of the content for this chapter derives from the author’s book Essential Ethics for Psychologists: Understanding and Mastering Core Issues (Nagy, 2011).

2

Individual states vary concerning laws relating to confidentiality and their exceptions and what steps psychologists must take when the threat of harm to a third party is revealed to the treating therapist.

DOI: 10.1037/13271-006 APA Handbook of Ethics in Psychology: Vol. 1. Moral Foundations and Common Themes, S. J. Knapp (Editor-in-Chief) Copyright © 2012 by the American Psychological Association. All rights reserved.

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basis for competence, two general ethical principles relating to competence, bias and prejudice, general concepts about achieving and maintaining competence, therapy, assessment, clinical supervision, teaching, maintaining boundaries with patients, students, and trainees, research and publication, use of technology and telehealth, transitioning to new areas of competence, and ethical transgressions— exceeding one’s competence comfort zone. THE MORAL BASIS FOR COMPETENCE Understanding the moral principles that underlie a code of conduct helps psychologists to interpret the ethical standards. The foundational ethical theories and moral principles that guide the practice of psychology are discussed in more detail in Chapter 1 of this volume. Although the standards are numerous, and fairly specific, they still cannot address every situation and professional role played by psychologists. The General Principles contained in the Ethical Principles of Psychologists and Code of Conduct (the Ethics Code; American Psychological Association [APA], 2010) is helpful in this regard. These principles articulate unenforceable, aspirational guidelines that describe the general values underlying the standards in the Ethics Code. The high standards described in the General Principles are best understood by considering that human behavior in a moral sense can be broadly classified into various categories. According to Beauchamp and Childress (2001) there are four categories of moral actions: (a) actions that are right and obligatory (e.g., telling the truth), (b) actions that are wrong and prohibited (e.g., committing murder), (c) actions that are optional and morally neutral—neither obligatory nor wrong (e.g., performing common daily activities), and (d) actions that are optional but morally meritorious and praiseworthy (e.g., donating a kidney to a needy patient who is unknown to the donor). This last category does not necessarily pose an exceptionally high threshold, as Beauchamp and Childress also made the case that “not all supererogatory acts are exceptionally arduous, costly, or risky” (p. 41). They pointed out that the line between what is mandatory and what is optional is not always apparent. 148

Psychologists would do well to continually aim for morally meritorious and praiseworthy conduct rather than to focus their sights on simply avoiding incompetence. This last category is largely the domain of the General Principles and addresses behavior best described as supererogatory. The word supererogatory derives from the Latin super-erogare (i.e., to pay out over and above what is required) and refers to a class of actions that are not “required” but go beyond the call of duty (e.g., a good Samaritan) (Blackburn, 2005). Supererogation has four defining principles, according to Beauchamp and Childress (2001): a supererogatory act (a) is optional—neither required nor forbidden by common-morality standards, (b) exceeds what the common morality expects or demands, (c) is intentionally undertaken to promote the welfare of others, and (d) is morally good and praiseworthy in itself (not merely undertaken from good intentions). As applied to the Ethics Code, supererogatory acts primarily are presented in the General Principles section of the code (see the following section). But first we will address the concept of a floor and a ceiling in the house of ethics—how minimal standards and lofty goals each have a place in this document.

Ethical Floor and Ceiling The Ethics Code’s floor and ceiling both relate to moral values as they can be applied to psychological work. The Ethical Standards constitute the floor— they describe minimal levels of performance that are expected from the ethical psychologist. There is no choice about compliance; the ethical standards require psychologists to engage in certain behaviors in the course of carrying out their work and specifically prohibit others. For example, the therapist who treats a man who is addicted to a chemical substance must first have a minimal level of competence (e.g., education and training) before beginning to treat the patient. It would not be sufficient for her to be welltrained as a psychotherapist but not trained in the treatment of addictions per se, as the Ethics Code requires compliance with the standards addressing the attainment of mastery before accepting such patients. If she lacks the proper training, she runs the risk of harming the patient by using inappropriate

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interventions or strategies, or, at best, not providing an intervention that is beneficial to the patient. At the same time, psychologists are required to take reasonable steps to avoid harming their patients, students, and others with whom they work, as stated in Standard 3.04, Avoiding Harm, in a section entitled “Human Relations.” This prohibition against inflicting harm on others requires psychologists to avoid behaving in a way that would likely have an adverse impact. And when harm to another is foreseeable and unavoidable, they must take steps to minimize it. The psychologist in the media who spontaneously makes negative and inaccurate comments concerning the lifestyle or values of gays or lesbians is failing to avoid harm to these individuals. His lack of competence in media presentations and ignorance of the facts may result in damaging comments that may be heard by a large audience—on radio, television, or the Internet—possibly contributing to increased antipathy for members of these minority groups. The ceiling of the Ethics Code resides within the General Principles. These principles are behavioral objectives on which psychologists set their sights but are not required to attain. They also are to be used in ethical decision making when the ethical standards fail to provide adequate guidance or advice about what to do in a specific situation. These five General Principles constitute the moral basis and the aspirational goals of all psychologists who wish to go beyond complying with the minimal standards set by the Code of Conduct (i.e., enforceable ethical standards). Ethical questions often arise during the normal course of a psychologist’s work—teaching, consulting, carrying out research, and so on. Those psychologists who attempt to discover their supererogatory obligations, however, are more likely to actively seek out the ethical questions hidden in their professional activities (Knapp & VandeCreek, 2006). In doing so, they may find the General Principles particularly useful, even though the language is lofty, sometimes vague, and lacking in the kind of specific directives that are more commonly found in the ethical standards (e.g., musts and must-nots). The five General Principles are Principle A, Beneficence and Nonmaleficence; Principle B,

Fidelity and Responsibility; Principle C, Integrity; Principle D, Justice; and Principle E, Respect for People’s Rights and Dignity. The areas of psychological competence are best represented in Principles A and D and are examined in the section Two General Ethical Principles Relating to Competence.

How Supererogatory Values Help A psychologist who understands the supererogatory values contained in the General Principles (the ceiling of ethical conduct) will be better able to use the Code of Conduct for ethical decision making even when specific standards do not exactly address the encountered situation that raises an ethical question. Psychologists are not expected to merely comply with stated rules to avoid sanctions from an ethics committee or licensing board. Hopefully, they also will develop a deeper understanding of the moral underpinnings for the ethical standards, such as those described in the General Principles, for guidance in ethical decision making, particularly when ethical rules conflict, or laws and ethical standards are incompatible. Case Example 1 A psychotherapist is ambivalent about offering treatment to a 17-year-old young man with autistic disorder, because he has had little training in diagnosing or treating individuals with this pervasive developmental disorder. By reflecting on the risk of harm versus the probability of providing help to the young man, given his lack of experience, the therapist takes into account General Principle A, Beneficence and Nonmaleficence. And by honestly appraising the boundaries of his competence and limitations of his expertise he honors the spirit of Principle D, Justice. These overarching principles set the ethical tone for standards pertaining to competence. After considering them, as well as the relevant ethical standards, the therapist decides to refer the adolescent to another therapist experienced in treating this disorder. 149

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TWO GENERAL ETHICAL PRINCIPLES RELATING TO COMPETENCE In this section we examine the two General Ethical Principles that primarily address competence: Principle A, Beneficence and Nonmaleficence, and Principle D, Justice.

General Ethical Principle A: Beneficence and Nonmaleficence The first General Principle is Principle A, Beneficence and Nonmaleficence. Beneficence means to do good, rendered from the Latin, and nonmaleficence means to avoid harming others, in the course of carrying out one’s professional work. These concepts have roots dating back to the Hippocratic oath in the 4th century BCE, when medical doctors codified the competing demands of helping their patients and avoiding harming them. The following two examples from clinical practice illustrate how these concepts have a bearing on competence. The first scenario addresses a classic challenge faced by therapists who may experience a sexual attraction to a client or patient. Case Example 2 A male therapist attempts to balance how to competently establish a working alliance with a friendly female patient, while, at the same time, avoiding developing a personal friendship or romantic relationship with her, lest he lose his objectivity and ultimately his competence. The patient mistakes the therapist’s empathy and warmth for feelings of friendship and even love, and begins to behave in a flirtatious manner. However, the therapist does not respond to her seductiveness, choosing, instead, to address the topic of interpersonal boundaries in the treatment setting. Ultimately, he avoids harming his patient by finding equilibrium between the personal relationship (e.g., having friendly feelings for the patient) and the professional one (e.g., maintaining sufficient objectivity to maintain his competence and serve as an agent of change for her). Preserving this 150

critical balance is part of the artistry and science of psychotherapy, in spite of an occasional patient’s wish that it might be otherwise. The next scenario addresses a training setting in which three individuals are involved in a professional relationship: supervisor, supervisee, and patient. Case Example 3 A clinical supervisor must balance providing training for her supervisee with maintaining the welfare of the patient receiving treatment. In a particularly challenging situation, such as a suicidal patient with a personality disorder and alcohol dependency, it may appear as though the patient would be better served by consulting a licensed practitioner rather than a trainee. However, with competent supervision of the therapistin-training the treatment will hopefully progress satisfactorily. However, if the supervisor is negligent in performing her duties—meets less often for supervisory sessions or fails to pay attention to emergent risks that are being disclosed by the patient—she may contribute to harming both the therapist-in-training and the client. The therapist–trainee is being harmed by receiving substandard supervision and the patient is being harmed by receiving inadequate treatment by the trainee, and may be at increased risk for committing suicide. Principle A also reminds psychologists of their obligation to be mindful of problems with their own physical and mental health, and how they could affect others. Psychologists are subject to the same human frailties as anyone else. The competence of an otherwise-excellent supervisor, teacher, or management consultant could be significantly affected by a chronic medical condition, medication, sleep deprivation, or major life stress, such as the death of a family member, divorce, or financial adversity. Consider the following example in which a health problem strongly affects the physiological and

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psychological well-being of a psychologist and interferes with her competence. Case Example 4 A psychotherapist with chronic back pain must take daily medication to mitigate her suffering that unfortunately dulls her mental acuity and cognitive functioning. She finds that her effectiveness is impaired in carrying out diagnostic testing and simply listening carefully to her more challenging therapy clients. In particular, she struggles to be alert enough to provide treatment to a single mother with depression who is having difficulty parenting her alcoholic son. The therapist knows that she has an ethical obligation to monitor the extent to which her medications detract from her competence to provide treatment, or engage in any other psychological work, for that matter. She considers various options in dealing with her more challenging patient, such as (a) terminating and referring the patient to another therapist or (b) accommodating in some other way, such as having shorter therapy sessions, scheduling her patient only at a time of day when she is most alert (e.g., mornings), altering the times of taking her medication, taking brief naps during the day, or pursuing some other means. In coping with such a health problem, the psychologist would not find suggested courses of action in either Principles A or D or in the ethical standards, except in a general way. Consulting these two sections of the Ethics Code may prompt the psychologist to be vigilant about matters of her own mental and physical health, to note when her professional competence might be declining, and to take appropriate and timely action. Maintaining sound mental health and sufficient emotional competence to practice is covered in Chapter 7 of this volume.

General Ethical Principle D: Justice The fourth General Principle, Justice, often has application in the legal arena, such as when a

psychologist is asked to testify about his or her psychological assessment of divorcing parents who are litigating about child custody, or when a psychologist delivers a report to the court about a defendant’s competence to stand trial. Justice derives from the Latin root justitia, meaning justice, or equality, and it has been defined as follows in legal settings: fairness, moral rightness, and a scheme or system of law in which every person receives his or her due from the system, including all rights, both natural and legal (see http://dictionary.law.com). This principle has a bearing on competence, and it prompts psychologists to be aware of their own biases and prejudices in the course of their work, as these can lead to unjust practices. It also asks psychologists to make certain that they do not exceed the boundaries of their competence and the limitations of their expertise. Because these concepts are not always readily apparent, they may be difficult for psychologists to grasp. Prejudices and biases may stem from one’s earliest days, involving family of origin, ethnicity, cultural conditioning, specific life events, sense of humor, and other factors—much of which may unconsciously affect the psychologist’s adult thoughts and actions. The boundaries of competence are not always easily noted either, as psychologists sometimes find themselves being “nudged” beyond their comfort zone, in clinical and consulting cases, supervision, forensic situations, and other areas, without adequate reflection about the risks they are encountering. BIAS AND PREJUDICE A lack of impartiality may come from holding unfounded assumptions about a particular individual or group that affect how the psychologist teaches, designs and conducts research, evaluates, or provides treatment for a person. These unfounded assumptions can profoundly affect competence, resulting in judgments, decisions, interventions, and other actions that harm others, either by what they accomplish or fail to accomplish. This issue is addressed in Section 3 of the Ethics Code, by Standard 3.01, Unfair Discrimination. What we might term competence in human diversity, which prohibits psychologists from engaging in unfair discrimination, can be formed on 151

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the basis of the following factors: age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, socioeconomic status, or any basis proscribed by law. Therapists willing to become more knowledgeable about these important factors in their patients’ lives not only avoid prejudice but also go beyond providing services that meet minimal standards by proactively augmenting their clinical skills and their ability to be truly helpful to others. Those striving for very high levels of competence also may experience better outcomes as well as a sense of continuing professional improvement over time.

Age Developmental issues manifest themselves continuously throughout life, requiring psychologists to maintain their knowledge and skills commensurately. Those who diagnose, provide treatment, teach, or do research with people from infancy, early childhood, adolescence, adulthood, and later life must not presume competence without proper education, training, supervision, or other life experiences. They continuously enhance their skills by means of individual or peer group consultation, attending workshops, reading journals that focus on issues relevant to the age group being treated, and being up to date on APA publications, such as Guidelines for Psychological Practice With Older Adults (2004) and Guidelines for the Evaluation of Dementia and Age-Related Cognitive Decline (1998).

Gender Gender may be considered to be a subculture unto itself, with its own range of genetic predispositions, physiology, perceptions, cognitions, and behavior patterns conditioned since birth by family and culture. The competence of a researcher could be compromised by unwittingly introducing gender bias into any phase of an investigation, including formulation of the research hypothesis, collection of data, and even interpretation of the results. Competence of a teacher, supervisor, or therapist can be impaired by gender bias consisting of unwarranted assumptions about the inherent nature of males and females. These assumptions can affect grading academic performance, psychological 152

assessment, carrying out psychotherapy, and the very nature of their relationships—including developing a multiple role relationship concurrent with the professional one that could impair competence (e.g., business relationship, friendship, romantic relationship). It is an ongoing task to enhance one’s knowledge of the opposite sex by remaining current on the research, attending seminars, observing publications from the APA such as the lengthy document Guidelines for Psychological Practice With Girls and Women (2007b), and other means.

Sexual Orientation An essential component of psychological competence is having awareness of and accepting the broad variety of sexual orientations and preferences. A systematic bias or fear of homosexuals (or heterosexuals) may impair a psychologist’s work in much the same way that gender bias does. A psychologist’s vulnerable or panicky feelings, anger, avoidant or hostile behavior, or other signs of a homophobic response diminish competence and adversely affect the working relationship. The APA publication Guidelines for Psychotherapy With Lesbian, Gay, and Bisexual Clients contains 16 recommendations concerning diagnosis, treatment, family relationships, social prejudice and discrimination, risks and challenges of being gay, health matters, obligations of the psychologist working with gay clients and patients, and other matters (APA, Division 44, Committee on Lesbian, Gay, and Bisexual Concerns Task Force, 2000). This document helps therapists, consultants, and researchers to be aware of their own potential for bias for or against gays or lesbians, prompting them either to limit their professional contacts or to obtain supervision, consultation, psychotherapy, or other rehabilitative experience to enhance their competence in working with these minorities.

Race, Ethnicity, National Origin, and Language Ignorance or prejudice about race or national origin of immigrants or first-generation Americans can impair a psychologist’s ability to work competently. The extensively diverse population in some regions of the United States may pose significant challenges

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in learning about the values, norms, social customs, idiosyncrasies, attitudes about mental health, and other attributes of those from other cultures. As an example, one might consider the therapist working with a Latino man who intends to bring a family member into the consulting office with him. This might seem to be an unusual practice to a North American psychologist with conventional values. However, the personal boundaries among Latinos are typically more inclusive of others, and it might be quite natural to include a sibling or even a close friend. On the other hand, the management consultant working with a Japanese corporate executive who consistently avoids eye contact should remember that such a behavior is not indicative of rudeness or disrespect. Quite to the contrary, in the Japanese culture, avoidance of eye contact is more likely to represent a sign of respect accorded to an authority figure. Being enlightened about such cultural differences is the focus of the APA publication Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (APA, 2003). Although psychologists certainly are not expected to develop proficiency in the native tongue of every client or student from a foreign country, they at least may show the inclination to learn certain fundamentals and customs, such as greetings or important nonverbal interactions. Demonstrating such a willingness has the potential of assisting in the relationship and enhancing the professional service being offered.

Religion A pervasive prejudice regarding religion on the part of an investigator, teacher, consultant, or therapist can detract from objectivity and competence. Whether the bias is against Jews, Muslims, Christians, or any other faith, the psychologist holding such views risks carrying out poorly conducted research, substandard teaching or training, and incompetent consulting or psychotherapy. Possessing an innate curiosity and being willing to learn about the religious teachings of one’s patients, supervisees, or students may help the psychologist to have better understanding and empathy for them as well as deliver superior services.

Prejudice based on an individual’s religious faith is particularly relevant for those psychologists who assess or provide treatment to members of the clergy. A positive bias could just as easily affect competence as a negative one. This could result in inaccurate assessments, psychological reports that omit important conclusions and recommendations, and treatment that fails to address the more difficult aspects of a patient’s behavior and dynamics because of a therapist’s positive bias about the patient. For example, a devoutly Catholic psychologist with a bias who is asked to evaluate a priest accused of molesting children may not be able to carry out an objective assessment and, as a reslt, may misperceive or deliberately minimize signs of psychopathology when interpreting test results or writing a psychological report.

Disability To competently serve, teach, or investigate those with physical or mental impairments, psychologists must be aware of the array of factors and special needs unique to each disability. People with special needs include those with sensory impairments (e.g., blind or hearing impaired), chronic pain or degenerative diseases, HIV/AIDS, spinal cord or other severe injuries, fatal illnesses, or other conditions impairing daily functioning. People with special needs also include those with mental disorders, such as mental retardation, pervasive developmental disorders (e.g., Autism spectrum disorders), schizophrenia, dementias, or other brain disorders from head injuries or illness (e.g., stroke, heart attack). Remaining competent in working with such specialized populations requires participating in ongoing education and remaining up to date on the current research.

Socioeconomic Status Psychologists must sometimes acquire special skills for working with those from lower or higher socioeconomic groups. An example would be the therapist who must adjust his treatment objectives and strategies to suit the needs of a woman living in a housing project who has been physically abused by her husband. She may have an urgent need for protection and safe refuge, along with her children, and may need to move to a woman’s shelter. This patient may have little interest in developing psychological 153

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insight into the causes of her problems that fails to address her immediate needs. It may constitute incompetent practice for the therapist to disregard the pressing necessities of life in favor of focusing on history taking or developing psychological insight. In fact, by disregarding such exigencies, the therapist may run the risk of jeopardizing the very safety of the patient he is attempting to help. Researchers investigating those of lower or higher socioeconomic status should take steps to educate themselves about attributes of these groups that might affect the validity of the results. Such steps might include familiarizing oneself with dialects, values, dress, nonverbal cues, interpersonal style, relationships, and prejudices of the group being studied—all of which could affect the research hypothesis, experimental design, data gathering, interpersonal relationship with the investigator, or other aspects of the study. Failure to pay attention to these factors could have direct consequences on the investigation and ultimately the knowledge base by making a contribution that is biased, distorted, or inaccurate in some other way. One such example of incompetence in a research setting follows, in which the investigator is initially unaware of his blind spots that result from a traumatic experience. Case Example 5 A male researcher, who recently experienced a painful and costly divorce, has been investigating gender roles in marriage. He currently is gathering data for his study, interviewing husbands and wives and rating short essays that they have written on the topic of marital satisfaction. He finds that he is becoming increasingly impatient and irritable while listening to the wives describe their perception of their roles within the marriage and consistently is rating their written essays with a negative bias, as confirmed by his coinvestigator. He slowly arrives at the conclusion 3

that he may be unable to competently and objectively gather data and interpret results at this time. This is because he is suffering from depression because of his recent divorce and has residual angry feelings at his ex-wife that he has generalized to the female participants in his research project. He decides to withdraw from the data gathering temporarily and begin psychotherapy to address his mood disorder and resentment. Fortunately this investigator had sufficient selfinsight to benefit from consultation with his coinvestigator and to terminate his involvement with the project. He also had the good judgment to seek needed treatment rather than to just wait for his depression to “pass.” The topic of ethics in research is thoroughly addressed in Volume 2, Chapter 16, in this handbook. GENERAL CONCEPTS ABOUT ACHIEVING AND MAINTAINING COMPETENCE Psychologists who practice and consult generally complete doctoral studies at a regionally accredited institution (e.g., university or professional school of psychology) and then have a period of professional supervised experience or internship. Then they must pass the Examination for Professional Practice in Psychology (the same content in all 50 states and Canadian provinces, but with different passing scores) and show evidence of a thorough knowledge of the state laws regulating clinical practice.3 After completing these steps, one holds the license to publicly claim the title psychologist and offer professional services to consumers for a fee (e.g., individual or group therapy, assessment, clinical supervision of trainees, forensic activities, management consulting). Licensing boards can ensure only that psychologists meet the minimal standards of competence, but they do not ensure excellence. Professional judgment on the part of psychologists

The APA allows its members to claim a doctoral degree from a nonregionally accredited institution only if it serves as the basis for licensure in the state. A psychologist who moves to another state, at some point, may no longer claim the doctoral degree in the new state if his or her degree is from a nonregionally accredited institution of learning. It is possible for a professional school of psychology or university to be licensed or accredited by a particular state but at the same time, fail to meet the standards of the regional accrediting body, such as the North Central Association of Schools and Colleges, the Western Association of Schools and Colleges, and so on.

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always remains an essential ingredient in the ongoing quest for superior mastery of psychological skills. Those who work in academic or health care settings as teachers, researchers, or administrators or in some other nonclinical capacity normally do not require a psychology license. Although they may not directly offer clinical services to the public for a fee, they must be mindful of maintaining competence in their chosen area.

Vanity Credentials Credentials, degrees, certifications, and honors should be awarded on the basis of academic or other work that has been performed and appropriately evaluated by a legitimate entity. At times one may observe vanity credentials listed on resumes, curriculum vitae, the Internet, or promotional materials extolling the supposed skills and knowledge of the psychologist, when, in reality the psychologist’s work was never reviewed adequately and the primary requirement for receipt of the credential was the payment of a fee.

Maintaining Competence Those holding a license to practice psychology generally are required by their home state to maintain and upgrade their knowledge and skills during each renewal period of their license. This maintenance normally consists of accruing a certain number of credit hours by attending lectures and workshops on psychological topics, participating in online webinars, reading books and articles, or participating in other experiences that are coordinated with mandatory continuing education programs (e.g., hospital grand rounds presentations). In addition, many psychologists maintain their skills by regularly consulting with peers—that is, other clinicians, fellow supervisors, researchers, management consultants, and teachers. When these peer-to-peer consultations, whether one on one or in groups, are carried out in a collaborative and compassionate manner, they can be extremely helpful and enhance competence. Participating in such consultations also may increase self-awareness on the part of clinicians, encouraging therapists to have a reflective practice, striking an adequate balance between humility and confidence and a desire to seek out feedback on

performance. This is discussed more fully in Chapter 19 of this volume dealing with professional liability and risk management. Maintaining sound mental health is an inherent part of competence, requiring a degree of selfawareness about the normal human experiences that may affect how one carries out work. This includes such things as personal life transitions and stresses (e.g., birth of a child, deaths of family members or friends, divorce), changes in mood, the impact of physiological disorders (e.g., illness, chronic pain conditions), medication side effects (e.g., impaired cognitive functioning), and other experiences that compromise one’s ability to work effectively. Psychologists may be subject to the same frailties as others when suffering emotional distress, including dependency on alcohol and other chemical substances, poor professional boundaries with clients and patients, compulsive sexual behavior, and excessive sensation seeking or risk taking. They also may suffer from untreated personality disorders or other conditions yet procrastinate in getting treatment, even though their competence is being diminished. Any preexisting condition may become exacerbated as the daily work of psychologists takes its toll. This may include secondary posttraumatic stress disorder (PTSD) from listening to graphic details of patients’ traumatically abusive experiences or the stress of having too many challenging patients at one time—such as suicidal patients, children being molested by family members, or those with borderline personality disorder who require extra attention or emergency hospitalizations. How one navigates these difficult waters was addressed by Norcross and Guy (2007), who affirmed that psychologists must learn to leave their work at the office and embrace life habits that are restorative in nature, including seeking consultation or psychotherapy. Part of being self-aware about one’s competence may include having a lifestyle that promotes good mental health—adhering to the advice that we give to our patients. This includes the following therapeutic habits: (a) adequate sleep, (b) regular physical exercise, (c) regularly engaging in play or fun activities (e.g., hobbies, social activities), (d) nurturing the relationship with one’s significant other, (e) engaging in friendships and other social activities, and (f) any 155

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other activities and life habits that are critical for sustaining good mental health. These matters are addressed more fully in Chapter 7 of this volume, dealing with emotional competence and well-being. THERAPY Psychotherapy has been defined as a method of working with patients and clients to assist them to modify, change, or reduce factors that interfere with effective living (Fabrikant, 1998). According to a metastudy of 50 publications, carried out by Grencavage and Norcross (1990), there are six common factors in psychotherapy: (a) the development of a therapeutic alliance, (b) the opportunity for catharsis, (c) the acquisition and practice of new behaviors, (d) patient positive expectations, (e) beneficial therapist qualities, and (f) provision of a rationale for the patient’s problems. A detailed review of common factors in psychotherapy may be found in the conclusions and recommendations of APA’s Division 29 Task Force on empirically supported therapy relationships (Ackerman et al., 2001). The APA and the Council of Specialties in Professional Psychology (CSPP; initially sponsored by the APA and the American Board of Professional Psychology [ABPP]) have identified two levels of competent practice. Those offering psychological services may achieve the following levels of competent practice: (a) proficiency (i.e., possessing adequate knowledge and skills to practice psychology), and (b) specialty (i.e., possessing competence in a particular area of psychological practice).

Proficiency Proficiency was defined by the APA (1995) as a “circumscribed activity in the general practice of professional psychology or one or more of its specialties.” Attaining proficiency consists of meeting the following three criteria: (a) distinctiveness, described as a body of knowledge and professional application relevant to one or more parameters of practice; (b) acquisition of knowledge and skills, described as a core of psychological knowledge and skills, including specific methods for how psychologists typically acquire same; and (c) parameters of practice, described as the substantial, specific, and 156

distinctive psychological knowledge and skills providing the bases for service with respect to at least one of the essential parameters of practice. These parameters include the following: (a) specific population, (b) psychological, biological, or social problem, and (c) procedure and techniques.

Specialty A specialty is defined by the CSPP as “a defined area of professional psychology characterized by a distinctive pattern or configuration of competent services to specified problems and populations” (see the CSPP website: http://cospp.org). It is based on broad and general education and training in the science and practice of psychology, and it requires the acquisition of advanced knowledge and skills from an accredited doctoral program (and possibly additional organized sequence of education and training in postdoctoral programs), followed by an examination designed to assess competence, independent of the state licensing exam. An important organization related to specialties is the American Board of Professional Psychology (see http://abpp.org), incorporated in 1947. It provides the following rationale for specializing in its mission statement: to increase consumer protection by examining and certifying psychologists who demonstrate competence in approved specialty areas. Currently, 13 specialty areas are recognized by ABPP: (a) clinical child and adolescent psychology, (b) clinical health psychology, (c) clinical neuropsychology, (d) clinical psychology, (e) cognitive and behavioral psychology, (f) counseling psychology, (g) couple and family psychology, (h) forensic psychology, (i) group psychology, (j) organizational and business consulting psychology, (k) psychoanalysis in pychology, (l) rehabilitation psychology, and (m) school psychology (CSPP, 2009). Each specialty area has its own formal definition, required levels of specialty training (doctoral or postdoctoral level), and specialty board certification (e.g., source of board certification, such as the American Board of Group Psychology for group psychologists).

Certification in Substance Abuse Treatment The APA Practice Organization’s College of Professional Psychology (COPP) certifies licensed

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psychologists in the treatment of those with alcohol and other psychoactive–substance use disorders. This is useful for therapists verifying their expertise to third-party payers (e.g., health insurance, Medicare) when treating chemically dependent patients (APA, Practice Organization, 2010). To become certified, candidates for such certification must have treated alcohol and other substance use disorders as a licensed psychologist for at least three years, must provide health services in psychology, and must pass COPP’s examination.

Prescription Privileges Few states currently permit psychologists to prescribe medications as an adjunct to rendering clinical services, although there has been active lobbying on the part of some psychologists to change this situation. In 1997, the COPP submitted a proposal to the APA Council of Representatives presenting a rationale for such a change (Bricklin, 2000). In what might be seen as a premature move, it also proposed to catalyze psychologists’ interest in prescribing by overseeing the development of an examination that would be offered in states and Canadian provinces to grant prescriptive authority whenever the laws changed to permit such activities. As a result, COPP developed the Psychopharmacology Examination for Psychologists, which will constitute the final hurdle for those wishing to prescribe. Candidates for the exam must also possess a doctoral degree in psychology, provide health services in psychology, possess a currently valid license in good standing to practice psychology independently, and must successfully complete a postdoctoral program of education in an organized program of intensive didactic instruction.

Evidence-Based Practice, 2006). This evolved from a similar concept developed by the Institute of Medicine 5 years earlier and has as its purpose to “promote effective psychological practice and enhance public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention” (Institute of Medicine, 2001, p. 147). The APA task force considered “best available research” to include scientific results derived from intervention strategies, assessment, clinical problems, and patient populations in both laboratory and field settings, as well as clinically relevant results of basic research in psychology and related fields. As of this writing, the majority of treatments that qualify as evidence-based practice in psychology are cognitive— behavioral in nature, ranging from 60% to 90% of available interventions (Norcross, 2004). Eight components of clinical expertise are described in the report: ■

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Psychotherapy: Evidence-Based Practice Evidence-based practice refers to therapeutic interventions offered by psychologists that integrate science and practice, a concept that has become an important goal in current health care systems and health care policy. This practice was defined in 2006 by the APA Presidential Task Force on EvidenceBased Practice as the integration of the best available research with clinical expertise, within the context of patient characteristics, including culture, values, and preferences (APA, Presidential Task Force on

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Assessment, diagnostic judgment, systematic case formulation, and treatment planning (e.g., accurate diagnosis, setting appropriate treatment goals and tasks) Clinical decision making, treatment implementation, and monitoring of patient progress (e.g., skill and flexibility, tact, timing, pacing, framing of interventions, balancing consistency of interventions with responsiveness to patient feedback, monitoring progress) Interpersonal expertise (e.g., forming a therapeutic relationship, encoding and decoding verbal and nonverbal responses, creating realistic and positive expectations, empathy) Continual self-reflection and acquisition of skills (e.g., capacity to reflect on one’s own experience, knowledge, hypotheses, emotional reactions, and behaviors; awareness of limits of knowledge, skills, and biases affecting one’s work) Evaluation and use of research evidence in both basic and applied psychological science (e.g., having an understanding of research methodology, validity, and reliability, being open to data, clinical hypothesis generation, and the capacity to use theory to guide interventions) Knowledge of the influence of individual, cultural, and contextual differences on treatment 157

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(e.g., individual, social, and cultural variables, including age, development, ethnicity, culture, race, gender, sexual orientation, religious commitments, and socioeconomic status) Use of available resources as needed (e.g., seeking consultation; recommending adjunctive or alternative services when needed; cultural sensitivity) Formation of a cogent rationale for clinical strategies (e.g., a planful approach to the treatment of psychological problems; reliance on the therapist’s well-articulated case formulation concerning the client or patient, reliance on relevant research supporting the effectiveness of a certain treatment, if it exists)

An opposing view presented by Westen and Bradley (2005) raises the question of overreliance on evidence-based practice, arguing that empirically supported therapies often focus predominantly on brief, focal treatments for specific disorders (e.g., major depressive disorder) as defined by the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994). Westen and Bradley stated that evidence-based practice should consist of more than a list of empirically supported therapies for discrete disorders. They believe that a true metric for the effectiveness of therapy should be how its outcomes compare favorably to the outcomes obtained by experienced clinicians, not whether it survives a test of the null hypothesis (i.e., that it works better than nothing, or better than something intended to fail). In deciding when or whether to use evidencebased therapies, the psychologist ultimately should develop a professional rationale to support his or her decision. One should be able to cite outcome or process literature or other professionally accepted literature in making such a decision, aware that patient demographics, diagnosis, clinical setting, length of anticipated treatment, financial resources, and other factors are contributing to the decision.

Practice Guidelines APA began developing practice guidelines in 1993, covering a range of topics applying to those offering direct services to consumers as well as those who carry out research. The criteria for these practice guidelines were established by the Committee on Professional Practice and Standards (a committee of the APA Board of Professional Affairs). The first attribute cited is “Respect for Human Rights and Dignity”—underscoring the guidelines’ sensitivity to cultural, individual, and role differences among psychological service providers and their client populations, including but not limited to age, gender, race, ethnicity, national origin, religion, sexual orientation, disability, language, and socioeconomic status (APA, 2002). Practice guidelines are intended to be aspirational in nature—that is, they provide suggestions, advice, and recommendations, but they do not establish rules or regulations to which psychologists must adhere. They offer help and practical guidance in best practices, but they do not raise or lower the bar established by the Ethics Code. Instead, they address many more specifics and details that any ethics code ever could, or should. Although psychologists generally would not be penalized or sanctioned for failure to comply with a particular practice guideline, they should be cautious about deviating from it and have a well-developed rationale for doing so in their clinical and forensic work. The practice guidelines are published by APA, APA divisions, or APA committees, and many of them are available online (see http://www.apa.org/ practice/guidelines/index.aspx). These guidelines are revised periodically, reflecting changes in the American culture and demographics, laws, and the nature of psychological practice. They are listed in chronological order, including the date of their adoption by APA.4 ■

Specialty Guidelines for Forensic Psychologists (APA, 1991)5

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Additional resources that psychologists might find useful are Statement on the Disclosure of Test Data (APA, 1996); Statement on Services by Telephone, Teleconferencing, and Internet (APA, 1997); Criteria for Evaluating Treatment Guidelines (APA, 2002a); Criteria for Practice Guideline Development and Evaluation (APA, 2002b); Criteria for the Evaluation of Quality Improvement Programs and the Use of Quality Improvement Data (APA, 2009a); and APA Disaster Response Network Member Guidelines (APA, 2011).

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The Specialty Guidelines for Forensic Psychologists (APA, 1991) were being revised when this book went to press and are expected to be completed by February 2012 (personal communication with Randy Otto, April 25, 2011).

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Guidelines for the Evaluation of Dementia and AgeRelated Cognitive Decline (APA, 1998) Guidelines for Psychological Evaluations in Child Protection Matters (APA, 1999) Guidelines for Psychotherapy With Lesbian, Gay, and Bisexual Clients (APA, Division 44, 2000) Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (APA, 2003) Guidelines for Psychological Practice With Older Adults (2004) Guidelines Regarding the Use of Nondoctoral Personnel in Clinical Neuropsychological Assessment (APA, 2006) Record Keeping Guidelines (APA, 2007b) Guidelines for Psychological Practice With Girls and Women (APA, 2007a) Guidelines for Child Custody Evaluations in Family Law Proceedings (APA, 2009)

Professional organizations and entities other than the APA also have developed practice guidelines that inform practitioners about accepted standards of practice. These are commonly referred to as treatment guidelines or clinical guidelines. Examples include the American Academy Pediatrics’ Screening for Suicide Risk in the Pediatric Emergency and Acute Emergency Care Setting (2007) and the American Psychiatric Association’s Practice Guideline for the Treatment of Patients With Alzheimer’s Disease and Other Dementias (2007). Many of these practice guidelines can be found at the website of the National Guideline Clearinghouse, an initiative of the Agency for Healthcare Research and Quality (see http://www.guideline.gov/associations). Some of these entries include thorough reviews of research, and others represent consensus guidelines, summarizing expert opinions in the field.

Complementary and Alternative Medicine Psychologists and other health care professionals increasingly are offering therapy experiences that are outside the realm of conventional medicine, as described by the National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine (NCCAM; see http://nccam.nih. gov/health/whatiscam/overview.htm). These include

complementary medicine (interventions that are used in addition to conventional medicine) and alternative medicine (interventions that are used in place of conventional medicine). Integrative medicine combines treatments from conventional medicine, complementary medicine, and alternative medicine that have evidence of safety and effectiveness, such as using hypnosis for pain control, nausea, or other symptoms. The NCCAM is a federal agency for scientific research whose mission is to explore complementary and alternative healing practices and interventions. In addition to studying whole medical systems, such as homeopathic medicine, naturopathic medicine, traditional Chinese medicine, and Ayurveda, it also studies the following four domains: (a) mind–body medicine (e.g., patient support groups and cognitive behavioral therapy, meditation, prayer, art therapy); (b) biologically based practices (e.g., herbs, foods, vitamins); (c) manipulative and body-based practices (e.g., chiropractic, osteopathic manipulation, massage); and (d) energy medicine, consisting of biofield therapies (e.g., qi gong, Reiki, therapeutic touch) and bioelectromagnetic-based therapies (e.g., electromagnetic fields). Mental health providers who are competently trained to use these interventions must provide patients with adequate information about safety and effectiveness in advance, including information about the means for evaluating effectiveness and monitoring potential harm. Patients should be informed of more conventional treatments of known effectiveness because these may pose less of a risk. This information should be provided regardless of the patient’s enthusiasm for participating in such a treatment or indifference to receiving thorough informed consent. Providing such informed consent supports patient autonomy, protects patients from harm and exploitation, and protects practitioners from complaints or grievances by a patient who feels that he or she has been harmed through the use of a nonvalidated technique or feels that he or she has paid for a useless intervention promoted by the psychologist.

Remaining Within One’s Boundaries of Competence The first ethical standard in Section 2 of the Ethics Code, Competence, Standard 2.01, clearly states that 159

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psychologists must practice within their boundaries of competence, whether doing therapy, research, teaching, supervising, management consulting, or any other professional activity. The metrics for competence stated in this standard are formal education, training, supervision, consultation, continuing education and independent study, and professional experience. Deciding how much training is enough before employing a new technique or strategy is an important matter of professional judgment on the part of the psychologist. Certainly, the neophyte therapist who has attended a 2-hour seminar on biofeedback training would not likely be considered competent to begin treating patients with this modality. Additionally, evidence suggests that mental health professionals are not immune to faddism— considering the inappropriate use of psychosurgery in the 1940s and 1950s and facilitated communication in the 1970s and 1980s. Furthermore, improper use of hypnotic techniques for treating adults with repressed memories of childhood abuse in the 1980s and later is another example of questionable competence. Fortunately, as time went on, therapists became more prudent and competent in using hypnosis in both diagnosing and treating adults with repressed memories of childhood trauma. We could argue that venturing beyond one’s area of competence is something that therapists may do, to some extent, every time they spontaneously develop a creative metaphor or novel strategy when working with a particularly unusual or challenging patient. A therapist may decide that the empirically based approach may not fully address the needs of a particular patient, at a particular stage of treatment, who is dealing with a particular symptom or dilemma. As a result, the therapist may employ a novel or imaginative intervention. The Ethics Code was not intended to stifle the use of creative therapeutic approaches that the therapist might not have studied in a journal or book. Rather, its intent is to remind therapists to always reflect on the possible attendant risk of harm when a novel strategy or tactic is employed and to secure informed consent in advance of treatment (more information can be found in Chapter 12 of this volume). If using an 6

unusual therapeutic intervention, the therapist bears the responsibility to inform clients and patients in advance and to avoid actions that could be harmful to or exploitative of them. In the author’s view, these two ethical concepts—providing informed consent and avoiding harming or exploiting others— accounts for the vast majority of the 89 ethical standards making up the Ethics Code (Nagy, 2011). An extreme and tragic example of an ill-founded therapeutic intervention that was far outside the standard of care involved two Colorado practitioners in 2000. The two “therapists” were Connell Watkins, an unlicensed and nonregistered practitioner, and Julie Ponder, a licensed marriage and family therapist from California. The two women carried out an intervention with a 10-year-old girl, Candace Newmaker, whom they determined suffered from attachment disorder, and devised a treatment strategy that was fatal (Advocates for Children in Therapy, 2003). As the child’s mother and a pediatric nurse practitioner looked on, the two therapists provided the young child with a supposedly corrective “rebirthing experience.” They required her to assume a fetal position on the floor, wrapped her up tightly in a flannel sheet, piling many pillows on top, and added their own weight on top—a combined total of 673 pounds. In spite of panicky cries from the child that she could not breathe, the therapists continued the treatment until she fell silent, 50 minutes into the session. They waited an additional 20 minutes, urging the child not to be a “quitter” in the rebirthing process. When they finally checked on her, she had suffocated, and all attempts to revive her were unsuccessful. To be sure, rebirthing therapy, the way Watkins and Ponder applied it, may have been innovative, but no institutional review board would have approved such a dangerous intervention if it had been submitted as a clinical research protocol, and no research existed that would support exposing participants to such a traumatic and risky experience.6 At times, a psychotherapist may ethically venture beyond his area of competence, when other more competent therapists may not be available, as addressed in Standard 2.01(d), Competence. This situation

This was excerpted from the author’s book Essential Ethics for Psychologists: Understanding and Mastering Core Issues (Nagy, 2011).

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invokes the general principle of Beneficence and Nonmaleficence—to help but at the same time to avoid harming recipients of their services. Consider the psychologist practicing in a rural area of Missouri who receives a telephone call from an anxious mother of an adolescent girl who is losing weight, has drastically reduced her intake of food, is exercising for 3 hours daily, has amenorrhea, has losses of consciousness, and frequently goes online to learn about more effective ways to lose weight. This psychologist may be unskilled in treating anorexia in adolescents but recognizing the health risks, may agree to meet with the woman and her daughter and serve as the first contact in facilitating medical care for the adolescent. Hopefully, the psychologist will refer the woman and her daughter to a nearby hospital or local family practitioner for evaluation and treatment. If there are no other treatment options locally, the psychologist may ethically provide treatment to the girl and her family if he increases his competence—for example, relying on telephone or online consultation with those knowledgeable about the disorder, conducting independent study of available literature and resources, attending workshops and seminars on the topic later on, and pursuing any other means to increase his knowledge and skills. In nonemergency situations in which practitioners may be in short supply, potential patients may seek services for which the therapist lacks adequate training. How far out of his or her competence comfort zone a therapist may venture is a question that must be addressed in these situations. Case Example 6 A psychologist is contacted by a 14-year-old girl who has a strong desire to learn hypnosis for improving her study skills in school. He is tempted to accept this patient, even though he has no formal training in hypnosis. He has read several journal articles including hypnotic scripts but never had face-to-face training, supervision, or consultation. However, he is aware of relaxation techniques and diaphragmatic breathing. He wonders if he should accept this patient for hypnosis simply because she is highly

motivated and holds strong beliefs about its effectiveness. Administering hypnosis in this situation would be an example of overestimating the psychologist’s clinical skills to satisfy a patient’s request. In this case, the psychologist was competent to provide nonhypnotic interventions that likely would help improve the girl’s study skills without risking the use of hypnosis, for which he was not trained, and incurring any untoward effects that might result from it. Consider the following example of a nonemergency situation in an underserved area. Case Example 7 A psychologist is contacted by the wife of a 59-year-old man who is experiencing minor problems of memory in language and daily activities. The psychologist has never treated an individual with mild cognitive impairment before and is unskilled in differentially diagnosing this disorder from a mood disorder with cognitive–emotional features or a medical condition. She knows that there is a multidisciplinary clinic specializing in the treatment of incipient dementia in a city that is 125 miles away, and she wonders if she should attempt to treat the patient herself or simply refer him to that clinic for a comprehensive evaluation. She decides to telephone the neurospychologist on staff at the clinic for advice. Both agree that a diagnostic assessment at the clinic would be best as the first step and that pending the outcome, the local psychologist could serve as a therapeutic resource to the man and his wife in combination with any treatment he might receive at the clinic. In an emergency, when other treatment options are scarce, a psychologist may ethically intervene until the emergency is resolved, as discussed in Standard 2.02, Providing Services in an Emergency. An emergency may consist of a natural disaster (e.g., an earthquake or tornado), could include an incident of domestic violence (e.g., spouse battering, 161

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child molestation, or elder abuse), or could emerge suddenly within the treatment setting of ongoing psychotherapy. Case Example 8 A therapist begins treating a Vietnam War veteran and discovers after several sessions that he was a prisoner of war (enduring many months of interrogation and torture), currently suffers from nightmares and panic attacks, is alcohol dependent, and intends to commit suicide to end all his suffering. The treating therapist has never treated a patient with such severe PTSD symptoms or imminent suicidality, and she does not consider herself competent to do so at this time and wishes to withdraw from her role as his therapist. She has already developed a beginning therapeutic alliance with the patient, however, and may be able to serve as a temporary resource, particularly if he has never been in treatment before. She sees her obligation as providing treatment to reduce the risk of suicide, if possible, while attempting simultaneously to locate a more suitable therapist or treatment facility. She also may seek a voluntary or involuntary hospitalization for the patient, refer him to a therapist who has experience with suicidal patients or those with severe PTSD symptoms if she can, or take some other step that would preserve his safety and well-being. She plans to end her role as the primary treating therapist after the patient has had an adequate number of sessions for processing transition and termination and has successfully transitioned to the new therapist or facility.

Enhancing Competence in Therapists Sometimes psychologists claim special areas of competence after completing a course of study, training, supervision, or consultation; however, it is not always clear which criteria must be met before 162

publicly making such a claim. Self-assessment can be helpful, as described by Belar et al. (2001) in clinical health psychology by presenting a template for self-assessment and a list of activities that may be completed to reach the goal of competence. Psychologists claiming areas of competence in addition to their license or academic degree should consult the APA or the professional literature to become informed about criteria to be met, including clinical experience, academic coursework, professional training, consultation, or other experiences. The erosion of competence over time rarely is monitored specifically by licensing boards or ethics committees unless the therapist receives complaints from a patient or third party. Yet it may well be true that subtle changes in therapists impair their competence or blunt their diagnostic and treatment skills simply as a function of age, life experience, or other factors. Such erosion of skills may be more apparent with major life transitions, such as the death of a therapist’s parent or spouse, or chronic pain. But therapists also should be aware of nuanced changes in their behavior that can serve as red flags of diminished competence, such as becoming careless in professional duties, taking unwarranted shortcuts, failing to write clinical notes or complete insurance papers, procrastinating in returning important phone calls or e-mails, being repeatedly late for appointments, making scheduling errors, experiencing difficulty remaining focused on a patient during the therapy hour, forgetting important patient disclosures from previous sessions, failing to maintain confidentiality with other treating health care providers, and other lapses. One way to help therapists obtain evidence of their ongoing competence is to administer an outcome measure periodically to patients (Reese, Nosworthy, & Rowlands, 2009). By soliciting feedback on a regular basis, the therapist has access to additional data about the progress of treatment. Quantifying the seriousness of depression by administering a depression inventory at regular intervals may help the therapist know whether behavioral homework assignments are more beneficial to the patient than reading a self-help book on depression. Some ways of soliciting feedback may include asking questions about the patient’s perception of the treatment and the degree of satisfaction

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about the therapy relationship, as described by Burns (2005). Burns recommended obtaining a patient’s written feedback after every single therapy session to maximize the efficiency of treatment and to help therapists become aware of any shortcomings. It is possible that psychologists (and other health care professionals) have a tendency to be overly optimistic about their ability to help others and less sensitive to their limitations (DeAngelis, 2003). According to research by Okiishi et al. (2006), the reality is that some psychologists do outperform others. They found “super shrinks” and “underperforming shrinks” when examining 71 psychotherapists. The top seven therapists had a lower dererioration rate (5%) compared with the bottom seven therapists (11%) and had significantly higher treatment gains, possibly representing the difference between “just-good-enough” competence and “excellence.” There was no evidence that therapists at the low end of the distribution were behaving unethically (e.g., engaging in contraindicated multiple relationships or allowing prejudice to interfere with their competence) or that they were likely to be reported to or disciplined by a licensing board. If we conceive of ethical conduct as being more than “risk management” (avoiding being disciplined) but also as including the aspirational or supererogatory values of striving for our highest ethical ideals, we maximize our potential for having the best outcomes while continually enhancing competence. Maintaining and enhancing competence when working in new areas of practice where established standards do not exist poses its own set of problems. This includes such domains as telehealth, performance enhancement (e.g., sports psychology), parenting coordination (assisting high-conflict postdivorce parents to fulfill their obligations to their child while complying with court-ordered recommendations), prescribing medication, and any of the alternative medicine interventions for which standards may be lacking. It is especially important to develop strategies for monitoring patient outcomes in these situations. As an example, LeVine (2007) described her experiences as a prescribing psychologist in New Mexico, relying on case studies, consultations with primary care physicians, and detailed records for monitoring patient progress.

Terminating and Referring Case Example 8 introduces the topic of determining when treatment should be ended. Standard 10.10, Terminating Therapy, informs us that psychologists should terminate therapy when it is reasonably clear the that client or patient no longer needs treatment, is not likely to benefit from having further sessions, or actually is being harmed by continuing. Examples of harm include (a) continuing treatment that is no longer needed (e.g., the therapist inappropriately introduces new topics), causing the patient with meager resources to continue paying for sessions that are not needed, and (b) fostering dependency and undermining patient autonomy in the individual who is able and ready to make the transition to independent functioning but delays doing so because of the therapist’s reluctance to end treatment. When it is time to terminate treatment, the therapist has an ethical obligation to provide pretermination counseling (unless the patient declines) and to address a variety of topics that may persist (Knapp & VandeCreek, 2006). (More information can be found in Chapter 16 of this volume.) The therapist may wish to study the patient’s entire clinical record in preparation for reviewing treatment to date, as well as individual topics with the patient. This review may include evaluating the progress that has been made in treatment, reviewing any remaining goals that might be better achieved with the help of a different therapeutic modality (e.g., a therapist with a different theoretical orientation better suited to the patient, a therapist specializing in pain management, marital therapy, group therapy, mindfulness meditation training), and addressing any issues that relate to the patient’s life after therapy has ended. Terminating treatment with a patient who moves out of state may pose a set of unique problems for the therapist. Motivated by a desire to be helpful to a patient who interrupts treatment by moving, the therapist may use a variety of resources to locate a new psychologist (e.g., going online in search of licensed practitioners in the new city, contacting the state Psychological Association’s Information and Referral Service of the new locale, searching a directory such as the National Register of Healthcare 163

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Providers in Psychology; see http://www.national register.org). But how many psychologists would further investigate whether a potentially new treating therapist in another city was impaired, had recently received a complaint from the local licensing board, or had his or her membership suspended by the APA because of a serious ethics violation? There is much that a therapist attempting to refer a patient moving to a new city cannot know about the psychological resources there, the most significant of which is the level of proficiency of supposedly competent therapists who are in practice. The therapist who makes a referral to a new psychologist and should have known about his ethical or professional violations of the past (e.g., boundary violations such as sex with a patient) could incur liability if the new therapist harms the referred patient in the course of treatment. It may be wise to share responsibility with the patient seeking treatment in another part of the country, rather than assume full responsibility for such a referral. There are times when termination counseling may be dispensed with and treatment may end suddenly because of the emergent risk of harm to the therapist. This situation may occur when a therapist has been threatened by a patient or by someone else with whom the patient has a relationship (e.g., spouse, family member, friend). Patients have been known to stalk their therapists (e.g., send a barrage of unwanted e-mails or voice mail messages, wait for them in parking lots at the end of the day), seek out their residences and monitor their activities on a weekend, and even damage their therapists’ automobiles or other property (Knapp, 2007; Tishler, Gordon, & Landry-Meyer, 2000). A therapist is not obliged to continue offering therapy if her safety becomes jeopardized, and it would not be considered abandonment for the therapist to terminate treatment in response to a threat of harm or actual harm to herself, her family, or her possessions. (More information about dealing with life-endangering patients can be found in Chapter 14 of this volume.) It may even be appropriate for the therapist to contact the local police department or retain an attorney to consider legal alternatives, such as involuntary hospitalization, a restraining order against the patient, or some other measure, as well as the inherent risks of each course of action. Such action would require careful consideration of 164

ethical and legal regulations balancing patient confidentiality concerns with therapist safety. In the face of a direct threat against the therapist (e.g., menacing e-mails), the Tarasoff duty-to-warn requirement does establish some precedent when a credible threat to a third party is disclosed in therapy and the therapist must then contact the intended victim and the police (see Tarasoff v. Regents of University of California). When the party threatened is the therapist, he or she obviously is aware of the threat but may still use his or her legal option of notifying the police. It is important always to have full awareness of current legal statutes in one’s home state in anticipation of such emergencies. ASSESSMENT Instruments of assessment commonly used by psychologists fall into the following five categories: (a) cognitive and neuropsychological testing; (b) social, adaptive, and problem behavior testing; (c) family and couples testing, (d) personality testing; and (e) vocational testing (American Educational Research Association, American Psychological Association, & National Council on Measurement in Education [AERA, APA, & NCME], 1999). Competence in using these instruments as well as other forms of assessment is addressed by a document entitled The Standards for Educational and Psychological Testing. It consists of a glossary, three sections (Test Construction, Fairness in Testing, and Testing Applications), and 264 standards, and it provides the highest standards in the sound and ethical use of tests as well as comprehensive criteria for the evaluation of tests, testing practices, and the effects of test use (AERA, APA, & NCME, 1999). This document is somewhat unusual because its standards are prescriptive only—there are no consequences for violating them because there is no entity responsible for enforcing them. (More information on psychological assessment can be found in Volume 2, Chapter 4, this handbook.) Competent assessment includes using tests in an appropriate manner and being well informed of a test’s purpose and limitations, including reliability, validity, normative statistics, and other information

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that would inform its use. The following case presents an example of incompetent assessment, including the use of the wrong test for the job. Case Example 9 A psychotherapist who was skilled at providing therapy to highly successful businessmen was retained by the attorney of a divorced man who was litigating for a more favorable custody arrangement of his young daughter. The attorney asked the psychologist to evaluate his client and assess his parenting abilities. Unfortunately, the psychologist was not as skilled in matters of assessment as he was in providing treatment. He selected the Wechsler Adult Intelligence Scale (WAIS-IV) as the sole basis for evaluating the man in the hopes of demonstrating his superior mental capacity and then, by inference, showing that he would have the potential to provide better parenting than his ex-wife for their daughter. Such an assessment did reveal the man’s high full-scale intelligence quotient, but it failed to uncover his low capacity for empathy in parenting and proneness to intense anger reactions, two factors that would likely affect a decision to award custody. By selecting an intelligence test for the purpose of evaluating a father’s parenting ability and overall mental health and arguing that the results supported a change in custody, the psychologist actually could contribute to a child’s being placed with the less capable parent. In this hypothetical case, the opposing counsel’s psychologist addressed the flaws in selecting the WAIS-IV as the primary instrument for evaluating parenting competency, and the court ordered a new evaluation. Competent assessment includes providing adequate informed consent before beginning the evaluation (except in legally mandated situations, when consent is implied as in routine education testing or in decisional capacity situations), selecting the appropriate test (most recent edition), only using a test for which the psychologist has adequate knowledge and

training, ensuring proper test conditions, scoring appropriately or selecting a reputable scoring service, and explaining the results to the client in a manner that he or she can comprehend. When interpreting results, psychologists must consider various test factors such as the client’s test-taking abilities and other characteristics—situational, personal, linguistic, and other cultural differences that might affect psychologists’ judgments or the accuracy of their interpretations (Standard 9.06, Interpreting Assessment Results). Interpretation also includes releasing the client’s actual test data to the client, if requested, as long as there is little or no risk of harm. The conditions for releasing test data are addressed by Standard 9.04, Release of Test Data, and by Federal Law, in the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Ethics Code regulates who may competently administer psychological tests, and clearly prohibits psychologists from delegating professional tasks to unqualified persons (e.g., clerical persons, untrained supervisees). It also requires those who develop tests and other assessment techniques (e.g., structured clinical interview) to use appropriate psychometric procedures and current scientific or professional knowledge for test design, standardization, validation, elimination of bias, and recommendations for use (see Standard 9.05, Test Construction). CLINICAL SUPERVISION Although the topic of supervision is covered in detail in Chapter 13 of Volume 2 in this handbook, some basic concepts are addressed here. Clinical supervision of the therapist-trainee is the final hurdle for aspiring psychologists before taking the licensing exam and increasingly is being addressed as a professional activity unto itself requiring specific training (Falender & Shafranske, 2004; Haynes, Corey, & Moulton, 2003; Thomas, 2010). A state licensing board or ethics committee also can mandate supervision in cases in which the psychologist, a licensed practitioner, has violated an important ethical or legal rule. Competence in supervision is addressed by the Association of State and Provincial Psychology Boards, which lists the following seven 165

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general areas: organized sequence of training, breadth and depth of training, hour requirement, supervision, supervisor qualifications, training sequence, and setting (see http://www.asppb.org). Thomas (2010) described two examples of common supervisory errors that may negatively affect the professional relationship. The first one involves going beyond the normal boundaries of supervision by being overly inquisitive about the trainee’s private life (e.g., focusing on his family of origin, sexual history, and other matters that go well beyond topics that the trainee expects to confront according to informed consent at the outset). The second includes quietly and implicitly altering the supervisory relationship by transmuting it into psychotherapy (e.g., gathering inappropriate history during the supervisory hour, encouraging inappropriate selfdisclosure and catharsis). TEACHING Those engaged in teaching at the high school, college, and graduate levels and beyond are guided by all of the General Principles of the Ethics Code, but the following four principles are particularly relevant: Principle A, Beneficence and Nonmaleficence; Principle B, Fidelity and Responsibility; Principle C, Integrity; and Principle E, Respect for People’s Rights and Dignity. (More information can be found in Volume 2, Chapter 12, this handbook.) Section 7 of the Ethics Code, Education and Training, contains seven ethical standards, many of which pertain directly to competence. Also included in these standards are the general themes of informed consent and avoiding multiple role relationships (e.g., sexual relationships with students and supervisees, the dual role of student and mandated group therapy participant).

Accuracy in Describing Education and Training Programs and in Teaching Competent teaching includes providing accurate descriptions at the outset about the content and nature of the learning experiences to be encountered, as stated in Standard 7.02, Description of Education and Training Program, and 7.03, Accuracy in Teaching. This may include informing 166

students, trainees, or workshop participants about the didactic and experiential aspects of the course, training goals and objectives, and requirements that must be met for satisfactory completion. Teachers also must offer a course syllabus that accurately portrays the subject area to be covered and the nature of course experiences. Teachers are obligated to present psychological information and knowledge in an accurate fashion, separating their bias or personal views from factual representations, as needed.

Assessing Performance Competent teaching and training includes competently assessing the learning that has been acquired. According to Standard 7.06, Assessing Student and Supervisee Performance, psychologists must establish a timely and specific process for providing feedback to students and trainees, and this process must be disclosed at the outset. This same standard requires teachers to base their evaluations on actual performance, not on such extraneous factors as friendly feelings, sexual attraction, or prejudice based on cultural or gender identity or other personal variables that may influence objectivity.

Avoiding Harmful Multiple Role Relationships Many standards in the Ethics Code address multiple role relationships and the potential for damage that may accompany some of them. In particular, Standard 7.05, Mandatory Individual or Group Therapy, helps teachers, professors, and supervisors avoid a unique form of harmful multiple role relationships with students. Some training programs require students to participate in individual or group therapy as a part of their graduate education experience. This standard was created to ensure that faculty who evaluate students’ academic performance never concurrently play the role of individual or group therapist to the same individual(s). The roles of professor and group therapist are so discretely different, requiring differing informed consent and competencies, that they must never be played by the same individual at the same time. This standard also clearly mandates that students may select a therapist who is not personally affiliated with the academic institution.

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MAINTAINING BOUNDARIES WITH PATIENTS, STUDENTS, AND TRAINEES Therapists, teachers, and supervisors have an ethical responsibility to maintain and model appropriate boundaries in their professional roles. There can be a heightened risk of impaired competence as well as harm and exploitation when a psychologist introduces a secondary role, such as business partner, coauthor, employee, friend, or lover. For example, the professor who develops special affection for a particular student may no longer be objective in evaluating or grading her, to the detriment of other students in the class or program. The topics of maintaining boundaries and avoiding harmful multiple relationships are explored in detail in Chapters 9 (dealing with boundaries) and 11 (dealing with sexualized relationships) of this volume, but they are introduced here as they pertain to competence. Not all multiple roles are harmful, and what may be acceptable in one role likely may be inappropriate in another. A professor might invite a group of students to her home for a barbecue at the end of the semester, but a psychotherapist would not normally engage in such social activities with current patients. A supervisor might possibly agree to coauthor a journal article or a book with someone with whom he has just completed a year of supervision. A therapist who has just terminated treatment with a patient, however, would be unlikely to do so, depending on the probability that the former patient might relapse and desire additional treatment and other factors. A general rule for psychologists maintaining optimal competence and objectivity is to be cautious about initiating or accepting a secondary or tertiary role in addition to their primary professional one. This does not prohibit psychologists from developing friendly feelings, and it does not lengthen the list of unethical acts by declaring that every supervisor who has lunch with his supervisee has necessarily committed an unethical act. Rather, it raises the key question of “whose needs are being met?” by introducing an additional role (e.g., social) to the primary professional one. When the psychologist is the one whose needs are primarily going to be gratified by introducing a secondary role, he must be

cautious about implementing an additional role to the primary one. The literature is filled with examples of exploitation and its harmful aftereffects to those in a subordinate position by psychologists who have participated in a sexual relationship with them, whether or not the psychologist was in love, was a sexual predator, or had some other motive (Gabbard, 1989, 1995; Holroyd & Brodsky, 1977; Pope, 1994, 2000; Pope, Sonne, & Holroyd, 1993; Pope & Vasquez, 2007; Pope & Vetter, 1991; Thomas, 2010). (More information on this topic can be found in Chapter 11 of this volume.) Psychologists in a professional relationship are ultimately responsible for deciding about the ethicality of engaging in a multiple role relationship, whether they or others have chosen to initiate it. A student, patient, or supervisee may not have the professional competence, professional experience, or objective judgment to make a decision about beginning a secondary relationship in addition to the primary one. And the Ethics Code and state or federal law regulate only the behavior of the psychologist, not that of patients, students, or supervisees—unless they happen to be members of the APA or are licensed mental health providers. Kitchener (1988) developed three guidelines for helping psychologists determine when commencing a multiple-role relationship would increase the probability of harm and, hence, should be avoided. They are as follows: (a) as the incompatibility of expectations increases between roles, so will the potential for harm; (b) as the obligations associated with different roles diverge, the potential for loss of objectivity and divided loyalties increases; and (c) as the prestige and power differential between the professional’s and consumer’s roles increase, so too does the potential for exploitation. According to Kitchener’s guidelines, psychologists should avoid engaging in the questionable relationship (e.g., anticipated multiple role) as the risk of harm increases. Others have addressed the decision-making process concerning embarking upon a multiple role relationship (e.g., business media presentation, coauthorship, friendship, sex) in different ways (Gottlieb, 1993; Gutheil & Gabbard, 1993; Sonne, 2006; Younggren & Gottlieb, 2004). 167

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RESEARCH AND PUBLICATION The Research and Publication section of the Ethics Codes contains more standards than any other section. Because this topic is fully explored in Volume 2, Chapters 16 through 20, this handbook, competence in research receives less attention in this chapter.

Research The ethical standards addressing research include the following topics: obtaining institutional approval for carrying out research; obtaining informed consent from research participants; providing equitable options to clients, patients, students, and other subordinate research participants; offering inducements for participating in research; using deception; debriefing research participants; using animals humanely in research; reporting research results; and a relatively recent addition, sharing research data for verification by other investigators. Providing informed consent to research participants who are deciding whether to become involved is one of the most important phases of research. It finds its genesis in four of the five General Principles: Principle A, Beneficence and Nonmaleficence; Principle B, Fidelity and Responsibility; Principle C, Integrity; and Principle E, Respect for People’s Rights and Dignity. Transgressions in research are commonly reported in the Newsletter of the Office of Research Integrity, a branch of the U.S. Department of Health and Human Services (see http://ori.hhs.gov). One of the most destructive ethical transgressions related to research involves fraud. The following excerpt is an example of research fraud that was committed by a psychiatry research assistant whose project was funded by a National Institute of Mental Health (NIMH) grant: Case Example 10 ORI [Office of Research Integrity] found that Ms. _______________, a former research assistant, Department of Psychiatry at the University of Illinois at Chicago, engaged in scientific misconduct in clinical research supported by a grant from NIMH by fabricating data in the records of 41 patients, including dates on which she claimed to have conducted 168

interviews in certain clinics, fabricating patient consent forms and questionnaires from patients participating in the project, and submitting false information in “Study Daily Logs” that recorded each day’s events. For 3 years beginning December 7, 1998, Ms. _______________ is prohibited from serving in any advisory capacity to the PHS, and her participation in any PHS-funded research is subject to supervision requirements. Research fraud, including the fabrication of data or research results as reported here, may occur at the finest academic institutions, as graduate students and faculty members fall prey to the pressures to publish, are careless about data collection, are overcommitted with academic responsibilities, or have some other motive to commit fraud. Competence in conducting research and reporting results is of utmost scientific importance. The research outcomes contribute to the knowledge base in psychology, potentially affecting those who do clinical work, supervise, teach, and do management consulting as well as those working in any area of psychology.

Publication Competence in publishing is largely grounded in Principle C, Integrity, with an emphasis on honesty, truthfulness, and striving to keep promises and avoiding unwise or unclear commitments. The ethical standards concerning publishing address plagiarism, publication credit, and publication one’s data or results as original work more than once. Plagiarism and publication credit appeared in an early form in the first edition of the Ethics Code (APA, 1953). Assigning publication credit for a journal article when multiple authors are involved can be a complex task—deciding how to acknowledge the relative merit of contributions made by each author. And when students collaborate with faculty, or when a significant power differential emerges because of academic rank, abuses have occurred with the lower ranking author being relegated to secondary authorship even though the student might have made the primary contribution. When an article is based on the student’s doctoral disserta-

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tion, in a multiple-author article, the ethical standard requires that the student be listed as the principal author. (More information about competence in scholarship can be found in Volume 2, Chapter 15, this handbook.) USE OF TECHNOLOGY AND TELEHEALTH Psychologists are increasingly turning to computer technology for a variety of reasons—computer scoring for psychological assessment, managing the business aspects of their practice (e.g., billing), record keeping (as regulated by some state laws), conducting research (e.g., engaging research participants and gathering data by using the Internet), providing online information on a variety of topics, and even offering clinical services via videoconferencing. (More information on these topics can be found in Volume 2, Chapters 10 and 18, this handbook.) The Ethics Code rarely seems to address competence in these areas, and the words information technology, computer, online, website, and e-mail are nowhere to be found in the 2002 edition. However, it does discuss “electronic transmission” in four standards (3.10, Informed Consent; 4.02(c), Discussing the Limits of Confidentialtiy; 5.01(a), Avoidance of False or Deceptive Statements; and 5.04, Media Presentations) as well as in the Introduction and Application Section. Future revisions of the code are likely to include standards that address competent rendering of psychological services that are assisted by technology.

Computers in Clinical Work For many years, computers have assisted clinicians in providing biofeedback training to patients suffering chronic pain, headaches, Reynaud’s syndrome, and other maladies. Recent clinical research on neurofeedback, also known as EEG biofeedback, is helping in the development of interventions for patients with behavioral problems, such as attention deficit hyperactivity disorder, learning disorders, and certain sleep problems. Computer systems, including personal digital assistants and cellphones, are being used for patients who desire to log symptoms as they occur throughout the day as well as therapeutic responses as learned in psychotherapy, for those suffering

eating disorders, obsessive–compulsive disorder, depression, and anxiety disorders, to name a few. More recently clinicians have been turning to computers to create virtual reality worlds for hospitalized patients with serious burns who must undergo painful debridement and changes of dressing as a part of treatment (Hoffman, Patterson, & Carrougher, 2000). Virtual reality systems also are being used to treat a variety of anxiety disorders such as phobias—fear of flying, fear of enclosed spaces, and so on. Competent training and ongoing consultation, as needed, is important as a prerequisite for carrying out these novel applications using computer technology. As the potential for benefiting patients is vastly increased by means of using powerful instrumentation, such as computers that create authentic virtual reality experiences, so too may the potential for harming patients increase as well. Behavioral telehealth refers to the use of technology to deliver mental health care, including transmissions channels (telephone lines or high-speed connections) and devices (telecommunication devices such as telephones, computers, modems, videophones, etc.; Maheu, Pulier, Wilhelm, McMenamin, & BrownConnolly, 2005). Maheu et al. (2005) included a broad array of terms to be mastered when referring to telehealth activities—e-counseling, cybercounseling, cybertherapy, teletherapy, telemental health, telepsychiatry, e-therapy, and behavioral e-care. The use of telephones, e-mail, videoconferencing, and other means of electronic communication by psychologists can indeed be useful for those who live in remote areas; are ill, elderly, disabled, or institutionalized (e.g., prisoners); or otherwise are unable to have face-to-face psychological treatment. (More information on the ethical issues related to telehealth can be found in Volume 2, Chapter 10, this handbook.)

Other Areas Competence in the courtroom is an area in which psychologists rarely have had much formal education before they receive their first subpoena, although there is an increasing trend to include law-related courses in graduate training. There is much to learn about being an expert witness, fact witness, or percipient treating expert, and how to competently discharge those responsibilities in a judicial procedure. 169

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Before venturing into the forensic arena, psychologists should attend workshops or take courses. Psychologists who are interviewed by journalists in the print or electronic media, or who regularly appear on radio, television, or the Internet are well advised to seek education and training in these areas. (More information on dealing with media psychology can be found in Volume 2, Chapter 11, this handbook.) TRANSITIONING TO NEW AREAS OF COMPETENCE Sometimes psychologists wish to change their area of practice, such as (a) the psychotherapist who wishes to move into the field of management consulting, or vice versa; (b) the group therapist who wishes to specialize in sports psychology and performance enhancement; (c) the researcher working in a university setting who desires to assess or treat patients; (d) the neuropsychologist who wishes to specialize in forensic psychology; or (e) the clinician who wishes to add hypnosis or biofeedback training to her repertoire. Each of these situations requires the psychologist to acquire a basic body of skills and knowledge before attempting to assume the new responsibilities. In some cases, the change might require additional coursework, supervised professional experience, and a written examination, such as in the case of the researcher turned licensed practitioner. In other cases, the psychologist may simply need additional study and training, extensive consultation with a psychologist already proficient in the new area, or other education experiences addressing current issues relevant to competence, such as in the case of the licensed neuropsychologist wishing to specialize in forensics. The range of professional competence within psychology is sufficiently broad that expertise in one area does not necessarily readily translate into another. Someone may be adept at treating certain personality disorders but have little awareness of the highly adversarial nature of the forensic setting or how to best serve as an expert witness in rendering courtroom testimony before a judge and a jury. A psychologist contemplating passage into new territory is wise to consult not only those already experienced but also the appropriate APA division for guidance about how to best go about this transition. 170

ETHICAL TRANSGRESSIONS—EXCEEDING ONE’S COMPETENCE COMFORT ZONE Practicing outside one’s area of competence can be a distressing experience for both the psychologist and client or patient. This situation may emerge unpredictably, such as the scenario in Case Example 8. Other situations in which practicing beyond one’s area of competence may occur follow: ■

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Being the sole practitioner in a rural area and being expected to treat anyone seeking your services, regardless of your education, training, supervision, or clinical experience Taking a brief workshop or training session in a new modality of treatment and attempting to employ it with a particularly challenging patient without consultation or supervision Suffering a physical disorder (e.g., chronic pain) or mental disorder (e.g., major depression) and attempting to continue fulfilling your psychological duties Using, scoring, and interpreting a psychological test on which you have little or no experience or training and for which you have never read the manual Being in a deposition or providing court testimony and encountering a clever attorney who induces you to make statements or judgments about an individual that you cannot support Being encouraged by an attorney who has hired you to take positions of advocacy on behalf of her client when you may feel uncertain about doing so Supervising a trainee in an area in which you yourself are not proficient Becoming overly friendly with a supervisee and losing your ability to provide objective and competent supervision Being overly enterprising in the business aspects of developing your independent practice, and claiming competence in assessment and treatment when you lack adequate knowledge and skills Dealing with situations best described as outliers, such as being proficient in marital therapy but never having encountered a raging and potentially violent husband in your office, face to face Paying research participants too much money as an inducement, resulting in coercing their

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engagement in the protocol and possibly biasing the data Teaching a course or seminar in which you carelessly make inaccurate statements, misstate the research, overgeneralize, oversimplify, minimize, exaggerate, spin, or otherwise distort the information that you present Transitioning to a new area of competence such as the psychotherapist who wants to begin a specialty in management consulting, but fails to take coursework, do the requisite study, or obtain consultation or supervision.

It is clear that there are many reasons why a wellintentioned and ethically observant psychologist might stray beyond the boundaries of his or her competence, as discussed above. There are consequences for both the client and as discussed above the psychologist when this happens.

Consequences for the Client or Patient Sometimes individuals may feel or be harmed by a psychologist who exceeds her boundary of competence, particularly when they have suffered a tangible loss due to an improper technique or procedure. This can be a financial loss, such as continuing to pay for ongoing treatment with an incompetent therapist instead of being referred elsewhere, or some other type of loss that is experienced as harmful or destructive. One example would be a court-ordered psychological evaluation of divorcing parents who are in litigation for child custody (as described in Case Example 9 earlier in this chapter). Lapses in competence might include any of the following: using inappropriate means of assessment, spending significantly more time assessing one parent than the other, making obvious omissions in the assessment procedure, making errors in scoring and interpreting tests, making inaccurate statements in a psychological report, or making inaccurate statements in a deposition or court proceeding. The psychologist who performs in a substandard manner may negatively affect the outcome of a custody settlement—harming both the child and the parent. The child might be harmed if placed with the less competent parent and subjected to abusive or neglectful parenting. The more

competent parent may be harmed by an unwarranted unfavorable decision by the court resulting in a reduction in visitation rights or loss of physical or legal custody. Child custody evaluations are inherently stressful for parents, children, extended family members, and other participants. They can lead to ill feelings and strained relationships among parents who, in most cases, will be working together to raise the children after a court decision is made. For this reason, in addition to carrying out the evaluation competently and accurately, a good psychologist will try to minimize harm by having a thorough informed consent process that is ongoing throughout the evaluation, including explaining decisions clearly; ensuring that collateral contacts understand how their information will be used; and, in general, making an effort to minimize the stress of the process. As a result, the parents will understand the steps in the process and the reasons why things are being done the way they are, and they will feel secure that their concerns will be heard. Another example would be the male therapist who has a difficult ongoing life stress and then becomes overinvolved with a challenging patient, such as a young, flirtatious woman diagnosed with borderline personality disorder. Consider the therapist who has recently experienced a difficult and painful divorce and now succumbs to the seductiveness of his new patient, develops a sexual relationship with her, stops treating her but continues the relationship, and then ends the romantic relationship some months later. He diminished his competence the moment he acted on the sexual attraction, even though his intent may not have been to exploit the patient in any way. By becoming sexually involved, he has severely eroded his objectivity and ability to competently treat her. By discontinuing treatment, he has truncated her therapy in the interest of pursuing the love affair and likely has severely damaged her ability to trust future therapists or treatment settings. By finally ending the sexual relationship and rejecting her, he gives the former patient reason to feel betrayed, angry, depressed, and even suicidal. Even if this scenario had turned out otherwise— with no sexual relationship—the potential still exists for impaired competence when the psychologist internally responds to feelings of sexual attraction. 171

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Although not necessarily unethical, natural feelings of sexual attraction for a patient can alter treatment if not properly addressed. The therapist may feel his role quickly shifting into that of friend, potential lover, or even voyeur, with attendant private fantasies and loss of objectivity. Such private distractions transform the therapy sessions into social chitchats, with ever-diminishing psychotherapeutic impact, as the psychologist’s detachment and competence falter and his full range of therapeutic interventions is no longer available to him. The patient may be unaware that this is happening and may never file a complaint. It is the therapist, feeling distracted by a sexually attractive patient, who bears a moral obligation to reflect on this situation and take appropriate steps— such as consulting with a peer or a therapist, seeking additional training, reading, or some other means of addressing the dilemma.

Consequences for the Psychologist Incompetence frequently is cited by disgruntled clients, patients, and supervisees as one of the major reasons for bringing a grievance, such as initiating a lawsuit against the psychologist, initiating a complaint with the APA Ethics Office (if the psychologist is a member), or initiating a complaint with the state licensing board. (More information about these actions can be found in Chapter 18 of this volume.) Complaints filed with the APA Ethics Committee generally are handled by correspondence, by seeking information from the complainant and then requesting responses from the complaintee. Ultimately, the Ethics Committee may impose a directive, a saction, or a punitive order on the psychologist found to be in violation, depending in part on the nature and severity of the violation and the degree of harm perpetrated on others. CONCLUSION It is clear that competence embraces a broad range of factors that are interconnected. These include a psychologist’s personality, physical health, mental health, life experience, academic training, supervision, professional experience, and continuing education. It is a dynamic construct, not a static one, constantly subject to metamorphosis throughout various stages of life. This dynamism invites the ethical 172

psychologist to maximize and maintain professional competence by continuously engaging in self-monitoring for each of the professional roles that he or she plays while carrying out his or her work.

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