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, teach-
ing, 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 mini-
mal level of capability to the expert level, and
including mastery of both knowledge and skills
(Abeles, 1998). Defining, achieving, and maintain-
ing competence is the subject of this chapter.1
Epstein and Hundert (2002) provided a comprehen-
sive definition of competence as the habitual and
judicious use of communication, knowledge, techni-
cal skills, clinical reasoning, emotions, values, and
reflection in daily practice for the benefit of the indi-
vidual and community being served (p. 226). And
Epstein (2007) explained an important developmen-
tal aspect of competence as being gained through
deliberate practice and reflection on experience
(p. 388). By maintaining their competence, psychol-
ogists 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 psycho-
therapist who fails to recognize the seriousness of a
potentially dangerous situation and to take some
preemptive actionsuch 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 ser-
vices to clients and patients or consult with organiza-
tions, 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 mate-
rials not only harms the knowledge base by imbuing
it with inaccuracies, but also could have negative
effects on othersfor 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 compe-
tence 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 intro-
duced in this chapter. This chapter covers the moral

1
Some of the content for this chapter derives from the authors 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)
147
Copyright 2012 by the American Psychological Association. All rights reserved.
Thomas F. Nagy
basis for competence, two general ethical principles
relating to competence, bias and prejudice, general
concepts about achieving and maintaining compe-
tence, therapy, assessment, clinical supervision,
teaching, maintaining boundaries with patients, stu-
dents, and trainees, research and publication, use of
technology and telehealth, transitioning to new
areas of competence, and ethical transgressions
exceeding ones 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 psy-
chology are discussed in more detail in Chapter 1 of
this volume. Although the standards are numerous,
and fairly specific, they still cannot address every sit-
uation and professional role played by psycholo-
gists. 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, aspira-
tional 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., com-
mitting murder), (c) actions that are optional and
morally neutralneither 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 cat-
egory 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 man-
datory 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 optionalneither
required nor forbidden by common-morality stan-
dards, (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 under-
taken from good intentions). As applied to the
Ethics Code, supererogatory acts primarily are pre-
sented 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
ethicshow minimal standards and lofty goals each
have a place in this document.
Ethical Floor and Ceiling
The Ethics Codes 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 specifi-
cally 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 well-
trained 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

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 sec-
tion entitled Human Relations. This prohibition
against inflicting harm on others requires psycholo-
gists 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 com-
ments 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 com-
ments that may be heard by a large audienceon
radio, television, or the Internetpossibly contrib-
uting 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 mini-
mal standards set by the Code of Conduct (i.e.,
enforceable ethical standards). Ethical questions
often arise during the normal course of a psycholo-
gists workteaching, consulting, carrying out
research, and so on. Those psychologists who
attempt to discover their supererogatory obliga-
tions, 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 particu-
larly useful, even though the language is lofty,
sometimes vague, and lacking in the kind of spe-
cific 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,
Competence
Fidelity and Responsibility; Principle C, Integrity;
Principle D, Justice; and Principle E, Respect for
Peoples Rights and Dignity. The areas of psycho-
logical 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 ceil-
ing 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 ques-
tion. Psychologists are not expected to merely com-
ply 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 stan-
dards 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 probabil-
ity 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 exper-
tise 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 adoles-
cent to another therapist experienced in
treating this disorder.
149
Thomas F. Nagy
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 ones 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 prac-
tice 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 devel-
oping a personal friendship or romantic
relationship with her, lest he lose his
objectivity and ultimately his compe-
tence. The patient mistakes the thera-
pists 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 bound-
aries in the treatment setting. Ultimately,
he avoids harming his patient by finding
equilibrium between the personal rela-
tionship (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 patients 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 therapist-
in-training the treatment will hopefully
progress satisfactorily. However, if the
supervisor is negligent in performing her
dutiesmeets less often for supervisory
sessions or fails to pay attention to emer-
gent risks that are being disclosed by the
patientshe may contribute to harm-
ing both the therapist-in-training and
the client. The therapisttrainee is being
harmed by receiving substandard super-
vision 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 man-
agement 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
 Competence

psychological well-being of a psychologist and inter- psychologist is asked to testify about his or her psy-
feres with her competence. chological assessment of divorcing parents who are
litigating about child custody, or when a psycholo-
Case Example 4
gist delivers a report to the court about a defendants
A psychotherapist with chronic back
competence to stand trial. Justice derives from the
pain must take daily medication to miti-
Latin root justitia, meaning justice, or equality, and it
gate her suffering that unfortunately dulls
has been defined as follows in legal settings: fairness,
her mental acuity and cognitive function-
moral rightness, and a scheme or system of law in
ing. She finds that her effectiveness is
which every person receives his or her due from the
impaired in carrying out diagnostic test-
system, including all rights, both natural and legal
ing and simply listening carefully to her
(see http://dictionary.law.com).
more challenging therapy clients. In par-
This principle has a bearing on competence, and
ticular, she struggles to be alert enough
it prompts psychologists to be aware of their own
to provide treatment to a single mother
biases and prejudices in the course of their work, as
with depression who is having difficulty
these can lead to unjust practices. It also asks psy-
parenting her alcoholic son. The therapist
chologists to make certain that they do not exceed
knows that she has an ethical obligation
the boundaries of their competence and the limita-
to monitor the extent to which her medi-
tions of their expertise. Because these concepts are
cations detract from her competence to
not always readily apparent, they may be difficult for
provide treatment, or engage in any other
psychologists to grasp. Prejudices and biases may
psychological work, for that matter. She
stem from ones earliest days, involving family of
considers various options in dealing with
origin, ethnicity, cultural conditioning, specific life
her more challenging patient, such as
events, sense of humor, and other factorsmuch of
(a) terminating and referring the patient
which may unconsciously affect the psychologists
to another therapist or (b) accommodat-
adult thoughts and actions. The boundaries of
ing in some other way, such as having
competence are not always easily noted either, as
shorter therapy sessions, scheduling her
psychologists sometimes find themselves being
patient only at a time of day when she is
nudged beyond their comfort zone, in clinical and
most alert (e.g., mornings), altering the
consulting cases, supervision, forensic situations,
times of taking her medication, taking
and other areas, without adequate reflection about
brief naps during the day, or pursuing
the risks they are encountering.
some other means.
In coping with such a health problem, the psy-
BIAS AND PREJUDICE
chologist would not find suggested courses of action
in either Principles A or D or in the ethical stan- A lack of impartiality may come from holding
dards, except in a general way. Consulting these two unfounded assumptions about a particular individual
sections of the Ethics Code may prompt the psy- or group that affect how the psychologist teaches,
chologist to be vigilant about matters of her own designs and conducts research, evaluates, or provides
mental and physical health, to note when her profes- treatment for a person. These unfounded assump-
sional competence might be declining, and to take tions can profoundly affect competence, resulting in
appropriate and timely action. Maintaining sound judgments, decisions, interventions, and other
mental health and sufficient emotional competence actions that harm others, either by what they accom-
to practice is covered in Chapter 7 of this volume. plish or fail to accomplish. This issue is addressed in
Section 3 of the Ethics Code, by Standard 3.01, Unfair
General Ethical Principle D: Justice Discrimination. What we might term competence in
The fourth General Principle, Justice, often has human diversity, which prohibits psychologists from
application in the legal arena, such as when a engaging in unfair discrimination, can be formed on

151
Thomas F. Nagy
the basis of the following factors: age, gender, gender
identity, race, ethnicity, culture, national origin, reli-
gion, sexual orientation, disability, socioeconomic
status, or any basis proscribed by law. Therapists will-
ing 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 augment-
ing 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 improve-
ment over time.
Age
Developmental issues manifest themselves continu-
ously throughout life, requiring psychologists to
maintain their knowledge and skills commensu-
rately. 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 edu-
cation, training, supervision, or other life experi-
ences. 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 cul-
ture. 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 unwar-
ranted 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 relationshipsincluding devel-
oping 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 ones
knowledge of the opposite sex by remaining current
on the research, attending seminars, observing pub-
lications from the APA such as the lengthy docu-
ment Guidelines for Psychological Practice With Girls
and Women (2007b), and other means.
Sexual Orientation
An essential component of psychological compe-
tence is having awareness of and accepting the broad
variety of sexual orientations and preferences. A sys-
tematic bias or fear of homosexuals (or heterosexu-
als) may impair a psychologists work in much the
same way that gender bias does. A psychologists
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 con-
cerning diagnosis, treatment, family relationships,
social prejudice and discrimination, risks and chal-
lenges 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, psy-
chotherapy, 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 psychologists ability to work competently.
The extensively diverse population in some regions
of the United States may pose significant challenges

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 val-
ues. 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 exec-
utive 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 cul-
tural 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 cer-
tain 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 reli-
gious teachings of ones patients, supervisees, or stu-
dents may help the psychologist to have better
understanding and empathy for them as well as
deliver superior services.
Competence
Prejudice based on an individuals 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 impor-
tant conclusions and recommendations, and treat-
ment that fails to address the more difficult aspects of
a patients behavior and dynamics because of a thera-
pists positive bias about the patient. For example, a
devoutly Catholic psychologist with a bias who is
asked to evaluate a priest accused of molesting chil-
dren may not be able to carry out an objective assess-
ment and, as a reslt, may misperceive or deliberately
minimize signs of psychopathology when interpret-
ing 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 degener-
ative diseases, HIV/AIDS, spinal cord or other severe
injuries, fatal illnesses, or other conditions impair-
ing 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, demen-
tias, or other brain disorders from head injuries or
illness (e.g., stroke, heart attack). Remaining com-
petent 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 socio-
economic groups. An example would be the thera-
pist 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 pro-
tection and safe refuge, along with her children, and
may need to move to a womans shelter. This patient
may have little interest in developing psychological
153
Thomas F. Nagy
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 thera-
pist 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 dia-
lects, values, dress, nonverbal cues, interpersonal
style, relationships, and prejudices of the group
being studiedall 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 trau-
matic experience.
Case Example 5
A male researcher, who recently expe-
rienced a painful and costly divorce, has
been investigating gender roles in mar-
riage. 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 nega-
tive bias, as confirmed by his coinvestiga-
tor. He slowly arrives at the conclusion
3
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.
154
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 feel-
ings 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 psy-
chotherapy to address his mood disorder
and resentment.
Fortunately this investigator had sufficient self-
insight to benefit from consultation with his coin-
vestigator 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 pub-
licly claim the title psychologist and offer profes-
sional services to consumers for a fee (e.g.,
individual or group therapy, assessment, clinical
supervision of trainees, forensic activities, manage-
ment 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

always remains an essential ingredient in the ongo-
ing quest for superior mastery of psychological skills.
Those who work in academic or health care set-
tings 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, curric-
ulum vitae, the Internet, or promotional materials
extolling the supposed skills and knowledge of the
psychologist, when, in reality the psychologists
work was never reviewed adequately and the pri-
mary requirement for receipt of the credential was
the payment of a fee.
Maintaining Competence
Those holding a license to practice psychology gen-
erally 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 webi-
nars, reading books and articles, or participating in
other experiences that are coordinated with manda-
tory continuing education programs (e.g., hospital
grand rounds presentations). In addition, many psy-
chologists maintain their skills by regularly consult-
ing with peersthat is, other clinicians, fellow
supervisors, researchers, management consultants,
and teachers. When these peer-to-peer consulta-
tions, whether one on one or in groups, are carried
out in a collaborative and compassionate manner,
they can be extremely helpful and enhance compe-
tence. 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
Competence
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 self-
awareness 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 ones 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 sub-
stances, 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 treat-
ment, even though their competence is being dimin-
ished. 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 timesuch 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 psy-
chologists 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 ones competence
may include having a lifestyle that promotes good
mental healthadhering to the advice that we give to
our patients. This includes the following therapeutic
habits: (a) adequate sleep, (b) regular physical exer-
cise, (c) regularly engaging in play or fun activities
(e.g., hobbies, social activities), (d) nurturing the
relationship with ones significant other, (e) engaging
in friendships and other social activities, and (f) any
155
Thomas F. Nagy
other activities and life habits that are critical for sus-
taining 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 work-
ing 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 quali-
ties, and (f) provision of a rationale for the patients
problems. A detailed review of common factors in
psychotherapy may be found in the conclusions and
recommendations of APAs 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 compe-
tent practice: (a) proficiency (i.e., possessing ade-
quate 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 spe-
cialties. 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 psycholo-
gists 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 spec-
ified problems and populations (see the CSPP web-
site: 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 pro-
gram (and possibly additional organized sequence of
education and training in postdoctoral programs), fol-
lowed by an examination designed to assess compe-
tence, 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 pro-
vides the following rationale for specializing in its
mission statement: to increase consumer protection
by examining and certifying psychologists who dem-
onstrate 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 neuropsy-
chology, (d) clinical psychology, (e) cognitive and
behavioral psychology, (f) counseling psychology,
(g) couple and family psychology, (h) forensic psy-
chology, (i) group psychology, (j) organizational
and business consulting psychology, (k) psycho-
analysis in pychology, (l) rehabilitation psychology,
and (m) school psychology (CSPP, 2009). Each spe-
cialty 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 Organizations College of
Professional Psychology (COPP) certifies licensed

psychologists in the treatment of those with alcohol
and other psychoactivesubstance 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 COPPs examination.
Prescription Privileges
Few states currently permit psychologists to pre-
scribe medications as an adjunct to rendering clini-
cal services, although there has been active lobbying
on the part of some psychologists to change this sit-
uation. 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 psychol-
ogy, 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.
Psychotherapy: Evidence-Based Practice
Evidence-based practice refers to therapeutic inter-
ventions offered by psychologists that integrate sci-
ence 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 Evidence-
Based 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
Competence
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 sup-
ported principles of psychological assessment, case
formulation, therapeutic relationship, and interven-
tion (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 compo-
nents of clinical expertise are described in the report:
Assessment, diagnostic judgment, systematic
case formulation, and treatment planning (e.g.,
accurate diagnosis, setting appropriate treatment
goals and tasks)
Clinical decision making, treatment implementa-
tion, and monitoring of patient progress (e.g.,
skill and flexibility, tact, timing, pacing, framing
of interventions, balancing consistency of inter-
ventions with responsiveness to patient feedback,
monitoring progress)
Interpersonal expertise (e.g., forming a therapeu-
tic 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 ones own experience,
knowledge, hypotheses, emotional reactions,
and behaviors; awareness of limits of knowledge,
skills, and biases affecting ones work)
Evaluation and use of research evidence in both
basic and applied psychological science (e.g.,
having an understanding of research methodol-
ogy, 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, cul-
tural, and contextual differences on treatment
157
Thomas F. Nagy

(e.g., individual, social, and cultural variables, Practice Guidelines

including age, development, ethnicity, culture,
race, gender, sexual orientation, religious com-
mitments, and socioeconomic status)
Use of available resources as needed (e.g., seeking
consultation; recommending adjunctive or alter-
native services when needed; cultural sensitivity)
Formation of a cogent rationale for clinical
strategies (e.g., a planful approach to the treat-
ment of psychological problems; reliance on the
therapists well-articulated case formulation con-
cerning 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 favor-
ably to the outcomes obtained by experienced clini-
cians, 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 evidence-
based 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.
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
Dignityunderscoring the guidelines sensitivity to
cultural, individual, and role differences among psy-
chological service providers and their client popula-
tions, including but not limited to age, gender, race,
ethnicity, national origin, religion, sexual orienta-
tion, disability, language, and socioeconomic status
(APA, 2002). Practice guidelines are intended to be
aspirational in naturethat is, they provide sugges-
tions, 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 psy-
chologists generally would not be penalized or sanc-
tioned for failure to comply with a particular
practice guideline, they should be cautious about
deviating from it and have a well-developed ratio-
nale 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

4
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).
5
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).

158

Guidelines for the Evaluation of Dementia and Age-
Related 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 treat-
ment 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 Associations Practice Guideline for the
Treatment of Patients With Alzheimers 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, summa-
rizing 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
Competence
complementary medicine (interventions that are used
in addition to conventional medicine) and alternative
medicine (interventions that are used in place of con-
ventional medicine). Integrative medicine combines
treatments from conventional medicine, complemen-
tary medicine, and alternative medicine that have
evidence of safety and effectiveness, such as using
hypnosis for pain control, nausea, or other symp-
toms. 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) mindbody
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, mas-
sage); and (d) energy medicine, consisting of biofield
therapies (e.g., qi gong, Reiki, therapeutic touch) and
bioelectromagnetic-based therapies (e.g., electromag-
netic 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 monitor-
ing potential harm. Patients should be informed of
more conventional treatments of known effectiveness
because these may pose less of a risk. This informa-
tion should be provided regardless of the patients
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 exploita-
tion, 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 tech-
nique or feels that he or she has paid for a useless
intervention promoted by the psychologist.
Remaining Within Ones Boundaries
of Competence
The first ethical standard in Section 2 of the Ethics
Code, Competence, Standard 2.01, clearly states that
159
Thomas F. Nagy
psychologists must practice within their boundaries
of competence, whether doing therapy, research,
teaching, supervising, management consulting, or
any other professional activity. The metrics for com-
petence stated in this standard are formal education,
training, supervision, consultation, continuing edu-
cation 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 bio-
feedback training would not likely be considered
competent to begin treating patients with this modal-
ity. 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 communica-
tion 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 compe-
tence. Fortunately, as time went on, therapists
became more prudent and competent in using hyp-
nosis in both diagnosing and treating adults with
repressed memories of childhood trauma.
We could argue that venturing beyond ones 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 thera-
peutic 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 tac-
tic 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
This was excerpted from the authors book Essential Ethics for Psychologists: Understanding and Mastering Core Issues (Nagy, 2011).
160
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 authors view,
these two ethical conceptsproviding informed
consent and avoiding harming or exploiting others
accounts for the vast majority of the 89 ethical stan-
dards 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 strat-
egy that was fatal (Advocates for Children in
Therapy, 2003). As the childs mother and a pediat-
ric nurse practitioner looked on, the two therapists
provided the young child with a supposedly correc-
tive 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 topa com-
bined total of 673 pounds. In spite of panicky cries
from the child that she could not breathe, the thera-
pists continued the treatment until she fell silent,
50 minutes into the session. They waited an addi-
tional 20 minutes, urging the child not to be a quit-
ter in the rebirthing process. When they finally
checked on her, she had suffocated, and all attempts
to revive her were unsuccessful. To be sure, rebirth-
ing therapy, the way Watkins and Ponder applied it,
may have been innovative, but no institutional
review board would have approved such a danger-
ous intervention if it had been submitted as a clini-
cal research protocol, and no research existed that
would support exposing participants to such a trau-
matic 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

invokes the general principle of Beneficence and
Nonmaleficenceto 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 drasti-
cally reduced her intake of food, is exercising for 3
hours daily, has amenorrhea, has losses of conscious-
ness, and frequently goes online to learn about more
effective ways to lose weight. This psychologist may be
unskilled in treating anorexia in adolescents but rec-
ognizing 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 prac-
titioner 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 competencefor example, relying on
telephone or online consultation with those knowl-
edgeable 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 practitio-
ners 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 com-
fort 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 for-
mal training in hypnosis. He has read
several journal articles including hyp-
notic scripts but never had face-to-face
training, supervision, or consultation.
However, he is aware of relaxation tech-
niques and diaphragmatic breathing. He
wonders if he should accept this patient
for hypnosis simply because she is highly
Competence
motivated and holds strong beliefs about
its effectiveness.
Administering hypnosis in this situation would
be an example of overestimating the psychologists
clinical skills to satisfy a patients request. In this
case, the psychologist was competent to provide
nonhypnotic interventions that likely would help
improve the girls 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 none-
mergency 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
cognitiveemotional features or a medi-
cal 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 won-
ders 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 neurospy-
chologist 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 thera-
peutic 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 inci-
dent of domestic violence (e.g., spouse battering,
161
Thomas F. Nagy

child molestation, or elder abuse), or could emerge publicly making such a claim. Self-assessment can
suddenly within the treatment setting of ongoing be helpful, as described by Belar et al. (2001) in
psychotherapy. clinical health psychology by presenting a template
for self-assessment and a list of activities that may
Case Example 8
be completed to reach the goal of competence.
A therapist begins treating a Vietnam
Psychologists claiming areas of competence in addi-
War veteran and discovers after several
tion to their license or academic degree should con-
sessions that he was a prisoner of war
sult the APA or the professional literature to become
(enduring many months of interroga-
informed about criteria to be met, including clinical
tion and torture), currently suffers from
experience, academic coursework, professional
nightmares and panic attacks, is alcohol
training, consultation, or other experiences.
dependent, and intends to commit sui-
The erosion of competence over time rarely is
cide to end all his suffering. The treat-
monitored specifically by licensing boards or ethics
ing therapist has never treated a patient
committees unless the therapist receives complaints
with such severe PTSD symptoms or
from a patient or third party. Yet it may well be true
imminent suicidality, and she does not
that subtle changes in therapists impair their compe-
consider herself competent to do so at
tence or blunt their diagnostic and treatment skills
this time and wishes to withdraw from
simply as a function of age, life experience, or other
her role as his therapist. She has already
factors. Such erosion of skills may be more apparent
developed a beginning therapeutic alli-
with major life transitions, such as the death of a
ance with the patient, however, and may
therapists parent or spouse, or chronic pain. But
be able to serve as a temporary resource,
therapists also should be aware of nuanced changes
particularly if he has never been in treat-
in their behavior that can serve as red flags of dimin-
ment before. She sees her obligation as
ished competence, such as becoming careless in pro-
providing treatment to reduce the risk
fessional duties, taking unwarranted shortcuts,
of suicide, if possible, while attempting
failing to write clinical notes or complete insurance
simultaneously to locate a more suitable
papers, procrastinating in returning important
therapist or treatment facility. She also
phone calls or e-mails, being repeatedly late for
may seek a voluntary or involuntary
appointments, making scheduling errors, experienc-
hospitalization for the patient, refer him
ing difficulty remaining focused on a patient during
to a therapist who has experience with
the therapy hour, forgetting important patient dis-
suicidal patients or those with severe
closures from previous sessions, failing to maintain
PTSD symptoms if she can, or take some
confidentiality with other treating health care pro-
other step that would preserve his safety
viders, and other lapses.
and well-being. She plans to end her
One way to help therapists obtain evidence of their
role as the primary treating therapist
ongoing competence is to administer an outcome
after the patient has had an adequate
measure periodically to patients (Reese, Nosworthy,
number of sessions for processing tran-
& Rowlands, 2009). By soliciting feedback on a regu-
sition and termination and has success-
lar basis, the therapist has access to additional data
fully transitioned to the new therapist
about the progress of treatment. Quantifying the seri-
or facility.
ousness of depression by administering a depression
inventory at regular intervals may help the therapist
Enhancing Competence in Therapists know whether behavioral homework assignments are
Sometimes psychologists claim special areas of more beneficial to the patient than reading a self-help
competence after completing a course of study, book on depression. Some ways of soliciting feedback
training, supervision, or consultation; however, it is may include asking questions about the patients per-
not always clear which criteria must be met before ception of the treatment and the degree of satisfaction

162

about the therapy relationship, as described by Burns
(2005). Burns recommended obtaining a patients
written feedback after every single therapy session to
maximize the efficiency of treatment and to help ther-
apists 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 under-
performing shrinks when examining 71 psycho-
therapists. 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 multi-
ple 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 out-
comes 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, perfor-
mance enhancement (e.g., sports psychology),
parenting coordination (assisting high-conflict post-
divorce parents to fulfill their obligations to their
child while complying with court-ordered recom-
mendations), prescribing medication, and any of the
alternative medicine interventions for which stan-
dards 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 psycholo-
gist in New Mexico, relying on case studies, consul-
tations with primary care physicians, and detailed
records for monitoring patient progress.
Competence
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 fur-
ther sessions, or actually is being harmed by con-
tinuing. Examples of harm include (a) continuing
treatment that is no longer needed (e.g., the thera-
pist inappropriately introduces new topics), caus-
ing the patient with meager resources to continue
paying for sessions that are not needed, and (b) fos-
tering dependency and undermining patient auton-
omy in the individual who is able and ready to
make the transition to independent functioning but
delays doing so because of the therapists reluctance
to end treatment.
When it is time to terminate treatment, the thera-
pist has an ethical obligation to provide pretermina-
tion 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 patients 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 man-
agement, marital therapy, group therapy, mindful-
ness meditation training), and addressing any issues
that relate to the patients 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 Associations Information and
Referral Service of the new locale, searching a direc-
tory such as the National Register of Healthcare
163
Thomas F. Nagy
Providers in Psychology; see http://www.national
register.org). But how many psychologists would fur-
ther 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 thera-
pists 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 mem-
ber, 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 moni-
tor 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 ther-
apist 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 confi-
dentiality concerns with therapist safety. In the face
of a direct threat against the therapist (e.g., menac-
ing 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 thera-
pist, 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 ones home state in antici-
pation of such emergencies.
ASSESSMENT
Instruments of assessment commonly used by psy-
chologists 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 instru-
ments 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 onlythere are no con-
sequences 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
tests purpose and limitations, including reliability,
validity, normative statistics, and other information

that would inform its use. The following case pres-
ents an example of incompetent assessment, includ-
ing 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 attor-
ney of a divorced man who was litigating
for a more favorable custody arrange-
ment of his young daughter. The attor-
ney asked the psychologist to evaluate
his client and assess his parenting abili-
ties. 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 dem-
onstrating his superior mental capacity
and then, by inference, showing that he
would have the potential to provide bet-
ter parenting than his ex-wife for their
daughter. Such an assessment did reveal
the mans 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 fathers parenting ability and overall
mental health and arguing that the results supported
a change in custody, the psychologist actually could
contribute to a childs being placed with the less
capable parent. In this hypothetical case, the oppos-
ing counsels 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 ade-
quate informed consent before beginning the evalua-
tion (except in legally mandated situations, when
consent is implied as in routine education testing or
in decisional capacity situations), selecting the appro-
priate test (most recent edition), only using a test for
which the psychologist has adequate knowledge and
Competence
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 fac-
tors such as the clients test-taking abilities and other
characteristicssituational, personal, linguistic, and
other cultural differences that might affect psycholo-
gists judgments or the accuracy of their interpreta-
tions (Standard 9.06, Interpreting Assessment
Results). Interpretation also includes releasing the
clients actual test data to the client, if requested, as
long as there is little or no risk of harm. The condi-
tions 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 compe-
tently administer psychological tests, and clearly
prohibits psychologists from delegating profes-
sional tasks to unqualified persons (e.g., clerical
persons, untrained supervisees). It also requires
those who develop tests and other assessment tech-
niques (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 hur-
dle for aspiring psychologists before taking the
licensing exam and increasingly is being addressed
as a professional activity unto itself requiring spe-
cific training (Falender & Shafranske, 2004; Haynes,
Corey, & Moulton, 2003; Thomas, 2010). A state
licensing board or ethics committee also can man-
date 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
Thomas F. Nagy
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 com-
mon 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 trainees pri-
vate life (e.g., focusing on his family of origin, sex-
ual 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 supervi-
sory relationship by transmuting it into psychother-
apy (e.g., gathering inappropriate history during the
supervisory hour, encouraging inappropriate self-
disclosure and catharsis).
TEACHING
Those engaged in teaching at the high school, col-
lege, and graduate levels and beyond are guided by
all of the General Principles of the Ethics Code, but
the following four principles are particularly rele-
vant: Principle A, Beneficence and Nonmaleficence;
Principle B, Fidelity and Responsibility; Principle C,
Integrity; and Principle E, Respect for Peoples
Rights and Dignity. (More information can be found
in Volume 2, Chapter 12, this handbook.) Section 7
of the Ethics Code, Education and Training, con-
tains seven ethical standards, many of which pertain
directly to competence. Also included in these stan-
dards 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 encoun-
tered, 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 por-
trays the subject area to be covered and the nature of
course experiences. Teachers are obligated to pres-
ent 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 compe-
tently assessing the learning that has been acquired.
According to Standard 7.06, Assessing Student and
Supervisee Performance, psychologists must estab-
lish a timely and specific process for providing feed-
back 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 per-
sonal 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 rela-
tionships with students.
Some training programs require students to par-
ticipate in individual or group therapy as a part of
their graduate education experience. This standard
was created to ensure that faculty who evaluate stu-
dents 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 differ-
ing 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.
 Competence

MAINTAINING BOUNDARIES WITH cautious about implementing an additional role to

PATIENTS, STUDENTS, AND TRAINEES the primary one.
The literature is filled with examples of exploita-
Therapists, teachers, and supervisors have an ethical
tion and its harmful aftereffects to those in a subordi-
responsibility to maintain and model appropriate
nate position by psychologists who have participated
boundaries in their professional roles. There can be
in a sexual relationship with them, whether or not
a heightened risk of impaired competence as well as
the psychologist was in love, was a sexual predator,
harm and exploitation when a psychologist intro-
or had some other motive (Gabbard, 1989, 1995;
duces a secondary role, such as business partner,
Holroyd & Brodsky, 1977; Pope, 1994, 2000; Pope,
coauthor, employee, friend, or lover. For example,
Sonne, & Holroyd, 1993; Pope & Vasquez, 2007;
the professor who develops special affection for a
Pope & Vetter, 1991; Thomas, 2010). (More infor-
particular student may no longer be objective in
mation on this topic can be found in Chapter 11 of
evaluating or grading her, to the detriment of other
this volume.)
students in the class or program. The topics of main-
Psychologists in a professional relationship are
taining boundaries and avoiding harmful multiple
ultimately responsible for deciding about the ethical-
relationships are explored in detail in Chapters 9
ity of engaging in a multiple role relationship,
(dealing with boundaries) and 11 (dealing with sex-
whether they or others have chosen to initiate it. A
ualized relationships) of this volume, but they are
student, patient, or supervisee may not have the pro-
introduced here as they pertain to competence.
fessional competence, professional experience, or
Not all multiple roles are harmful, and what may
objective judgment to make a decision about begin-
be acceptable in one role likely may be inappropri-
ning a secondary relationship in addition to the pri-
ate in another. A professor might invite a group of
mary one. And the Ethics Code and state or federal
students to her home for a barbecue at the end of
law regulate only the behavior of the psychologist,
the semester, but a psychotherapist would not nor-
not that of patients, students, or superviseesunless
mally engage in such social activities with current
they happen to be members of the APA or are
patients. A supervisor might possibly agree to coau-
licensed mental health providers.
thor a journal article or a book with someone with
Kitchener (1988) developed three guidelines for
whom he has just completed a year of supervision.
helping psychologists determine when commencing
A therapist who has just terminated treatment with
a multiple-role relationship would increase the prob-
a patient, however, would be unlikely to do so,
ability of harm and, hence, should be avoided. They
depending on the probability that the former patient
are as follows: (a) as the incompatibility of expecta-
might relapse and desire additional treatment and
tions increases between roles, so will the potential
other factors.
for harm; (b) as the obligations associated with dif-
A general rule for psychologists maintaining
ferent roles diverge, the potential for loss of objectiv-
optimal competence and objectivity is to be cautious
ity and divided loyalties increases; and (c) as the
about initiating or accepting a secondary or tertiary
prestige and power differential between the profes-
role in addition to their primary professional one.
sionals and consumers roles increase, so too does
This does not prohibit psychologists from develop-
the potential for exploitation. According to
ing friendly feelings, and it does not lengthen the
Kitcheners guidelines, psychologists should avoid
list of unethical acts by declaring that every supervi-
engaging in the questionable relationship (e.g., antic-
sor who has lunch with his supervisee has necessar-
ipated multiple role) as the risk of harm increases.
ily committed an unethical act. Rather, it raises the
Others have addressed the decision-making process
key question of whose needs are being met? by
concerning embarking upon a multiple role relation-
introducing an additional role (e.g., social) to the
ship (e.g., business media presentation, coauthor-
primary professional one. When the psychologist is
ship, friendship, sex) in different ways (Gottlieb,
the one whose needs are primarily going to be grati-
1993; Gutheil & Gabbard, 1993; Sonne, 2006;
fied by introducing a secondary role, he must be
Younggren & Gottlieb, 2004).

167
Thomas F. Nagy
RESEARCH AND PUBLICATION
The Research and Publication section of the Ethics
Codes contains more standards than any other sec-
tion. 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 con-
sent from research participants; providing equitable
options to clients, patients, students, and other sub-
ordinate 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 partici-
pants 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 Peoples 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 for-
mer research assistant, Department of
Psychiatry at the University of Illinois at
Chicago, engaged in scientific miscon-
duct 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 question-
naires from patients participating in the
project, and submitting false informa-
tion in Study Daily Logs that recorded
each days 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 over-
committed 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 ethi-
cal standards concerning publishing address plagia-
rism, publication credit, and publication ones 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 com-
plex taskdeciding how to acknowledge the rela-
tive 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 students doctoral disserta-

tion, in a multiple-author article, the ethical stan-
dard requires that the student be listed as the
principal author. (More information about compe-
tence 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 reasonscomputer scor-
ing 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 partici-
pants and gathering data by using the Internet), pro-
viding 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 compe-
tence in these areas, and the words information tech-
nology, 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 revi-
sions of the code are likely to include standards that
address competent rendering of psychological ser-
vices 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, Reynauds syndrome, and
other maladies. Recent clinical research on neuro-
feedback, also known as EEG biofeedback, is helping
in the development of interventions for patients with
behavioral problems, such as attention deficit hyper-
activity disorder, learning disorders, and certain sleep
problems. Computer systems, including personal dig-
ital 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
Competence
eating disorders, obsessivecompulsive disorder,
depression, and anxiety disorders, to name a few.
More recently clinicians have been turning to
computers to create virtual reality worlds for hospi-
talized patients with serious burns who must
undergo painful debridement and changes of dress-
ing 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 phobiasfear of flying, fear of enclosed
spaces, and so on. Competent training and ongoing
consultation, as needed, is important as a prerequi-
site for carrying out these novel applications using
computer technology. As the potential for benefiting
patients is vastly increased by means of using pow-
erful 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 tele-
phones, computers, modems, videophones, etc.;
Maheu, Pulier, Wilhelm, McMenamin, & Brown-
Connolly, 2005). Maheu et al. (2005) included a broad
array of terms to be mastered when referring to tele-
health activitiese-counseling, cybercounseling,
cybertherapy, teletherapy, telemental health, telepsy-
chiatry, 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 per-
cipient treating expert, and how to competently dis-
charge those responsibilities in a judicial procedure.
169
Thomas F. Nagy
Before venturing into the forensic arena, psycholo-
gists 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 univer-
sity 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 reper-
toire. Each of these situations requires the psycholo-
gist 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 psycholo-
gist already proficient in the new area, or other educa-
tion experiences addressing current issues relevant to
competence, such as in the case of the licensed neu-
ropsychologist 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 terri-
tory is wise to consult not only those already experi-
enced but also the appropriate APA division for
guidance about how to best go about this transition.
170
ETHICAL TRANSGRESSIONSEXCEEDING
ONES COMPETENCE COMFORT ZONE
Practicing outside ones area of competence can be a
distressing experience for both the psychologist and
client or patient. This situation may emerge unpre-
dictably, such as the scenario in Case Example 8.
Other situations in which practicing beyond ones
area of competence may occur follow:
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 psycho-
logical duties
Using, scoring, and interpreting a psychological test
on which you have little or no experience or train-
ing and for which you have never read the manual
Being in a deposition or providing court testi-
mony 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 com-
petent 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 poten-
tially violent husband in your office, face to face
Paying research participants too much money
as an inducement, resulting in coercing their

engagement in the protocol and possibly biasing
the data
Teaching a course or seminar in which you care-
lessly make inaccurate statements, misstate the
research, overgeneralize, oversimplify, minimize,
exaggerate, spin, or otherwise distort the infor-
mation that you present
Transitioning to a new area of competence such
as the psychotherapist who wants to begin a spe-
cialty 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 well-
intentioned and ethically observant psychologist
might stray beyond the boundaries of his or her
competence, as discussed above. There are conse-
quences 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 compe-
tence, particularly when they have suffered a tangi-
ble 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 harm-
ful or destructive.
One example would be a court-ordered psycho-
logical evaluation of divorcing parents who are in
litigation for child custody (as described in Case
Example 9 earlier in this chapter). Lapses in compe-
tence might include any of the following: using inap-
propriate means of assessment, spending significantly
more time assessing one parent than the other, mak-
ing obvious omissions in the assessment procedure,
making errors in scoring and interpreting tests, mak-
ing 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 out-
come of a custody settlementharming both the
child and the parent. The child might be harmed
if placed with the less competent parent and sub-
jected to abusive or neglectful parenting. The more
Competence
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 mini-
mize 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 min-
imize the stress of the process. As a result, the parents
will understand the steps in the process and the rea-
sons 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 thera-
pist who has recently experienced a difficult and
painful divorce and now succumbs to the seductive-
ness of his new patient, develops a sexual relation-
ship 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 pursu-
ing the love affair and likely has severely damaged
her ability to trust future therapists or treatment set-
tings. 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 relationshipthe potential still exists
for impaired competence when the psychologist
internally responds to feelings of sexual attraction.
171
Thomas F. Nagy
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 psychologists 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 com-
plainant and then requesting responses from the com-
plaintee. Ultimately, the Ethics Committee may impose
a directive, a saction, or a punitive order on the psy-
chologist 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 psy-
chologists personality, physical health, mental
health, life experience, academic training, supervi-
sion, professional experience, and continuing educa-
tion. It is a dynamic construct, not a static one,
constantly subject to metamorphosis throughout var-
ious stages of life. This dynamism invites the ethical
172
psychologist to maximize and maintain professional
competence by continuously engaging in self-moni-
toring for each of the professional roles that he or she
plays while carrying out his or her work.
References
Abeles, N. (1998). Competency in psychology. In R. J.
Corsini & A. J. Auerbach (Eds.), Concise encyclope-
dia of psychology (2nd ed., p. 147). New York, NY:
Wiley.
Ackerman, S. J., Benjamin, L. S., Beutler, L. E., Gelso,
C. J., Goldfried, M. R., Hill, C., . . . Rainer, J. (2001).
Empirically supported therapy relationships:
Conclusions and recommendations of the Division
29 Task Force. Psychotherapy: Theory, Research,
Practice, Training, 38, 495497. doi:10.1037/0003-
3204.38.4.495
Advocates for Children in Therapy. (2003). Attachment
therapy on trial: The torture and death of Candace
Newmaker. Retrieved from http://www.children
intherapy.org/victims/newmaker.html
American Academy of Pediatrics. (2007). Screening for
suicide risk in the pediatric emergency and acute emer-
gency care setting. Retrieved from http://journals.lww.
com/co-pediatrics/Abstract/2007/08000/Screening_
for_suicide_risk_in_the_pediatric.4.aspx
American Educational Research Association, American
Psychological Association, & National Council on
Measurement in Education. (1999). The standards
for educational and psychological testing. Washington,
DC: Author.
American Psychiatric Association. (1994). Diagnostic
and statistical manual of mental disorders (4th ed.).
Washington, DC: Author.
American Psychiatric Association. (2007). Practice guide-
line for the treatment of patients with Alzheimers dis-
ease and other dementias. Retrieved from http://www.
psychiatryonline.com/content.aspx?aID=152287
American Psychological Association. (1953). Ethical stan-
dards of psychologists. Washington, DC: Author.
American Psychological Association. (1991). Specialty
guidelines for forensic psychologists. Retrieved from
http://www.unl.edu/ap-ls/student/Specialty%20
Guidelines.pdf
American Psychological Association. (1995). Principles for
the recognition of proficiencies in professional psychol-
ogy. Retrieved from http://www.apa.org/ed/graduate/
specialize/proficiency-principles.aspx
American Psychological Association. (1996). Statement
on the disclosure of test data. American Psychologist,
51, 644648.
American Psychological Association. (1997). APA state-
ment on services by telephone, teleconferencing, and

Internet. Retrieved from http://www.apa.org/ethics/
education/telephone-statement.aspx
American Psychological Association. (1998). Guidelines
for the evaluation of dementia and age-related cogni-
tive decline. American Psychologist, 53, 12981303.
doi:10.1037/0003-066X.53.12.1298
American Psychological Association. (1999). Guidelines
for psychological evaluations in child protec-
tion matters. American Psychologist, 54, 586593.
doi:10.1037/0003-066X.54.8.586
American Psychological Association. (2002a). Criteria
for evaluating treatment guidlines. American
Psychologist, 57, 10521059. doi:10.1037/0003-066X.
57.12.1052
American Psychological Association. (2002b). Criteria
for practice guideline development and evaluation.
American Psychologist, 57, 10481051.
American Psychological Association. (2003).
Guidelines on multicultural education, training,
research, practice, and organizational change for
Psychologists. American Psychologist, 58, 377402.
doi:10.1037/0003-066X.58.5.377
American Psychological Association. (2004).
Guidelines for psychological practice with older
adults. American Psychologist, 59, 236260.
doi:10.1037/0003-066X.59.4.236
American Psychological Association. (2006). Guidelines
regarding the use of nondoctoral personnel in clinical
neuropsychological assessment. Retrieved from http://
www.div40.org/pdf/Nondoctoral_Personnel_in_
Assessment.pdf
American Psychological Association. (2007a). Guidelines
for psychological practice with girls and women.
Retrieved from http://www.apa.org/about/division/
activities/girls-and-women.pdf
American Psychological Association. (2007b). Record
keeping guidelines. American Psychologist, 62,
9931004. doi:10.1037/0003-066X.62.9.993
American Psychological Association. (2009a). Criteria
for the evaluation of quality improvement. American
Psychologist, 64, 551557. doi:10.1037/a0016744
American Psychological Association. (2009b). Guidelines
for child custody evaluations in family law proceedings.
Retrieved from http://www.apa.org/practice/guide-
lines/child-custody.pdf
American Psychological Association. (2010). Ethical
principles of psychologists and code of conduct (2002,
Amended June 1, 2010). Retrieved from http://www.
apa.org/ethics/code/index.aspx
American Psychological Association. (2011). Disaster
response network member guidelines. Retrieved from
http://www.apa.org/practice/programs/drn/guide.aspx
American Psychological Association, Division 44,
Committee on Lesbian, Gay, and Bisexual Concerns
Competence
Task Force. (2000). Guidelines for psychotherapy
with lesbian, gay, and bisexual clients. American
Psychologist, 55, 14401451. doi:10.1037/0003-
066X.55.12.1440
American Psychological Association, Practice
Organization. (2010). Certification for licensed psy-
chologists in substance abuse treatment. Retrieved
from http://www.apapracticecentral.org/ce/courses/
certificate-info.aspx
American Psychological Association, Presidential Task
Force on Evidence-Based Practice. (2006). Evidence-
based practice in psychology. American Psychologist,
61, 271285. doi:10.1037/0003-066X.61.4.271
Beauchamp, T. L., & Childress, J. F. (2001). Principles of
biomedical ethics (5th ed.). New York, NY: Oxford
University Press.
Belar, C., Brown, R., Hersch, L., Hornyak, L., Brown, R.,
& Reed, G. (2001). Self-assessment in clinical health
psychology: A model for ethical expansion of prac-
tice. Professional Psychology: Research and Practice,
32, 135141. doi:10.1037/0735-7028.32.2.135
Blackburn, S. (2005). Oxford dictionary of philosophy.
New York, NY: Oxford University Press.
Bricklin, P. M. (2000, July). The development of a credentialing
program in psychopharmacology. Presented at the Second
International Congress on Licensure, Certification, and
Credentialing of Psychologists, Oslo, Norway.
Burns, D. (2005). Tools, not schools, of therapy: Strategies
for therapeutic success. Los Altos Hills, CA: Author.
Council of Specialties in Professional Psychology. (2009).
Specialties represented on CoS. Retrieved from http://
cospp.org/specialties
DeAngelis, T. (2003 February). Why we overestimate our
competence. Monitor on Psychology, 34(2), 6062.
Epstein, R. M. (2007). Assessment in medical educa-
tion. New England Journal of Medicine, 356, 387396.
doi:10.1056/NEJMra054784
Epstein, R. M., & Hundert, E. M. (2002). Defining
and assessing professional competence. JAMA, 287,
226235. doi:10.1001/jama.287.2.226
Fabrikant, B. (1998). Psychotherapy. In R. J. Corsini & A.
J. Auerbach (Eds.), Concise encyclopedia of psychology
(2nd ed., p. 726). New York, NY: Wiley.
Falender, C., & Shafranske, E. (2004). Clinical supervision: A
competency-based approach. Washington, DC: American
Psychological Association. doi:10.1037/10806-000
Gabbard, G. O. (1989). Sexual exploitation in professional
relationships. Washington, DC: American Psychiatric
Press.
Gabbard, G. O. (1995). Transference and countertrans-
ference in the psychotherapy of therapists charged
with sexual misconduct. Psychiatric Annals, 25(2),
100105.
173
Thomas F. Nagy
Gottlieb, M. C. (1993). Avoiding exploitive dual rela-
tionships: A decision-making model. Psychotherapy:
Theory, Research, Practice, Training, 30, 4148.
doi:10.1037/0033-3204.30.1.41
Grencavage, L. M., & Norcross, J. C. (1990). What are the
commonalities among the therapeutic common fac-
tors? Professional Psychology: Research and Practice,
21, 372378. doi:10.1037/0735-7028.21.5.372
Gutheil, T. G., & Gabbard, G. O. (1993). Misuses
and misunderstandings of boundary theory in
clinical and regulatory settings. American Journal of
Psychiatry, 150, 188196.
Haynes, R., Corey, G., & Moulton, P. (2003). Clinical
supervision in the helping professions: A practical
guide. Pacific Grove, CA: Brooks/Cole-Thomson.
Health Insurance Portability and Accountability Act of
1996, Pub. L. No. 104191. 110 Stat. (codified as
amended in scattered sections of 42 U.S.C.)
Hoffman, H. G., Patterson, D. R., & Carrougher, G. J.
(2000). Use of virtual reality for adjunctive treatment
of adult burn pain during physical therapy: A con-
trolled study. Clinical Journal of Pain, 16, 244250.
doi:10.1097/00002508-200009000-00010
Holroyd, J. C., & Brodsky, A. M. (1977). Psychologists
attitudes and practices regarding erotic and non-erotic
physical contact with patients. American Psychologist,
32, 843849. doi:10.1037/0003-066X.32.10.843
Institute of Medicine. (2001). Crossing the quality chasm:
A new health system for the 21st century. Washington,
DC: National Academies Press.
Kitchener, K. (1988). Dual role relationships: What
makes them so problematic? Journal of Counseling
and Development, 67, 217221.
Knapp, S. J. (2007). Stalking: An occupational risk. The
National Psychologist, 16(2), 15.
Knapp, S. J., & VandeCreek, L. D. (2006). Practical ethics
for psychologists: A positive approach. Washington,
DC: American Psychological Association.
doi:10.1037/11331-000
LeVine, E. (2007). Experiences from the frontline:
Prescribing in New Mexico. Psychological Services, 4,
5971. doi:10.1037/1541-1559.4.1.59
Maheu, M. M., Pulier, M. L., Wilhelm, F. H.,
McMenamin, J. P., & Brown-Connolly, N. E. (2005).
The mental health professional and the new technolo-
gies: A handbook for practice today. Mahwah, NJ:
Erlbaum.
Nagy, T. (2011). Essential ethics for psychologists:
Understanding and mastering core issues. Washington,
DC: American Psychological Association.
doi:10.1037/12345-004
Norcross, J. C. (2004). Empirically supported treatments:
Context, consensus, and controversy. The Register
Report, 30, 1214.
174
Norcross, J. C., & Guy, J. (2007). Leaving it at the office.
New York, NY: Guilford Press.
Okiishi, J. C., Lambert, M. J., Egget, D., Nielson, S.,
Dayton, D. D., & Vermeersch, D. A. (2006). An
analysis of therapist treatment effects: Toward pro-
viding feedback to individual therapists on their
patients psychotherapy outcome. Journal of Clinical
Psychology, 62, 11571172. doi:10.1002/jclp.20272
Pope, K. (1994). Sexual involvement with therapists:
Patient assessment, subsequent therapy, foren-
sics. Washington, DC: American Psychological
Association. doi:10.1037/10154-000
Pope, K. (2000). Therapists sexual feelings: Research,
trends, and quandaries. In L. Szuchman & F.
Muscarella (Eds.), Psychological perspectives on human
sexuality (pp. 603658). New York, NY: Wiley.
Pope, K., Sonne, J., & Holroyd, J. (1993). Sexual feel-
ings in psychotherapy: Explorations for therapists and
therapists-in-training. Washington, DC: American
Psychological Association. doi:10.1037/10124-000
Pope, K., & Vasquez, M. (2007). Ethics in psychotherapy
and counseling: A practical guide (3rd ed.). San
Francisco, CA: Jossey-Bass.
Pope, K., & Vetter, V. (1991). Prior therapist-patient sexual
involvements among patients seen by psychologists.
Psychotherapy: Theory, Research, Practice, Training, 28,
429438. doi:10.1037/0033-3204.28.3.429
Reese, R., Nosworthy, L., & Rowlands, S. (2009). Does a
continuous feedback system improve psychotherapy
outcome? Psychotherapy: Theory, Research, Practice,
Training, 46, 418431. doi:10.1037/a0017901
Sonne, J. L. (2006). Nonsexual multiple relationships: A
practical decision-making model for clinicians. Retrieved
from http://kspope.com/site/multiple-relationships.php
Tarasoff v. Regents of University of California, 17 Cal. 3d
425, 551 P.2d 334, 131 Cal. Rptr. 14 (Cal. 1976).
Thomas, J. (2010). The ethics of supervision and consul-
tation: Practical guidance for mental health profes-
sionals. Washington, DC: American Psychological
Association. doi:10.1037/12078-000
Tishler, C. L., Gordon, L. B., & Landry-Meyer, L. (2000).
Managing the violent patient: A guide for psy-
chologists and other mental health professionals.
Professional Psychology: Research and Practice, 31,
3441. doi:10.1037/0735-7028.31.1.34
U.S. Department of Health and Human Services, Office of
Research Integrity. (1999, March). Case summaries.
ORI Newsletter, 7(2), 8.
Westen, D., & Bradley, R. (2005). Empirically supported
complexity: Rethinking evidence-based practice in psy-
chotherapy. Current Directions in Psychological Science,
14, 266271. doi:10.1111/j.0963-7214.2005.00378.x
Younggren, J., & Gottlieb, M. C. (2004). Managing
risk when contemplating multiple relationships.
Professional Psychology: Research and Practice, 35,
255260. doi:10.1037/0735-7028.35.3.255