FOCUS ON ETHICS

Jeffrey E. Barnett, Editor

In Case of Ethical Dilemma, Break Glass: Commentary on Ethical

Decision Making in Practice

Jeffrey E. Barnett Stephen H. Behnke

Arnold, Maryland, and Loyola College in Maryland American Psychological Association
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Susan L. Rosenthal Gerald P. Koocher

University of Texas Medical Branch at Galveston Simmons College

Psychologists are regularly confronted by a wide range of ethical challenges for which no clear solution
is apparent. Although the “Ethical Principles of Psychologists and Code of Conduct” (American
Psychological Association, 2002) is of some help when one faces such dilemmas, it cannot provide
definitive guidance or all needed answers. The process of ethical decision making is reviewed, and the
use of different models for ethical decision making is explored. Case examples highlight representative
challenges faced by psychologist practitioners. Three invited experts provide commentaries in response
to the points made and questions raised. They discuss ethical decision making from their perspectives and
make recommendations to practitioners for how they can conceptualize and address the dilemmas they
will face in their practices.

Keywords: ethics, ethical dilemmas, ethics challenges, ethical decision making

some situations. At times, we may wish we could just “break the

The Ethical Decision-Making Process in
Everyday Practice
Jeffrey E. Barnett
Psychologists are regularly confronted with a wide range of
ethical dilemmas and challenges. Even the most seasoned and
knowledgeable clinicians may be unsure of how to proceed in
glass” for an easy resolution to the challenge we face. But no such
easy solution exists.
Our training tells us that a resource to consult first is the “Ethical
Principles of Psychologists and Code of Conduct” (American
Psychological Association [APA] Ethics Code; APA, 2002). But
the Ethics Code makes it very clear that it neither holds all the
answers nor specifically addresses every situation or dilemma that
may confront psychologists in their professional activities. Instead,
“most of the ethical standards are written broadly, in order to apply

JEFFREY E. BARNETT received his PsyD in clinical psychology from Ye-
shiva University. He maintains an independent practice in Arnold, Mary-
land, and is an affiliate professor of psychology at Loyola College in
Maryland. His areas of professional interest include ethics, legal, and
professional practice issues in psychology. He is a member of the Amer-
ican Psychological Association Ethics Committee.
STEPHEN H. BEHNKE received his JD from Yale Law School and his PhD
in clinical psychology from the University of Michigan. A 1998 faculty
fellow in Harvard University’s program in ethics and the professions, he
assumed the position of director of ethics at the American Psychological
Association in November 2000. He is an instructor in the Department of
Psychiatry at Harvard Medical School.
SUSAN L. ROSENTHAL earned her PhD in psychology from the University of
North Carolina at Chapel Hill. She is the director of the Division of
Adolescent and Behavioral Health and professor of pediatrics at University
of Texas Medical Branch at Galveston. Her research and practice focus on
the promotion of health among adolescents and the role of parents in
supporting the growth and development of their adolescents.
GERALD P. KOOCHER earned his PhD in clinical psychology at the Univer-
sity of Missouri—Columbia. He currently serves as dean of the School for
Health Studies at Simmons College in Boston and editor of the journal
Ethics & Behavior.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Jeffrey
E. Barnett, 1511 Ritchie Highway, Suite 201, Arnold, MD 21012. E-mail:
drjbarnett1@comcast.net

Professional Psychology: Research and Practice, 2007, Vol. 38, No. 1, 7–12
Copyright 2007 by the American Psychological Association 0735-7028/07/$12.00 DOI: 10.1037/0735-7028.38.1.7

7
 8 FOCUS ON ETHICS
to psychologists in varied roles, although the application of an
Ethical Standard may vary depending on the context” (p. 1061).
The Ethics Code further delineates the importance of the General
Principles, which are aspirational in nature and intended for psy-
chologists to consider when confronting ethical dilemmas.
The APA Ethics Code is an excellent first source to examine for
guidance. But, as is clear in the statements above, it does not hold
all the answers or provide all needed guidance for psychologists
facing ethically challenging situations. In fact, as Pope and
Vasquez (1998) stated,
ethics codes cannot do our questioning, thinking, feeling, and re-
sponding for us. Such codes can never be a substitute for the active
process by which the individual therapist or counselor struggles with
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
the sometimes bewildering, always unique constellation of questions,
This document is copyrighted by the American Psychological Association or one of its allied publishers.
responsibilities, contexts, and competing demands of helping another
person. . . . Ethics must be practical. Clinicians confront an almost
unimaginable diversity of situations, each with its own shifting ques-
tions, demands, and responsibilities. Every clinician is unique in
important ways. Every client is unique in important ways. Ethics that
are out of touch with the practical realities of clinical work, with the
diversity and constantly changing nature of the therapeutic venture,
are useless. (pp. 17–18)
The General Principles of the APA Ethics Code are based on a
set of underlying virtues or metaprinciples described by authors
such as Kitchener (1984) and Thompson (1990). These include
beneficence, nonmaleficence, fidelity, autonomy, justice, and self-
care. These virtues are readily seen in the General Principles of the
Ethics Code and are present to guide psychologists in a process of
ethical decision making and judgment that goes far beyond merely
looking for a solution to a dilemma in the Ethics Code itself.
Several authors (e.g., Barnett & Johnston, 2003; Haug, 1994) have
suggested that these principles be used to form questions that
psychologists ask when unsure of how to act or respond in a
situation. Such questions may include but clearly are not limited to
“Will doing this be helpful to my client?” “Will this action likely
harm anyone?” “To whom do I owe an obligation or allegiance in
this situation?” “Will this action likely promote dependence on me
by my client?” “Are my actions consistent with how other psy-
chologists treat their clients?” and “Have I allowed my judgment
to become impaired as a result of inadequate attention to my own
care or needs?” Asking such questions and honestly considering
the answers may be helpful in augmenting the guidance received
from examining the APA Ethics Code.
This approach is consistent with Jordan and Meara’s (1990)
view of virtue ethics, which is contrasted with principle ethics, an
approach that focuses on specific standards of practice, such as
those found in the Ethical Standards of the APA Ethics Code.
Whereas these standards endeavor to instruct on discrete aspects of
appropriate and inappropriate behavior in particular situations—
that is, how we should act—virtue ethics addresses the underlying
ethics concepts reviewed above and seeks to provide more general
guidance on how we should be. Clearly, there is a place for both,
and each is important for psychologists to consider when con-
fronted with an ethical dilemma. For example, with regard to
standards, when facing a dilemma, psychologists should not limit
themselves to review of the APA Ethics Code. Thoughtful psy-
chologists will also consult pertinent state and local laws and
regulations as well as any site- or setting-specific policies. Psy-
chologists also need to be familiar with relevant practice guide-
lines and other documents that may set a professional standard of
conduct. Examples include the APA’s “Record Keeping Guide-
lines” (APA, 1993), “Guidelines for Child Custody Evaluations in
Divorce Proceedings” (APA, 1994), and “Guidelines on Multicul-
tural Education, Training, Research, Practice, and Organizational
Change for Psychologists” (APA, 2003). These and other APA
practice guidelines are readily accessible online at http://
www.apa.org/practice/prof.html.
In addition to considering the APA Ethics Code and relevant
laws, regulations, policies, and practice guidelines, psychologists
typically are also familiar with the need to consult with knowl-
edgeable colleagues to assist with their decision-making process.
Colleagues may be selected because they have particular areas of
competence pertaining to the dilemma being faced or by virtue of
prior experience on an ethics committee or licensure board. Ad-
ditionally, members of the APA may consult with the APA Ethics
Office, and those who purchase their malpractice insurance from
the APA Insurance Trust may consult with the trust’s staff. When
the dilemma one confronts has potential legal complications or
implications, consultation with an attorney is strongly recom-
mended as well.
Unfortunately, all of the above may not prove entirely helpful
for psychologists facing a wide range of ethical dilemmas. It is also
recommended that psychologists be familiar with and consider
using one of the currently available models for ethical decision
making. A number of general models exist, and readers are re-
ferred to Cottone and Claus’s (2000) comprehensive review of
these models, some of which may prove helpful for psychologists
in their deliberations when confronted with ethical dilemmas and
are reviewed in this article.
A model that represents a philosophical approach is Rest’s
(1984) model, which is based on moral reasoning and has the goal
of illuminating “the processes involved in the production of moral
behavior” (p. 19). This model endeavors to assist psychologists to
(a) interpret the situation in terms of how their actions affect the
welfare of others; (b) formulate a moral course of action by
identifying the moral ideal in a specific situation; (c) select, among
competing value outcomes of ideals, the one to act on, deciding
whether to try to fulfill their moral ideal; and (d) execute and
implement what they intend to do.
In contrast, Tarvydas’s (1998) practice-based model includes
the following steps: (a) interpret the situation, (b) review the
problem or dilemma, (c) determine the standards that apply to
dilemma, (d) generate possible and probable courses of action, (e)
consider the consequences for each course of action, (f) consult
with one’s supervisor and peers, (g) select an action by weighing
competing values given the context, (h) plan and execute the
selected action, and (i) evaluate the course of action. Additional
steps that can augment this model, as suggested by Keith-Spiegel
and Koocher (1985), include consulting with legal and ethical
guidelines and evaluating the rights, responsibilities, and welfare
of all involved.
A number of other ethical decision-making models exist for use
when one is confronted with special situations. Examples include
Younggren’s (2002) and Gottlieb’s (1993) models for ethical
decision making in multiple relationship situations. In Gottlieb’s
model, psychologists are asked to consider three dimensions of the
professional relationship—power, duration, and clarity of termi-
 FOCUS ON ETHICS
nation—to assist them in reaching a decision on whether to enter
an intimate relationship with a former client. Gottlieb postulated
that the higher the power differential was, the more significant the
duration of the professional relationship was, and the less clear and
definite the termination was, the greater is risk of harm to the
former client and the more the psychologist should eschew enter-
ing the intimate relationship. Yet, appropriately, even in those
situations in which the use of this decision-making model indicates
that entering into the secondary relationship may be appropriate,
Gottlieb advised psychologists to consult with colleagues and to
engage in an open discussion with the former client about the
relevant issues raised by use of the decision-making model prior to
ever initiating such a relationship.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Just as strict adherence to the APA Ethics Code will never
This document is copyrighted by the American Psychological Association or one of its allied publishers.
provide the guidance needed by psychologists when they are faced
with the myriad of complex dilemmas that may arise throughout
their career, no one model of ethical decision making holds all the
answers, either. Psychologists must still use their professional
judgment when weighing multiple and often competing demands,
needs, and goals. Representative examples (created by me) of
ethical dilemmas faced by psychologists include the following:
• A psychologist in independent practice working with a young
adolescent addresses the limits to confidentiality as part of the
informed consent process with the adolescent and her parents. The
issue of risk of imminent harm to self and others is included. The
adolescent has been sullen, withdrawn, and generally noncommu-
nicative with her parents, prompting them to initiate treatment. As
treatment progresses and the psychotherapy relationship develops,
she shares with the psychologist that she has been drinking alcohol
with her friends and is planning to begin smoking marijuana and
experimenting with “pills.” The psychologist considers sharing
this information with the adolescent’s parents because of concerns
about harm to her. The psychologist is unclear on how harm should
be defined, to whom an obligation is owed, and how disclosure or
nondisclosure might impact the psychotherapy relationship, the
course of treatment, and the adolescent’s relationship with her
parents.
• A psychologist is asked by a parent to conduct an evaluation
of a child to help delineate academic and emotional issues reported
to be impacting this child. Following the informed consent and
assent process with the parent and child, the evaluation is con-
ducted. When questioned, the parent reports that the parents di-
vorced many years ago and the other parent does not live in the
local area and so would not be able to participate in the evaluation.
Yet, several weeks later, the psychologist is contacted by the other
parent, who requests a copy of the report of the evaluation and
raises issues about the appropriateness of the psychologist con-
ducting the evaluation in the first place. The psychologist is unsure
about how to respond to this other parent, whether the report
should be released, who has the legal right to have the report, and
who had the legal right to authorize the evaluation.
Several ethics experts have been asked to comment on these
scenarios as well as on the issues raised in this commentary. I hope
that this discussion will be thought provoking for readers. This is
the first of an ongoing series of discussions of a wide range of
ethics issues of relevance to practicing psychologists. Those with
topics and dilemmas to suggest for inclusion in the future may
9
contact me at drjbarnett1@comcast.net. Although they are not
necessarily as convenient as breaking the glass for a quick remedy,
I hope that these commentaries will prove practical and useful for
readers as they confront a wide range of ethics dilemmas and
challenges in their professional work.
References
American Psychological Association. (1993). Record keeping guidelines.
American Psychologist, 48, 984 –986.
American Psychological Association. (1994). Guidelines for child custody
evaluations in divorce proceedings. American Psychologist, 49, 677–
680.
American Psychological Association. (2002). Ethical principles of psy-
chologists and code of conduct. American Psychologist, 57, 1060 –1073.
American Psychological Association. (2003). Guidelines on multicultural
education, training, research, practice, and organizational change for
psychologists. American Psychologist, 58, 377– 402.
Barnett, J. E., & Johnston, L. C. (2003). Navigating the ethical decision
making maze. Maryland Psychologist, 49(2), 7, 22.
Cottone, R. R., & Claus, R. E. (2000). Ethical decision-making models: A
review of the literature. Journal of Counseling & Development, 78,
275–283.
Gottlieb, M. C. (1993). Avoiding exploitive dual relationships: A decision-
making model. Psychotherapy, 30, 41– 48.
Haug, I. (1994, February). Notes from the ethics committee. Family Ther-
apy News, 27.
Jordan, A. E., & Meara, N. M. (1990). Ethics and professional practice of
psychologists: The role of virtues and principles. Professional Psychol-
ogy: Research and Practice, 21, 107–114.
Keith-Spiegel, P., & Koocher, G. P. (1985). Ethics in psychology. New
York: Random House.
Kitchener, K. S. (1984). Intuition, critical evaluation, and ethical princi-
ples: The foundation for ethical decisions in counseling psychology.
Counseling Psychologist, 12, 43–55.
Pope, K. S., & Vasquez, M. J. T. (1998). Ethics in psychotherapy and
counseling: A practical guide (2nd ed.). San Francisco: Jossey-Bass.
Rest, J. R. (1984). Research on moral development: Implications for
training counseling psychologists. Counseling Psychologist, 12, 19 –29.
Tarvydas, V. M. (1998). Ethical decision making processes. In R. R.
Cottone & V. M. Tarvydas (Eds.), Ethical and professional issues in
counseling (pp. 144 –155). Upper Saddle River, NJ: Prentice-Hall.
Thompson, A. (1990). Guide to ethical practice in psychotherapy. New
York: Wiley.
Younggren, J. N. (2002). Ethical decision-making and dual relationships.
Retrieved December 13, 2006, from http://kspope.com/dual/younggren
.php
Commentaries
The Role of Professional Judgment in Ethical
Decision Making
Stephen H. Behnke
Inherent in the notion of a profession is the exercise of judgment
and discretion. A good ethics code offers guidance in the ethical
course of action but leaves room for professional judgment and
discretion, because the complexity and nuance of a professional’s
work defy clear-cut or easy resolutions in many, if not most,
 10 FOCUS ON ETHICS
instances. Although the wish for an ethics code that addresses
every ambiguity a psychologist encounters is understandable, such
a code would be neither possible nor even desirable. Writing the
code would not be possible, because the code would have to
address a nearly infinite number of possibilities; the code would
not be desirable, because it would remove the element of judg-
ment, which is central to what belonging to a profession entails.
Barnett eloquently captures these features of ethical decision
making for the profession of psychology. He then points out that
no one methodology for resolving ethical dilemmas is likely to
suffice:
Just as strict adherence to the APA Ethics Code will never provide the
guidance needed by psychologists when they are faced with the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
myriad of complex dilemmas that may arise throughout their career,
This document is copyrighted by the American Psychological Association or one of its allied publishers.
no one model of ethical decision making holds all the answers either.
Psychologists must still use their professional judgment when weigh-
ing multiple and often competing demands, needs, and goals.
Barnett’s message, with which I fully concur, is that, at every level
of decision making, psychologists must apply their professional
judgment, take responsibility for their decisions, and, in so doing,
reject a unitary model of resolving dilemmas.
“In Case of Ethical Dilemma, Break Glass” nonetheless pro-
vides important points about our methodology. Barnett explains
that often psychologists must look beyond the Ethics Code, and
deciding where to look can be a crucial part of their decision
making. As his vignettes illustrate, cases have multiple dimensions
to consider; these include professional, legal, risk management,
and ethical dimensions. Although related, the dimensions are not
the same and may require separate analyses. The legal aspects of
a case may necessitate consultation with an attorney, the risk
management aspects may indicate the need to contact an insurance
carrier, the professional aspects may call for a clinical consulta-
tion, and the ethical aspects may be best addressed with someone
well versed in applying the Ethics Code. Collapsing these dimen-
sions into a single analysis may miss important considerations that
merit attention.
The first vignette entails a sullen adolescent who is apparently
on the cusp of experimenting with alcohol, marijuana, and pills in
some combination. The vignette does not mention sexual involve-
ments or driving under the influence of these substances, but such
possibilities cannot be discounted, and the combination of alcohol
with other, unknown substances elevates the risk. Also, the psy-
chologist should to attend to the age of the individuals who are
providing the alcohol and pills to this young adolescent. The
psychologist in the vignette “is unclear on how harm should be
defined, to whom an obligation is owed, and how disclosure or
nondisclosure might impact the psychotherapy relationship, the
course of treatment, and the adolescent’s relationship with her
parents.”
The psychologist may want first to review the initial informed
consent, which established an understanding of how confidential-
ity would be handled and which the Ethics Code requires. Ideally,
the initial discussion of these issues would have presented in-
formed consent as a process and would have anticipated with both
the adolescent and her parents how confidentiality and disclosures
would work should various behaviors in which adolescents often
engage be disclosed in the treatment. The psychologist may wish
to consult with an attorney to clarify state or federal statutes or
regulations that govern confidentiality for an adolescent of this age
with these treatment issues. Next, the psychologist may benefit
from consulting about the clinical aspects of the case with a
colleague who has expertise in working with adolescents, sub-
stance abuse, and possibly mood disorders. Finally, when the
psychologist has formulated a plan, it might be helpful to review
the plan with the psychologist’s insurance carrier, who could point
out risk management considerations that have been left unattended.
The vignette captures Barnett’s central point: The complexities of
our dilemmas demand multiple kinds of expertise, and no single
text or methodology can resolve all of our challenges.
The second vignette also invites consultation from a variety of
related but separate perspectives. This likewise common scenario
involves the assessment of a child whose parents divorced several
years earlier; following the psychologist’s evaluation, the parent
who does not live in the local area requests a copy of the report.
The vignette does not indicate the nature of the custody arrange-
ment or the quality of the parents’ current relationship, both of
which require attention. The psychologist “is unsure about how to
respond to this other parent, whether the report should be released,
who has the legal right to have the report, and who had the legal
right to authorize the evaluation.” As in the first vignette, consid-
erations include initial discussions regarding confidentiality and
access to treatment information, which ideally would have in-
cluded both parents; the clinical consequences of how the psychol-
ogist proceeds; the legal rights of each party, including the child;
the ethical implications of granting or denying the requesting
parent access to the information; and the exposure to liability the
psychologist may incur with each possible course of action. Infor-
mation from any of these contexts could affect how the psychol-
ogist moves forward.
In the first Focus on Ethics section, Barnett has offered reflec-
tions and given case examples that highlight the complexity of the
dilemmas facing practicing psychologists. Encountering such di-
lemmas is not an indication that a psychologist has gone ethically
or professionally astray. Rather, ethical dilemmas are a sign that
what psychologists do is challenging, nuanced, and, most of all,
important.
Ethical Decision Making in Practice Must
Consider the Developmental Context
Susan L. Rosenthal
Clinicians are confronted regularly with ethical challenges for
which there are no easy answers. As noted, the first step is to
consult the “Ethical Principles of Psychologists and Code of Con-
duct” (APA, 2002), but this document does not provide answers
for specific situations; thus, Barnett has presented a variety of
approaches to decision making. However, when one is working
with children and adolescents, such as in the case of the young
adolescent who is drinking alcohol and planning to smoke mari-
juana and experiment with pills, the effective application of an
ethical decision-making model is dependent on having an under-
standing of the developmental context (Koocher, 2003). The de-
velopmental context includes an understanding of psychological
 FOCUS ON ETHICS
development, family systems, and the law. In the case of this
young adolescent, the following four issues should be considered:
legal issues associated with maintaining confidentiality, involve-
ment of the parents in the therapeutic process, normative context
and behavioral risk, and the meaning to the adolescent of sharing
the information.
In the case described, the psychotherapist had explained the
limits of confidentiality; however, an explanation of the limits of
confidentiality is based on the behavior in question and the age of
the patient. The psychotherapist’s initial concern is in determining
whether the behavior represents harm to the adolescent and re-
quires parental notification, but other laws that govern confiden-
tiality also must be considered. The Health Insurance Portability
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
and Accountability Act designates the parents as personal repre-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
sentatives of their minor children and as having the right to the
medical information. Situations that allow the adolescent to act as
the individual and maintain confidentiality include his or her
consent to care under state minor consent laws, or receipt of
confidential care legally, or the parent’s assent to an agreement of
confidentiality (English & Ford, 2004). However, the Health In-
surance Portability and Accountability Act does not require the
psychotherapist to share; it simply does not provide protection to
the adolescent. There are state laws that require certain information
to be reported. For example, states have laws regarding minor
sexual intercourse and adult partners of minors that mandate
reporting even if the behavior was consensual.
These dilemmas are addressed more easily if the parents are
involved in the psychotherapeutic process. Presumably, the clini-
cian obtained a comprehensive family history of psychiatric illness
and substance abuse. This would help the clinician have some
understanding of family cultural attitudes toward substance use as
well as the level of risk. Parental supervision and monitoring of
and communication with their adolescent is associated with de-
creased adolescent risk taking. Thus, involvement of the parents
with the intent of enhancing adolescent–parent relationships is
prudent. This would help the psychotherapist make a decision
regarding the likely outcome of sharing such information with the
parent. Often, parents already suspect the adolescent is engaging in
the specific behavior. Parental involvement also may provide the
psychotherapist with a wider range of options for addressing the
information in a therapeutic manner. For example, psychotherapy
could include helping the parents add structure to reduce the
adolescent’s opportunities to engage in risk taking without sharing
this specific information.
The psychotherapist cannot make an assessment of potential
harm to the adolescent without knowing the normative context and
the potential for risk. Some risk-taking behavior in adolescence is
developmentally appropriate and part of healthy psychological
development. However, psychotherapists should base such a de-
cision not on their own personal experiences but rather on com-
munity and national data. In addition, there are some behaviors
that might be considered to fall within normal limits but can be
associated with significant health risks. It might not indicate psy-
chopathology for a 17-year-old to have sexual intercourse with an
established partner or to have one beer at a party; however, these
actions can be associated with health risks, such as sexually
transmitted infections and pregnancy or motor vehicle accidents if
the beer drinking precedes driving.
11
Finally, the psychotherapist should consider the meaning to the
adolescent of sharing the information. Psychotherapists are viewed
differently across the therapeutic process (e.g., expert, advocate,
protector) and may be viewed differently by different members of
the family (Koocher, 2003). The psychotherapist’s understanding
of this will be better informed by a familiarity with family systems
and with this particular family. For example, this adolescent is
sharing information with the psychotherapist about possible future
behaviors. There are several potential reasons for this, such as that
she is considering the behavior and values the psychotherapist’s
view on the appropriateness of her decisions (psychotherapist as
expert) or that she is asking for help not to engage in these
behaviors (psychotherapist as protector or parent).
Without a developmental understanding, the best decisions may
not be made. However, once a decision is made to share sensitive
information with parents, there are some guidelines for doing this,
which likely will lead to a more positive experience. First, children
and adolescents should always be given the opportunity to tell their
parents themselves and in the setting of their preference. If there is
no time urgency (e.g., no immediate suicidal risk), the planning for
this can take place over more than one session and become part of
the therapeutic work. The clinician should be prepared for every
possibility, ranging from the adolescent disclosing the information
in private to having the clinician share the information without the
adolescent present. The adolescent should be helped to anticipate
the parents’ reaction and the impact of the parents’ response. If the
child or adolescent chooses to share the information on his or her
own, a back-up plan should be outlined with the child or adoles-
cent to implement if he or she is not able to share the information.
Finally, a psychotherapist should never help a child or adolescent
tell a direct lie to a parent, although it is not always necessary to
share all of the details with the parents. With skills in managing
adolescents and families with developmental sensitivity, ethical
dilemmas such as the one presented by this adolescent can become
part of the therapeutic process of fostering psychological and
physical health.
References
American Psychological Association. (2002). Ethical principles of psy-
chologists and code of conduct. American Psychologist, 57, 1060 –1073.
English, A., & Ford, C. A. (2004). The HIPAA privacy rule and adoles-
cents: Legal questions and clinical challenges. Perspectives on Sexual
and Reproductive Health, 36, 80 – 86.
Koocher, G. P. (2003). Ethical issues in psychotherapy with adolescents.
Journal of Clinical Psychology, 59, 1247–1256.
All in the Family
Gerald P. Koocher
The two cases have important features in common. They involve
services to legal minors and potential conflicts of interest among
family members. Both also involve questions of consent, disclo-
sure, and trust. In addition, both occur with sufficient frequency
that clinicians who work with children and families will find them
reasonably familiar and anticipatable. Finally, both cases represent
 12 FOCUS ON ETHICS
situations in which an ounce of prevention can avoid a ton of
ethical angst. The decision-making process that applies best to
both cases involves engaging all the parties early, when possible,
and actively seeking appropriate inclusive participation, even
when one party attempts to cut the other out of the loop. When
prevention does not work, asking oneself a series of questions
about professional obligations and client vulnerabilities will often
help guide one to a decision.
Those who treat adolescents should reasonably expect that al-
cohol, drugs, sex, and other such topics of concern to parents will
come up in the course of their work. Adolescents who trust their
psychotherapists will also talk about a myriad of other topics they
would prefer not to share with their parents. A wise psychothera-
pist will discuss these fundamental truths with parents and teen-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ager together before embarking on a course of psychotherapy.
Parents have a responsibility for the safety and well-being of their
child during the 167 hr each week when the child is not in the
psychotherapist’s office. One hopes that adolescent clients will use
their psychotherapists to assist with problems they do not feel
comfortable raising at home. In some cases, life at home may form
the heart of the problem. Bringing up these general concepts in a
family session before beginning treatment allows all parties to
come to a degree of mutual understanding.
State laws generally leave parents in control over the privacy
rights of minors regarding psychotherapy. Parents can often be
persuaded to agree to respect the privacy of the treatment relation-
ship, particularly if they feel that the psychotherapist shares their
interest and values with respect to their child’s safety. The psy-
chotherapist can help to articulate typical adolescent behaviors that
would not warrant disclosure (e.g., an isolated episode of smoking
marijuana) as well as give examples of risky or dangerous behav-
iors that might warrant expression of concern to parents (e.g.,
significant substance abuse or criminal conduct). Such discussions
serve to put the adolescent on notice regarding limits of confiden-
tiality and may reassure the parents. The inherent difficulties lie in
the details (e.g., the maturity of the adolescent’s judgment, the
nature of the therapeutic alliance, parental strengths and weak-
nesses, and the psychotherapist’s own interpretation of risk). One
cannot foresee every potential circumstance, but one can raise the
issues for discussion at the outset of the professional relationship
and, in so doing, head off many potential problems.
The second case focuses on which parent has what rights with
respect to the children’s health and mental health records after a
divorce. Statutes vary from state to state, but any parent of a minor
whose parental rights have not been legally terminated generally
has a right to review his or her child’s records. Psychologists have
an obligation to both remain aware of and adhere to the laws in
jurisdictions where they practice. When one parent presents a
minor child for treatment or evaluation, the psychologist should
always ask about and seek the consent and participation of the
other parent. In this case, one parent reported “that the parents
divorced many years ago and the other parent does not live in the
local area and so would not be able to participate in the evalua-
tion.”
Unless the situation requires emergency intervention, the clini-
cian should make a good faith, well-documented effort to contact
the other parent. Exceptions might include cases in which the other
parent is incarcerated or has had his or her parental rights termi-
nated or in which some other objectively documented contraindi-
cations exist (e.g., restraining orders for domestic violence). In all
such cases, the word of one parent should require corroboration
(e.g., a confirmatory letter from a member of the bar or a copy of
a court order). A parent who truly seeks to serve only the best
interests of the child will not object to allowing contact with the
other parent or to providing necessary documentation. Occasion-
ally, one parent may seek to use a professional’s opinion, con-
strained by limited data, as a basis for seeking a change in custody.
In other situations, one parent may simply choose to unilaterally
limit the other parent’s access to information. By actively deciding
to routinely seek contact with both parents or by carefully docu-
menting sound reasons for not contacting one parent, clinicians
reduce the likelihood of manipulation and ethical complaints.
I recommend that when clinicians are attempting to resolve
similar dilemmas that involve different interests among family
members, they progress through a mental checklist, asking them-
selves a series of questions. (a) What legal obligations apply here?
(b) What full range of options do I have available? (c) What
problems or adverse consequences for the various parties can I
anticipate, depending on the course of action I select? (d) Which
party has the greatest vulnerability? (e) Which courses of action
will optimize a helpful outcome (i.e., accomplish the greatest
good), and which will cause the least harm? Choosing a legally
appropriate course of action that protects the most vulnerable
parties from harm and optimizes the likelihood of a beneficial
outcome will generally prove the most ethically defensible course
of action.
Received June 1, 2006
Revision received July 13, 2006
Accepted July 13, 2006 䡲