child views the behavior of parents

as intrusive and unwarranted. Or parents may want their daughter to become

more respectful to them, but the daughter is only interested in better relationships
with her peers at school.
At times, parents, adolescents, and psychologists also may all have differing
goals. For example, the parents may want their son to stay out of trouble with
the police, the son wants to get his parents off his back, and the psychologist
40 ethical dilemmas in psychotherapy
believes that the adolescent has a rather serious but unacknowledged depression
that needs treatment. Sometimes mixed agreement and disagreement on goals
exist: The parents want their son to do better in school and excel in athletics,
even though the son agrees with doing better in school but has little interest in
athletics.
Questions of how to balance the needs of, and obligations to, all the
members of the family do not have simple answers. However, psychologists
often can serve their patients best by avoiding dichotomizing goals and by
facilitating better communication among family members and helping them
to reach mutually acceptable solutions. Robbins et al. (2006) found that the
alliance between parents and psychologists and the alliance between adolescents
and psychologists predicted dropout rate; that is, psychologists may
encounter treatment failure unless they are able to build alliances with both
adolescents and parents. One of the goals of therapy may be to get parents
and adolescents to understand the effect of their behavior on each other.
Psychologists should neither blindly acquiesce to, nor dismiss, the concerns
of parents or adolescents. Principle-based ethics does not always mean immediately
trumping principles as much as it means balancing them.
There is a lot to be said for listening carefully to patients’ concerns. For
example, when asked about how they felt about their encounters with psychiatrists,
children responded that they appreciated when the psychiatrists
listened, asked questions, and actively exchanged ideas with them (Hartzell,
Seikkula, & von Knorring, 2009). More detailed interviewing may result in
the development of mutually compatible goals. That is, although parents and
children initially may disagree on what the presenting problem is, it may be
possible to develop common areas of agreement. For example, children initially
may agree that the goal of “getting my parents off my back” is something
they would be willing to work on, and that may lead to actions on their part
that may indirectly address some legitimate concerns of the parents.
This perspective is consistent with the idea of ethical gradualism or ethical
incrementing proposed by Francis (2009). According to this perspective, a
psychologist does not always have to take an uncompromising moral stance on
every ethical issue that arises. Although there can be no compromise on some
basic issues, at times, psychologists can balance overarching ethical principles
gradually or incrementally, according to the patient’s needs.
Boundaries of Competence
Similar balancing occurs with other standards. For example, psychologists
may provide services to patients in emergencies, even if they
lack the expertise that would ordinarily be needed to help those patients
(Standard 2.02). In an emergency, psychologists may be unable to help
patients (fulfilling the overarching principle of beneficence) without risking
the ethical decision-making model 41
harm (offending the overarching principle of nonmaleficence), but the
APA Ethics Code allows psychologists the option of having beneficence
temporarily trump nonmaleficence. However, psychologists should try to
minimize harm to the offended principle by referring patients to appropriate
services as soon as practically possible. In Chapter 3, we discuss in more detail
the importance of anticipating problems.
In emergencies and other similar situations, psychologists have little
time to think through a detailed response as would occur with System 2
thinking. Ideally, however, psychologists would have considered these types
of dilemmas ahead of time and could be more prepared to respond appropriately
and quickly, as needed.
Ethical Dilemmas Outside of the Enforceable Standards
Sometimes psychologists encounter situations for which the APA Ethics
Code provides no direction. For example, the 1992 APA Ethics Code did not
anticipate the widespread use of electronic media and was silent on how
psychologists should respond to those new technologies. Until APA released
its guidelines on telecommunications (APA, 2013), psychologists had to rely
primarily on peer-reviewed articles and their own discretion regarding how
or when to apply these technologies.
Another example deals with hate-filled speech. 1 Psychologists typically
encourage patients to express opinions freely, thereby promoting the overarching
ethical principle of respecting patient autonomy. However, some
patients may express opinions that disparage members of ethnic or sexual
minorities, or other marginalized groups. It could be argued that psychologists
should challenge hateful speech on the basis of general beneficence, because
such speech creates an atmosphere that permits, encourages, or condones
victimization of certain groups. Also, the quality of life in society, in general,
diminishes when any one group becomes marginalized or a victim of unfair
discrimination. This is an example in which the relevant overarching ethical
principles could overlap because an argument also could be made that the
hate-filled language offended the ethical principle of justice to the extent
that psychologists have an obligation to ensure that people are treated fairly.
Although psychologists may not be engaging in the unjust act themselves,
they could be seen as complicit by accepting an environment that condones
injustices and harm to marginalized people. We discuss this issue in more
detail in Chapter 9.
1Portions of this section are adapted from “How Should Psychologists Respond to Hate-Filled Comments?”
by S. Knapp, 2011, Pennsylvania Psychologist, October 2011, p. 7. Copyright 2011 by the Pennsylvania
Psychological Association. Adapted with permission.
42 ethical dilemmas in psychotherapy
Conflicts Between Overarching Ethical Principles
and Organizational Policies or Laws2
If the APA Ethics Code conflicts with an organizational policy, then
psychologists are required to “make known their commitment to the Ethics
Code, and take reasonable steps to resolve the conflict consistent with the
General Principles and Ethical Standards of the Ethics Code” (Standard 1.03).
However, the Code does not permit obedience to an organization policy
that involves violations of basic human rights.3 The APA Ethics Code—
appropriately, we believe—adopts a middle position. On one hand, it does
not permit psychologists to follow unethical practices of an organization
blindly and without protest. On the other hand, the Code does not require
psychologists to resign their positions; rather, it requires them to make a
reasonable effort to address the problem. As a practical matter, it is too difficult
for any ethics code to prescribe appropriate and detailed actions when
what constitutes a “reasonable” action usually depends on circumstances
and available options. Consider this example:
An Indignant Psychologist
A psychologist at a public facility was told that he had to start treating
older adults, even though he had little training or experience with
this population. The psychologist immediately went into his supervisor’s
office with a copy of the APA Ethics Code and highlighted the various
standards that he thought he would violate if he were to follow the supervisor’s
instructions. He pounded his fist on the desk, described all of the
violated standards, and uttered the refrain “You are unethical” with ever woow

that

is

impressive