Avoiding Harm and Exploitation

7
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Jason’s wife of 4 years left him because of his increasing

compulsive sexual behavior with Internet pornography.
Jason would commonly spend 3 to 4 hours each day
searching for new websites and participating in online
social networks focused on sex. This habit was interfering
with work, the couple’s financial security, and their
personal relationship.
Jason was upset by his wife’s departure and decided to
initiate treatment with Dr. Tauss, a local therapist who was
well-known in treating sexual addiction. Dr. Tauss was
confident of his innovative treatment and felt entitled to
charge exorbitant fees, given the power of this particular
addiction. He charged $3,000 for the initial 90-minute
evaluation, and each subsequent 45-minute session was
$600. Jason was initially shocked by Dr. Tauss’s fees but
went along with them because he was feeling desperate.
He had just spent the past week staying in his house each
day for 14-hour sessions in front of his computer and had
received a warning from his employer that he would be
fired unless he returned to his job immediately.
Jason made such excellent progress in treatment after
4 months, with only one relapse early in therapy, that his
wife decided to return to him. However, she questioned
the high therapy fees that Jason was paying and noted
that they were far higher than any other therapist. She
convinced Jason to seek a reduction in fee from Dr. Tauss
because the couple now had diminished financial resources.
However, Dr. Tauss denied Jason’s request for a lower fee,
pointing out that his job was secure now that his sexual
addiction was gone and saying he would have to
terminate treatment if Jason could not pay his fee. Jason
followed his wife’s advice and opted to stop treatment,
even though he was at significant risk of relapsing.
http://dx.doi.org/10.1037/12345-007 127
Essential Ethics for Psychologists: A Primer for Understanding and Mastering
Core Issues, by T. F. Nagy
Copyright © 2011 American Psychological Association. All rights reserved.
 128 ESSENTIAL ETHICS FOR PSYCHOLOGISTS

Introduction

The American Psychological Association (APA) Ethics Code has always

contained a rule against inflicting harm on others as a basic value under-
lying both practice and research. Whether in the role of researcher, pro-
fessor, supervisor, clinician, or management consultant, psychologists
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follow Principle A: Beneficence and Nonmaleficence, which states as

the highest goal that they must avoid harming others and attempt to
safeguard the welfare and rights of those with whom they interact. The
ethical standard that is the corollary to this principle does not specifically
address beneficence but focuses exclusively on avoiding harm. Standard
3.04, Avoiding Harm, is short and simply states the following: “Psychol-
ogists take reasonable steps to avoid harming their clients/patients,
students, supervisees, research participants, organizational clients,
and others with whom they work, and to minimize harm where it is
foreseeable and unavoidable” (APA, 2010).
Of the 89 ethical standards in the 2002 Ethics Code, approximately
72% are concerned with harming or exploiting others. This book’s sup-
plemental website (http://pubs.apa.org/books/supp/essentialethics/) con-
tains a list of the 64 ethical standards relevant to harm and exploitation
in the 2002 code. The vast majority of these prohibit exploitation per se,
and relatively few address harmful activities of psychologists that are not
necessarily exploitative. Exploitation may be seen as a subset of harm.
Although every dog is an animal, not every animal is a dog, and although
every exploitative act is harmful, harm can also occur when there is no
exploitation. How does one then define exploitation and harm?
In this chapter, I discuss what exploitation and harm are and how
psychologists should apply this concept to different roles.

Harm Versus Exploitation

Inflicting harm on the recipient of psychological services may not always

be an intentional act. A psychologist who harms someone may be
unaware that he or she has done so and certainly may never have delib-
erately engaged in the behavior or failed to fulfill the responsibilities that
resulted in harm. The incompetent therapist who fails to involuntar-
ily hospitalize a patient who discloses a plan, means, motivation, and
immediate intent to commit suicide harms the patient by his inaction.
Likewise, a psychologist may harm a patient applying for long-term dis-
ability by using an obsolete form of an assessment instrument instead
 Avoiding Harm and Exploitation 129

of the most current edition or by attempting to formally assess a client

who has such poor fluency in English that the assessment’s validity
would be flawed. The results of testing could be inaccurate and not
serve the best interests of the client, despite the assessor’s best inten-
tions. In each of these cases the resultant harm was more attributable
to incompetence or lack of awareness by the practitioner. The psychol-
ogists had nothing to gain and, possibly, had something to lose in the form
of future complaints or grievances that could be brought by the clients or
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family members in each case.

To exploit means to make use of unfairly, or benefit unjustly from the
work of another (Compact Oxford English Dictionary, 2009). Exploiting
another invariably means that the psychologist has deliberately intro-
duced a secondary role—he or she is about to engage in a multiple-role
relationship in which his or her own wants or needs might be gratified
in addition to the primary role of carrying out the work of clinician,
supervisor, professor, or other. A conflict occurs when the expectations
attached to one social role are incompatible with those of another role
(Kitchener, 1988). Kitchener (1988) developed three guidelines for
determining when relationships have a high probability of leading to
harm: (a) As the incompatibility of expectations increases between roles,
so will the potential for harm; (b) as the obligations associated with dif-
ferent roles diverge, the potential for loss of objectivity and divided loy-
alties increases; and (c) as the prestige and power differential between
the professional’s and the consumer’s roles increases, so does the poten-
tial for exploitation. The author makes the point that therapists should
increase the ethical prohibitions against engaging in the questionable
relationship as the risk of harm increases.
An example of exploitation is the researcher who attempts to attract
more participants for a study by omitting important details of the proto-
col in the informed consent that participants would possibly experience
as embarrassing, offensive, or otherwise aversive. The researcher self-
ishly benefits by duping prospective participants into taking part in this
research, which they might well have refused to do had the researcher
revealed certain critical details of the protocol.
Another example is the professor who encourages a romantic rela-
tionship with a current student who has expressed such an inclination.
Even though the student may have initiated it, the professor knows that
such a relationship is judged to be exploitative by the profession, given
the inherent power differential between teachers and students, and that
such a relationship is specifically forbidden by the Ethics Code as well.
The professor also may be indirectly harming other students in the class,
not only by modeling behavior that is prohibited by the Ethics Code but
also by eroding his or her objectivity in evaluating and grading students’
academic performance (i.e., playing favorites).
 130 ESSENTIAL ETHICS FOR PSYCHOLOGISTS

HARMFUL BUT NOT EXPLOITATIVE

Comparatively few ethical standards address inflicting harm that does
not necessarily constitute exploitation. These consist of the following
topical areas: (a) the psychologist’s own personal problems and conflicts,
(b) unfair discrimination, (c) third-party requests for services, (d) coop-
eration with other professionals, and (e) informed consent (APA, 2010).
The first of these addresses situations in which a psychologist experi-
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ences a psychological or health problem sufficiently serious to compromise

his or her ability to work. As noted in Chapter 4, psychologists are subject
to the same range of stresses, loss, trauma, and dysfunction that affect the
rest of humankind. A psychologist who is grieving the loss of a parent may
find, to his or her surprise, that he or she has developed blind spots and is
unable to be vigilant about his or her own biases or prejudices any longer.
The psychologist finds, to his or her chagrin, that he or she periodically has
lapses in complying with the standard prohibiting unfair discrimination.
This standard forbids psychologists from acting in a biased way with
clients, patients, students, and others on the basis of age, gender, gender
identity, race, ethnicity, culture, national origin, religion, sexual orienta-
tion, disability, socioeconomic status, or any basis proscribed by law.
Third-party requests for services introduce a multiple-role relation-
ship right at the outset and therefore can be confusing or even harmful
to the recipient of psychological services. The third party could be (a) a
parent referring a child to be treated for attention-deficit disorder, (b) the
court referring a defendant for a determination of mental competency
to stand trial, (c) a therapist referring a patient to a neuropsychologist for
diagnostic evaluation concerning a head injury, (d) an employer refer-
ring one of his or her best employees for treatment of alcohol depen-
dency, or (e) a neurologist referring a chronic pain patient for treatment
of depression and pain management. In each of these situations the psy-
chologist has a relationship both with the patient and the referring third
party and must “attempt to clarify at the outset of the service the nature
of the relationship with all individuals or organizations” (APA, 2010,
Standard 3.07, Third-Party Requests for Services). The psychologist must
also identify who the client is and the probable uses of the services pro-
vided or information acquired and disclose the fact that there could be
limits to confidentiality, more frequently in forensic settings.
Psychologists must cooperate with other professionals to serve
their clients and patients effectively unless prohibited for some reason.
Here, too, one could inflict harm on a client or patient inadvertently,
but not deliberately exploit them, by simply failing to collaborate with
a health care professional who referred someone for treatment. The
press of daily work might result in a failure to return phone calls or
triage appropriately—requesting and reviewing the records of a new
patient, following up with authorized requests from others who are
 Avoiding Harm and Exploitation 131

also treating the patient (e.g., marital or group therapists, medical spe-
cialists), or collaborating and following up in a timely manner with a stu-
dent’s high school teachers in response to a referral for an evaluation.
Finally, the requirement to provide informed consent, as discussed
in Chapter 5, is ubiquitous throughout the Ethics Code, and failure to
honor this rule could be harmful to others but is usually not intentionally
exploitative. Psychologists in nearly every role are required to provide
informed consent—as researchers, therapists, evaluators, supervisors, and
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even professors.

HARMFUL AND EXPLOITATIVE

Most serious harm caused by psychologists is also exploitative in nature;
the psychologist somehow stands to benefit at the expense of the other
and has made a deliberate decision to do so. This is most evident with the
therapist who preys on patients by initiating sexual activities; the thera-
pist gratifies him- or herself on a variety of levels and clearly exploits the
dependency and vulnerability of the patients. There may be what appear
to be “justifiable exceptions,” such as the lonely, recently divorced ther-
apist who falls in love with a patient and rationalizes that this consti-
tutes a valid exception to the no-sex rule. This psychologist may not be
fully aware of the potential for harm or exploitation inherent in the
multiple role that is about to commence and may even view the ensuing
relationship as beneficial for both his or her patient and him- or herself.
According to Gabbard (1994), psychoanalysts who engage clients
and patients in a sexual relationship generally all have narcissistic issues
and may be grouped into four categories: (a) the psychotic-disordered
clinician, (b) the predatory psychopathic and paraphilic clinician, (c) the
self-destructive clinician, and (d) the “lovesick” clinician. The psychotic
clinician experiences a loss of contact with reality characterized by delu-
sionally depressed or manic states with odd or bizarre ideas; this thera-
pist may believe that a sexual relationship with his or her patient is the
only way to effect change in the patient’s life. The psychopathic therapist
may be charming and intelligent but lacks a conscience or sense of guilt,
is unable to tell the truth, takes needless risks, is incapable of real love or
attachment, and fails to learn from unpleasant experiences (Corsini &
Auerbach, 1998). This therapist exploits and preys on clients and patients,
with no capacity for empathy for their needs, driven by paraphilic urges
(i.e., abnormal or extreme sexual desires frequently involving risk). The
self-destructive therapist responds to unconscious self-punitive needs
prompting him or her to make decisions and engage in activities that
could lead to ruin as a practicing therapist, such as jeopardizing his or
her license by engaging in sex with a patient. And the lovesick therapist
is one who feels that he or she has genuinely fallen in love with a
“special” patient; sometimes this individual may have recently had a
 132 ESSENTIAL ETHICS FOR PSYCHOLOGISTS

major personal loss (e.g., divorce, death of a child) and is experienc-

ing depression and attendant impaired judgment. Understanding the
psychological nature of these individuals who sexualize the therapeu-
tic relationship helps with diagnosing and rehabilitating the abusing
therapist.
Sometimes the theoretical orientation of a psychologist and the
nature of the treatment being offered play a role in helping to determine
what may be experienced by the client or patient as being harmful and
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what is not. It is interesting to note that what appears to be the same

intervention performed by psychologists with different informed consent
at the outset and different levels of competence may result in harming
one patient but helping another. For example, an experienced, behav-
iorally oriented psychologist uses in vivo desensitization with a patient
who is agoraphobic and unable to enter a public place such as a restau-
rant without experiencing overwhelming anxiety. The therapist prac-
tices exposure therapy with the patient by walking into a restaurant
with him, sitting down at a table, ordering something from the menu,
and then waiting for the patient’s anxiety level to decrease to a rea-
sonably comfortable level before eventually leaving the restaurant
with him at the end of the meal. The patient is informed in advance
of the treatment modality and understands the theoretical approach
prior to experiencing it.
What follows is a different scenario. A recently licensed, classically
trained psychoanalyst who read a journal article on the topic of expo-
sure therapy impulsively decides to offer the in vivo restaurant inter-
vention to a patient whom she is treating in psychoanalysis. However,
she fails to adequately prepare him for the experience in advance and
does not process the meaning of the experience afterward back in the
office, which is a departure from her normal practice. This is experi-
enced as confusing to the patient and increases his anxiety about the
treatment process, and he now feels that his therapist was being seduc-
tive with him by inviting him to lunch.
The analyst had not adequately prepared the patient or thought
through the process of how to integrate her first application of a behav-
ioral technique within ongoing psychoanalysis. There was inadequate
informed consent with the patient, a lack of shared expectations about
this particular intervention, and inadequate processing of the experi-
ence afterward. Hence, what appeared to be the same intervention—
meeting a patient for lunch in a restaurant—was experienced quite
differently by the two patients; this might have been due less to the
therapists’ differing theoretical orientations and more to a lack of com-
petence. The psychoanalyst should be commended for experimenting
with an approach that would not be acceptable to many of her peers,
but she requires additional training for its competent application to
patients.
 Avoiding Harm and Exploitation 133

Review of Harm and

Exploitation by Ethical Topic

I now briefly review each section of the Ethics Code for topics address-
ing harm and exploitation, although these topical words may not always
be mentioned in the ethical standards themselves. These topics are
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explored more comprehensively in the chapters that follow; they are pre-
sented here for the purpose of focusing on those specific interventions
that could result in harm and exploitation of others.

COMPETENCE
The standards discussing competence generally require that psychologists
(a) be competent at what they do, including providing services, teaching,
and conducting research, and (b) avoid areas in which they are incom-
petent. Although these may seem to be two sides of the same coin, there
actually are some differences between the two. For example, a therapist
in private practice treating a new patient who presents with major depres-
sion has good skills at diagnosing and treating depressed patients and
feels competent to offer the requested clinical services. However, after
four sessions, when the therapist learns that her patient is a Gulf War
veteran and had been a prisoner of war enduring months of torture, she
may have some doubts about her competence level to treat him, never
before having worked with a patient who had such an extreme history of
trauma resulting in posttraumatic stress disorder.
What began as practice within the psychologist’s area of compe-
tence soon expanded into an area that she felt ill equipped to treat.
Nevertheless, she may be motivated to continue treating because of
a combination of incentives: ethical concern for the continuity of care
with her patient (i.e., continuing the treatment she began with him)
and also her private financial motivation to maintain her income by
retaining as many patients as she can. Unfortunately, the business
motive can be confounding and lead to a decision that could be exploita-
tive in nature.
If the patient would be better served by referral to another practi-
tioner when the treating therapist doubts her own capacity to provide
ongoing clinical services, then she should make such a referral if there
are other competent therapists available. However, if she continues
treating when she could refer or fails to obtain consultation or additional
training to upgrade her skills, then she places the patient at risk of harm.
By allowing her role as a businessperson (private practitioner) to influ-
ence her clinical judgment (as a treating therapist), she falls victim to a
duality that could be exploitative of her patient.
 134 ESSENTIAL ETHICS FOR PSYCHOLOGISTS

HUMAN RELATIONS
This section of the Ethics Code focuses on the nature of the personal and
professional relationships that psychologists establish with colleagues,
clients and patients, students and supervisees, research participants,
organizational clients, and others with whom they work. It includes
Standards 3.04, Avoiding Harm, and 3.08, Exploitative Relationships,
as well as related standards on harassment and sexual harassment, con-
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flict of interests, multiple relationships, unfair discrimination, and others.

Certainly it is abusive to harass or demean another person on the basis of
factors such as age, gender, gender identity, race, ethnicity, culture,
national origin, religion, sexual orientation, disability, language, or
socioeconomic status. Harassment based on gender is not only prohibited
by the Ethics Code but has legal ramifications as well; it has been charac-
terized as a form of sex discrimination by the U.S. Equal Employment
Opportunity Commission (2002) that is a violation of Title VII of the
Civil Rights Act of 1964. Sexual harassment is defined as
unwelcome sexual advances, requests for sexual favors, and
other verbal or physical conduct of a sexual nature when
submission to or rejection of this conduct explicitly or implicitly
affects one’s employment, unreasonably interferes with their
work performance, or creates an intimidating, hostile or
offensive work environment. (U.S. Equal Employment
Opportunity Commission, 2002, para. 2)

The APA Ethics Code includes this language but adds the concept of inten-
tionality by requiring ascribed motivation on the part of the harasser, thus
creating a higher threshold for violation than the law. It defines sexual
harassment as (a) behavior that is unwelcome, offensive, or creates a hos-
tile workplace or educational environment, and the psychologist knows or is
told this (italics added), or (b) behavior that is sufficiently severe or intense
to be abusive to a reasonable person in the context. It concludes by stat-
ing that sexual harassment may be conceived of as a single intense or
severe act or multiple persistent or pervasive ones (APA, 2010, Standard
3.02, Sexual Harassment). Hence, a harasser might plead ignorance to
having transgressed and if the harasser was never “told” by the victim
might escape being found in violation of the ethical standard, even though
this individual might have violated the federal statute. The second part
of the ethical standard, admittedly, may strengthen the rule by citing the
“reasonable person” argument.
Sexual harassment and multiple-role relationships culminating in
sexual activities are viewed with extreme gravity by ethics committees
and state licensing boards, resulting in expulsion from the APA, loss
of license, and other sanctions. This includes sex with students and
supervisees (see the Education and Training section, which follows),
sex with current patients and clients, sex with their family members
 Avoiding Harm and Exploitation 135

or significant others, and sex with former patients (see the Therapy
section later in this chapter).
Other nonsexual multiple-role relationships can also result in harm
and exploitation, such as concurrently participating in the following
with an adult recipient of psychological services:
❚ a business venture (e.g., opening a joint website on eating disorders
with a client or patient),
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❚ any other service (e.g., tutoring in an academic course, giving

tennis lessons, providing a therapeutic massage as a licensed
masseuse),
❚ hiring one’s patient or bartering with him or her for psychologi-
cal services in a manner that constitutes a potentially risky mul-
tiple relationship (e.g., gardening, secretarial work at one’s office,
babysitting, odd jobs around one’s house, helping with computer
problems), and
❚ friendship (e.g., meeting one’s patient for dinner, including one’s
client or patient on family outings).
In each of these activities the psychologist is initiating a secondary
role or relationship in addition to the professional one, sometimes in
the role of employer (e.g., hiring the patient to babysit or do odd jobs)
and sometimes as a service provider (e.g., tutor). Moreover, this sec-
ondary role invariably meets his or her own needs in some fashion—
growing a business, bringing in more income, or meeting the social
needs of a psychologist.
The psychologist’s objectivity may be reduced when a secondary
role is added, and that can impair competence in any psychological
service or activity. The psychologist who begins a business venture
online with his or her patient but several months later has a disagree-
ment with the patient about the business plan or strategy may find that
he or she has lost effectiveness as a therapist. If that role bleeds into the
other, boundaries are forever compromised, and it may be impossible to
ever recover the original therapeutic alliance, thus harming the patient
by truncating treatment. What began as a business venture in good
faith, ended in exploitation of the patient’s vulnerability. Psychologists
have many patients and have learned through experience about bound-
aries between their personal and professional life. Patients often may
have only one therapist and usually are quite naive about professional
boundaries, trusting and relying on the experience of their therapist.
Exploitation of the trust may surface with certain dyads under certain
circumstances whenever the psychologist contemplates a secondary
role in addition to the therapeutic one.
It should be noted that not every multiple relationship is unethical
or destructive to patients. In fact, it may be commonplace in rural areas
 136 ESSENTIAL ETHICS FOR PSYCHOLOGISTS

with limited psychological resources for treating therapists to also know

their patients in another context, such as the cashier in the local grocery
store or the teacher of their junior high school age daughter.

PRIVACY AND CONFIDENTIALITY

In clinical settings, ethical rules as well as state and federal laws protect
the privacy of patients and clients. There are many examples in which
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harm may occur without exploitation, such as when patient privacy is

violated, either accidentally or with the best intentions of an unskilled
clinician. It is useful to consider the marital therapist who reveals to the
wife a private disclosure by the husband about a felony conviction prior
to their marriage. Although the disclosure may reflect the therapist’s
commitment to a policy of “no secrets in therapy,” this had never been
discussed in advance or authorized by the husband, and it may cause
significant harm to the marital relationship.
There are many examples of both harming and exploiting others by
violating their privacy. The psychologist both harms and exploits the
patient about whom the psychologist writes a journal article or a book
without first discussing it with the patient and obtaining prior authoriza-
tion. It would be best to wait until the termination of treatment to initiate
discussion of such a joint project because the power differential inherent
in the treatment setting could weaken the patient’s ability to decline.
Even psychologists working in educational and training settings must
safeguard the privacy of their students and supervisees, as discussed in
Chapter 6. Psychologists must avoid inquiry about certain personal topics
unless certain conditions prevail (e.g., prior consent, significant impair-
ment, risk of harming others).

ADVERTISING AND OTHER PUBLIC STATEMENTS

Advertising includes promotional messages for products or services in
newspapers or other print media (e.g., ads for clinical or consulting ser-
vices, books, workshops or seminars for mental health professionals or
the public), in telephone yellow pages, over the Internet, on radio or tele-
vision, or elsewhere. Even if a third party creates the advertising mes-
sage, the psychologist still assumes full responsibility for its content. It is
harmful and exploitative, as well as illegal, to attempt to influence the
thinking and behavior of others by falsely presenting one’s clinical skills,
such as claiming unattainable results. The psychologist who guarantees
outcomes (e.g., lasting weight loss from a single session) or who claims
to cure medical illness in the absence of clinical or experimental data
supporting such assertions is giving false hope to gullible patients. The
psychologist offering innovative treatment (e.g., individual psychother-
apy by e-mail) that lacks validating empirical support also risks exploit-
 Avoiding Harm and Exploitation 137

ing others. Innovation and experimenting with creative methods for

change are ethically acceptable only if the psychologist makes a good-
faith effort in clinical or research settings to offer full disclosure of any
risks and any other information that would affect one’s willingness to
participate and obtains informed consent as well. By such transparency
the psychologist allows consumers to make an objective choice that will
best meet their needs while minimizing the risk of exploitation.
Advertising that includes testimonials by current patients or clients
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is a clear example of a multiple-role relationship that has a high poten-

tial for harm and exploitation. The therapist immediately adds a second-
ary role—that of advertising or business executive—the moment he
or she asks a current patient to supply a testimonial about treatment.
The power differential inherent in clinical settings usually precludes a
patient from refusing such a request. It may feel both flattering and
coercive to the depressed patient engaged in psychotherapy to be asked
by his or her therapist to comment publicly on therapy effectiveness. It
may also be burdensome to decline such a request, disappointing the
very person who has helped the patient so much, without feeling addi-
tional guilt or shame, the very feelings that the patient has already been
struggling with in depression.
Public statements include everything that is said, written, or com-
municated in any way to another while in the role of a professional psy-
chologist. This includes résumés (e.g., affiliations, degrees), grants or
licensing applications, psychological reports, disclosures in depositions
or other legal proceedings, informed consent documents describing
treatment or research protocol, description of academic courses or train-
ing experiences (e.g., including clinical supervision or workshops), media
interviews (e.g., print or electronic media—radio, television, Internet,
e-mail), public lectures and oral presentations, as well as journal arti-
cles and books.
The potential for harm and exploitation comes with obvious exam-
ples of conflict of interest, such as the psychologist reporting his or her
positive research findings about a new antidepressant medication but
failing to disclose that the research was funded by the very pharmaceu-
tical firm that produced the antidepressant and that the psychologist
had given lectures or media statements in support of its use that were
paid for by the pharmaceutical firm. The public is led to believe that this
psychologist has empirical support for the statements and does not
know about the $100,000 or more the psychologist has already received
as an incentive.
Even academic settings pose risks of harm and exploitation. An
example is the inexperienced college instructor who teaches a new
course in group therapy but neglects to inform students in advance that
it will involve an experiential component that includes participation in
group therapy with truthful self-disclosure and will be led by another
 138 ESSENTIAL ETHICS FOR PSYCHOLOGISTS

faculty member. The instructor may fear students would avoid select-
ing the course were he or she to be completely accurate in describing
this requirement in the course catalogue. The harmful aspect is expos-
ing students to the pseudotherapy group without informing them in
advance, and the exploitative aspect meets the instructor’s needs by
assuaging his fears that too few students would select the course unless
he or she deceived them about its content and format.
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FINANCIAL ARRANGEMENTS
Clients and patients have a right to know about the complete cost of
psychological services in advance, and psychologists have an ethical obli-
gation to inform them. This is true in clinical and forensic settings, whether
or not health insurance or some other third party is being relied on for
payment. The client or patient must be informed, even if the person
does not inquire about cost. A neuropsychological evaluation can be
costly, ranging from $2,000 to $10,000 or more, and a psychological
evaluation in a child custody setting could be even more, ranging from
$5,000 to $20,000, depending on the region of the country, the com-
plexity of the assessment, and fees required for depositions and court
appearance.
Bartering products or services in exchange for psychological ser-
vices may be a creative way of transacting business in rural communi-
ties or with low-income patients. The lobster fisherman in Maine who
exchanges part of his catch for a therapy hour is using products as cur-
rency for which a fair market price has been established. The psychol-
ogist accepts the lobsters and, at the end of the year, completes the
appropriate Internal Revenue Service form documenting the transac-
tion. However, bartering for services may expose the patient and ther-
apist to the complications of a harmful multiple-role relationship. The
licensed electrician in Boston who agrees to rewire an aging electrical
system in his therapist’s Victorian house in exchange for treatment faces
a much more complex business arrangement. Now his therapist has also
become his customer with whom he is engaged in a contractual rela-
tionship for professional services. A multiple role has been established
that may confound the therapy relationship if things do not go quite
right. It is useful to consider the scenario of the patient–electrician who
makes a critical error in judgment when rewiring the children’s room.
While standing on a radiator to switch on the electric light, the thera-
pist’s young child receives a serious electrical shock. How would the
therapist feel about such a mishap, and how might this interfere with
the ongoing psychotherapy relationship? In a worst-case scenario the
new wiring could start a fire that destroys the house, resulting in seri-
ous injury or loss of life.
 Avoiding Harm and Exploitation 139

These may seem to be unlikely situations, but they draw attention to

the problems that can occur while bartering for services. The psychologist
may be dissatisfied with the work carried out by a careless or impaired
patient, at best, and harmed by it, at worst. And the potential for harm to
the therapeutic work may increase for other reasons as well because the
patient now has taken on the secondary role of employee of the therapist.
The patient who becomes familiar with his or her therapist’s living sit-
uation, family members, religious affiliation, political preferences, and
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intimate day-to-day habit patterns and quirks, as can happen with a

workman who visits a house over a period of days or weeks, may experi-
ence changes in the therapy relationship that irrevocably alter the treat-
ment process. The patient may begin to feel like “one of the family,” or
the therapist may also develop this feeling, thereby losing objectivity in
the therapy hour and impairing competence to diagnose and treat. On the
other hand, a decidedly negative result may emerge. The politically con-
servative Roman Catholic patient may be disappointed to learn that his or
her therapist is a liberal Democrat and a member of the American Civil
Liberties Union who supports policies formally opposed by the patient’s
church (e.g., stem cell research, abortion) after seeing literature or other
telltale signs taped to the therapist’s refrigerator door. This patient has
learned more than he or she ever wanted to know about the therapist’s
private beliefs and values by simply entering the therapist’s home to carry
out work and has certainly learned more than the patient would have
inquired about during therapy. The impact on therapy could be immense
or minimal, depending on the theoretical orientation of the therapist,
diagnosis of the patient, and other factors, but the risk is obvious.

EDUCATION AND TRAINING

The power differential inherent in academic and training settings presents
a variety of potential risks of harm and exploitation. Providing thorough
informed consent is an important part of avoiding harm, and instructors
and supervisors are required to inform students and trainees about the
educational experiences they are about to have in advance. For instruc-
tors, this includes information about course or program content, training
goals, objectives, and requirements to be met, as well as any compulsory
personal counseling, psychotherapy, experiential groups, consulting proj-
ects, or community service. An example of harm without exploitation is
the student who was not informed at the outset of a course require-
ment to participate in a discussion group in which self-disclosure about
emotional past losses is the focus. For the student with unresolved major
trauma such a requirement may be retraumatizing, and the requirement
certainly should have been disclosed in advance in the course catalogue
or by some other means.
 140 ESSENTIAL ETHICS FOR PSYCHOLOGISTS

For supervisors, avoiding harm includes informing the trainee about

the theoretical orientation of the supervisor as well as terms of the
agreement—frequency and duration of supervisory sessions, nature of
the patients or clients who will be seeking services, training goals and
expectations, details of scheduling (e.g., weekly quotas, anticipated
vacations), and any financial arrangements (if appropriate). The Asso-
ciation of Psychology Postdoctoral and Internship Centers is an important
professional association for those involved in training predoctoral and
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postdoctoral psychologists as well as for those involved in the national

match program.1 One of the most destructive experiences for students
and supervisees over the years has been engaging in multiple roles that
include sexual relationships (Pope, Levenson, & Schover, 1979). Both
harmful and exploitative, sex with one’s own student or supervisee,
regardless of who initiates it, clouds the objectivity and judgment of the
senior psychologist. Beginning with the 1992 revision of the Ethics
Code, there are no exceptions to this rule. Whether both parties expe-
rience this as an emotional commitment or merely a casual affair, sex-
ual acting out with students or supervisees in the same department,
agency, or training center over whom psychologists have or are likely
to have evaluative authority is strictly prohibited.
The student gains a lover but loses a supervisor because objectivity
and competence begin to erode. Mentors, instructors, and supervisors
are ideally positioned in the course of a student’s academic training to
model good boundaries, yet they may not have had much training,
guidance, or life experience themselves in how to carry this out. Many
if not most universities and other academic institutions have sexual
harassment and related policies. This book’s supplemental website
(http://pubs.apa.org/books/supp/essentialethics/) provides Stanford
University’s statement on consensual sexual or romantic relationships.

RESEARCH
Exploitation or harm in research can take several forms. The researcher
who fails to provide potential participants with adequate information
about the nature of the research in advance or fails to indicate that they
will be videotaped is at risk of harming or exploiting. For example, a
participant could be harmed if not informed that the research protocol
on marital relationships would include exposure to sexual content and
imagery, some of which the participant might find disturbing or offensive.
If the researcher deliberately omits this information from the informed

1
The monthly newsletter of the Association of Psychology Postdoctoral and Internship
Centers is freely available online and is filled with useful information about training and
supervision matters (http://www.appic.org/).
 Avoiding Harm and Exploitation 141

consent document, fearing that full disclosure might alienate potential

participants, the researcher is making a deliberate decision that will
benefit him or her and possibly harm a participant, thus both harming
and exploiting.
Using deception with research participants is acceptable only if cer-
tain criteria are met (see Chapter 11, this volume). And candidates should
never be deceived about the details of their expected participation, such
as monetary inducements, the duration of the protocol, anticipated expe-
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riences of the protocol (while preserving participants’ naiveté), or other

specifics that would influence their decision about participation. If the
investigator uses deception in the course of the protocol, the investigator
must debrief each participant as soon as is feasible after the data collec-
tion is completed. The researcher who is short staffed or delays debrief-
ing for some other reason for months after the conclusion of data
collection would be harming participants by allowing them to remain
deceived for so long a time and would be in violation of the ethical stan-
dard concerning deception.

PUBLICATION
Plagiarizing consists of copying the words or using the concepts obtained
from another without citing the source or attributing authorship. It is
both harmful and exploitative to an author if his or her published the-
oretical concepts or research results are lifted by another and used in
a professional context—journal article, book, professional lecture, or
media presentation—without acknowledging the source. In addition to
violating certain standards of the Ethics Code, such actions may also be
in violation of legal statutes, such as federal copyright laws involving
the protection of intellectual property.2
Another form of exploitation and harm in the area of publication con-
sists of deliberately claiming publication credit for a journal article, book
chapter, or professional presentation in any public forum for work that
was essentially created by others. Although seemingly related to plagia-
rism, it differs in the scope of the misrepresentation as well as the intent.
The senior psychologist who deliberately claims primary authorship in a
multiply authored article when he or she actually did none of the writing
and participated little in the research itself may be in violation of this rule.
The senior psychologist may feel entitled to be listed as the first author
because he or she contributed toward conceptualizing the investigation
as well as toward writing the grant that funded it. But it might be more

2
The first copyright law in the United States was enacted by Congress in 1790 on the
initiative of President James Madison, and within 2 weeks, the first work was registered
at the U.S. Copyright Office (U.S. Copyright Office, 2005).
 142 ESSENTIAL ETHICS FOR PSYCHOLOGISTS

appropriate for the senior psychologist to be listed as a junior author and

credited in the acknowledgment section or cited in the reference section
for contributions rather than to be listed as the primary author.

ASSESSMENT
The area of psychological assessment includes both the construction and
scoring of instruments of assessment as well as their use in a diversity of
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settings and purposes. Psychologists who perform assessments evaluate

students in primary and secondary schools, perform child custody eval-
uations for divorcing couples who are in litigation, evaluate patients in
clinical settings who present for treatment, evaluate candidates for work
in a variety of settings, perform workers’ compensation evaluations for
employees with injuries and disabilities, evaluate decisional capacity for
the infirm, and work in business and industry with management evalu-
ating job performance of employees.
In each of these settings there is always a potential for harm when
the evaluation is substandard and a potential for exploitation if the psy-
chologist is remunerated for incompetent work. The candidate apply-
ing for a job with the county fire department could be harmed if the
psychologist is careless in administering or scoring a test, carrying out a
structured interview, or writing a report. The Vietnamese mother seek-
ing custody of her young children could be harmed if the psycholo-
gist is not objective and methodical in evaluating both parents—using
evidence-based techniques, using the proper instruments of assessment
for a Vietnamese woman, using the same instruments with both par-
ents, spending the same amount of time assessing both, and more She
could lose access to her children if the assessment is not done properly,
and the children could be harmed for years by mistakenly being placed
with an abusive father. After parents receive an adverse judgment from
the court, it is not uncommon for them to sue a psychologist who has per-
formed an evaluation, claiming that that it was carried out incompetently,
regardless of any actual wrongdoing.
Exploitation in assessment could come in the form of a psychol-
ogist who constructs a new instrument without adhering to the well-
established scientific standards of test construction. This might include
failing to properly evaluate each item for its discriminatory value, failing
to establish validity and reliability for the test, and failing to adequately
standardize the instrument by gender, age, and ethnicity. The psychol-
ogist may then market his instrument in a manner that exaggerates its
usefulness, further adding to the exploitation of others—particularly to
psychologists who believe the inflated claims and purchase the test in
good faith. Such an instrument could harm individuals who take the test
(e.g., an adolescent being evaluated for a learning disability) because its
validity would be questionable. It could also harm the psychologists
 Avoiding Harm and Exploitation 143

who administer the test because their professional work could be legit-
imately questioned by their clients and patients and, ultimately, could
result in ethics complaints, licensing board investigations, or even law-
suits if the harm were sufficiently severe.

THERAPY
Ethical standards concerning harm and exploitation by therapists include
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(a) multiple-role relationships of a sexual nature and (b) improperly ter-

minating therapy. As mentioned in Chapter 2, although the very first
Ethics Code never mentioned the word sex, Principle 3, Moral and Legal
Standards, required psychologists to show a
sensible regard for the social codes and moral expectations for
the community in which he [sic] works, recognizing that
violations of accepted moral and legal standards on his part
may involve his clients, students, or colleagues in damaging
personal conflicts, and impugn his own name and the
reputation of his profession. (APA, 1959)
Presumably sex with current patients would have fallen into the cate-
gory of violating accepted moral and legal standards, as is addressed by
Hare-Mustin, later, in her classic 1974 journal article. Even more rele-
vant, perhaps, was Principle 8, Client Relationship, requiring a psychol-
ogist to inform “his prospective client of the important aspects of the
potential relationship that might affect the client’s decision to enter the
relationship” (APA, 1959).
Although no ethical standard specifically addresses hugs, handshakes,
pats, massages, or other forms of physical touch in the treatment setting,
there are eight that address sexual intimacies, sexual harassment, dis-
closure of sexual history or current sexual relationship, and related abuses
of those in professional relationships with psychologists. Most of these are
in the Therapy section, discussed in Chapter 10. There is no accompany-
ing glossary defining sexual activity in the Ethics Code, but if there were, it
would likely include the following characterization, in some form, stated
it in a teleological manner (e.g., a rule of conduct that takes the situa-
tion into account—is based on supposed goals and outcomes) rather
than a deontological (a rule of conduct considered valid regardless of the
situation or outcome) manner. Prohibited sexual activity would include
any verbal, nonverbal, or physical activity (i.e., touching oneself or
another) on the part of the therapist that has as its goal sexual arousal,
sexual gratification, or satisfying of sexual needs of that therapist with
a client or patient, regardless of the client’s or patient’s willing partic-
ipation. Such a definition would, of course, include physical touching
of any part of the body that could be considered sexually arousing to the
therapist or patient as well as unwarranted (a) drawing attention to the
patient’s body (e.g., staring, ogling), (b) inappropriately questioning a
 144 ESSENTIAL ETHICS FOR PSYCHOLOGISTS

patient about his or her sexual behavior, and (c) self-disclosure of the
therapist’s sexual history or any behavior that is intended to create sex-
ual stimulation or sexual pleasure of any participant in the consulting
room (e.g., therapist or patient).
By using a teleological definition, rather than a deontological one,
one can concisely create a decision rule for therapists that is easy to fol-
low. Basically, if what the therapist is about to say or do is intended to
increase the probability of sexual pleasure, erotic interest or arousal, or
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romantic relationship with the client or patient, it is off limits and must
be avoided. Specific standards concerning sex with current and former
patients are presented in Chapter 10.
The standard concerning termination of treatment requires that
(a) psychologists end treatment when it is clear that the client or patient
no longer needs it, is not likely to benefit, or is being harmed by contin-
ued service and (b) psychologists provide pretermination counseling
and suggest alternative services as appropriate (APA, 2010). It is likely
exploitative and harmful, financially and in other ways, to continue
with a patient long after the patient has resolved his or her original com-
plaint and wishes to terminate. Conversely, it could also be harmful to
abruptly end therapy simply because treatment met a temporary impasse,
or for some other reason that met the therapist’s needs rather than those
of the patient, without providing pretermination counseling and offering
alternative services. However, it is important to note that a therapist may
end treatment if the therapist feels threatened or endangered by the
patient or someone with whom the patient has a relationship.
The overarching teleological question to be repeatedly addressed by
therapists is, Whose psychological needs are being met in the course of
carrying out treatment? Certainly therapists may have insights about
their own problems as well as derive emotional satisfaction from the
process of providing counseling and psychotherapy. But that satisfac-
tion must stop short of using individual clients and patients for social or
sexual gratification or for increasing their income long after the therapy
goals have been met.
When psychologists harm or exploit others it may be due to a lack
of knowledge, poor training, inexperience, incompetence, an adverse
life situation resulting in impaired mental health, or even deliberate or
predatory motivations. Sometimes psychologists may see a red flag, rec-
ognizing that they are confronting a gray area, but may find little guid-
ance from the Ethics Code or legal statutes as to which course of action
to take. The next chapter addresses models of ethical decision making
that help address these issues so as to avoid exploiting and harming the
recipients of psychological services in therapy and other settings.