Applying Ethical Approaches to Evidence Based Psychotherapy— Jennifer Lundgren, UMKC (2008)

Evidence Based Psychotherapy (EBP) is designed to teach first and second year doctoral students in clinical psychology to critically evaluate the research base upon which EBP exists and to demonstrate skill in the use of its methods. This is a core course in our American Psychological Association (APA) approved doctoral program in clinical psychology, and it is completed before or during the students’ first clinical practicum.

Psychologists face several ethical dilemmas related to the science and practice of psychology. Since the mid-twentieth century, the APA has developed and published general ethical principles and comprehensive ethical standards for psychologists. These standards provide guidance for students and professionals in the appropriate resolution of ethical issues, professional competence, human relations, privacy and confidentiality, advertising and public representation, record keeping and fees, education and training, research and publication, assessment and therapy. Each of these ethical standards directly or indirectly relates to the practice of evidence-based psychotherapy.

In the context of EBP, this ethics project integrated ethics theory and the APA Professional Code of Ethics into the course material. Students were exposed to utilitarian and deontological approaches to ethical decision-making and applied these approaches to situations in professional psychology. Through in-class discussions, student activities, and formal assessment, students demonstrated appropriate ethical decision-making as it related to the research and practice of psychotherapy.

The aims of this project were to familiarize students with both theoretical and applied ethics in the context of professional behaviors. Specifically, by the end of the course students should be able to:

1. Differentiate between utilitarian and deontological approaches to ethical decision-making.
2. Apply ethical decision-making to relevant case examples using an ethical decision-making framework.
3. Summarize the five American Psychological Association ethical principles.
4. Identify and describe the ethical principles outlined in the professional Code of Conduct that relate directly and indirectly to the science and practice of service delivery.

Introducing Ethics

Students were introduced to formal ethics theory and the APA Code of Ethics through a class session entitled “When Interventions Harm.” Before attending this class session, students read literature and prepared discussion questions on harmful and iatrogenic psychotherapy practices and reviewed the APA Professional Code of Ethics. In class they engaged in an interactive Power Point lecture called “Professional Ethics in the Context of Psychotherapy (pdf),” during which I introduced the theoretical background students would also need to consider as they interpreted the professional code, including a discussion of utilitarian and deontological approaches to ethical thinking.

After the lecture, students were divided into groups and given one of the following case examples:

Case 1: You are employed as a clinician within a community mental health clinic. The executive director of this clinic tells you that he has obtained and reviewed clinical patient files of clients who were members of his church. In addition to his role as executive director of the clinic, he is a pastor in a local church. He told you that his knowledge of this confidential clinical information would be helpful to him in his role of pastor.

Case 2: A mother in your PTA group approaches you after a meeting. Her 15-year-old son has been very depressed since she and her husband divorced two years ago. She has found alcohol in his room and evidence that he is using marijuana. She asks if she can schedule an appointment with you on his behalf. She stresses that she believes you are someone that he would feel comfortable with, and that you might be his only hope for happiness. Before you can respond, she also states that she has been reading the Internet and thinks that EMDR is the best treatment for him “especially because he needs to reprocess the trauma of the divorce.”

Students used either a utilitarian or a deontological decision-making approach to arrive at a decision about how they would proceed, given either of these therapy-related ethical dilemmas. Once the group arrived at a conclusion, they consulted the APA Code of Conduct to determine if their decision was consistent with the code and what course of action should/should not be taken. Groups then shared their decision-making process and outcome with the class and were provided with feedback on their work.

Midterm Assessment

As part of a take-home midterm evaluation, students were provided with a new case that included multiple ethical dilemmas:

You are a partner in private community psychotherapy practice that has recently been established. To increase your referrals and case loads, you and your two colleagues decide to advertise your services in a local news magazine. Your colleagues have different training backgrounds than you, and despite your adherence to evidence based psychotherapy practices, your colleagues are very interested in offering energy-based treatments. They have been collecting some anecdotal evidence to support their use of Reiki as a therapy for panic disorder, but they have not yet conducted any controlled evaluations (e.g., single subject intervention research with their clients). They want to state in the advertisement that they have a 100% success rate in curing panic when using this treatment.

Students were asked to use either a utilitarian or a deontological decision-making approach to arrive at a decision about what should or should not be done. Students then consulted the APA Code of Conduct to determine if their decision was consistent with the Code and what course of action should/should not be taken. Students were evaluated on their ability to:

1. Accurately identify the ethical issues presented in the case
2. Fully describe the decision-making processes
3. Compare their decision with the APA Code of Conduct
4. Describe any discrepancies between their decision and the Code and develop a new course of action based on this analysis.

Final Examination

As part of an in-class (closed book) final examination, students were presented with a final case. This case modeled the psychology department's comprehensive examination-style questions. Each student was asked to identify the ethical dilemmas presented in the case and to present her or his course of action. Students were evaluated on the following:

1. Ability to accurately identify the ethical issues presented in the case
2. Ability to describe a course of action that was consistent with the APA Code.

The aim of this final assessment was not to evaluate students’ decision-making processes, but to evaluate their final decision, which was influenced by both the Code and their decision-making processes. In the “real world” their actual decision, and not the decision-making process, is the standard by which they will be judged as professionals.

Student learning was informally assessed during the initial class ethics introduction and during the student discussion of two cases that presented ethical dilemmas. Students in their second year of graduate study, compared to students in their first year of graduate study, were better able to recognize ethical dilemmas and to suggest appropriate courses of action. Groups, however, did not seem to differ on their understanding of formal ethical decision-making models. This is not surprising, as the second year students had previously taken a graduate course that reviewed the APA Code of Conduct.

Formal assessment of student learning occurred at the mid-term and final examinations. Each of these exams assessed different aspects of student learning. Specifically, at the mid-term examination, I wanted to assess how well students could describe and apply the steps of an ethical decision making model. Because students were allowed to take the examination home, I expected that most student responses would be strong. My prediction was correct, and all students performed well, earning full or nearly full credit on the question.

For the final examination, I chose an assessment approach that more closely replicated the type of ethical decision-making processes that student and professionals encounter in both the “real world” and in the context of students’ comprehensive examination taken after their second year of graduate training. In this final assessment I asked students to identify ethical dilemmas presented in a case and to describe their course of action. I chose not to assess their knowledge of formal ethical decision-making models because, in practice, it is often the outcome and not the process of ethical decision making that is judged by other professionals or regulatory bodies. Student performance on this final examination question ranged from 75% to 100%. Scores were lower than I had anticipated, so I made efforts to provide students with verbal feedback to explain why their answers were correct or incorrect. All students who were provided with corrective feedback reported that they understood why their answers were incorrect.

For more information, I've included some examples of student work below (pdfs):

• Midterm student example
• Final student example

My students reported using the ethical decision-making processes outside the classroom to help peers evaluate and make decisions when facing ethical dilemmas. I was pleasantly surprised by this, because I don’t recall any of my peers using such a process to handle ethical decisions when I was in training, and even now as a professional I rarely engage in such thorough ethical decision-making processes. I realized when listening to my students describe this process how important it has been to them in understanding why our field has an ethics code and how it has developed over the years. I believe that the students in my class have shown a more thorough understanding of ethical decision-making and are better equipped to respond to ethical dilemmas than I was as a graduate student.

I was eager to become involved in the EESE program because I was searching for new ways to infuse ethics in my graduate and undergraduate courses. The material provided by the EESE program was a natural fit with my course goals and enhanced my planned learning objectives. I plan to continue to use the materials and assessments in future graduate psychotherapy courses and hope to include information on both ethics and ethical decision-making in future sections of my undergraduate history of psychology course.