This is a presentation for social workers in Baltimore.

1. John D. Gavazzi, PsyD ABPP
Baltimore County Department of Health
June 2014
Ethics in Practice:
Mandated Reporting, Professional
Boundaries, and Ethical Decision-
making

2.  List the differences between ethical, legal,
and risk management concerns
 Outline a model for integrating professional
ethics with personal values
 Use one decision-making model to work
through an ethical vignette

3. The process is often ambiguous

4. 1. Move away from the “ethical” versus
“unethical” decision.
2. In some ethical decisions, there is not
“right” or “correct” answer for everyone.
3. Most clinicians make ethical decisions on a
daily basis

5. Having an ethics code or attending
lectures on ethics codes are among
the least effective ways to ensure
ethical behavior.

6. People should not act on principle
(standing on principle can be an unprincipled stand)

7. Rational Social Worker: Know the Code!!
Social
Worker
Patient
Learn the rules
Apply the rules
Outcomes will follow

8. PatientSocial Worker
Learn the rules
Apply the rules
Outcomes will follow
Understand patient
dynamics
Understand the
relationship
Know the Code + Know your patient

9.  Clinical Decision-making
 Risk management
 Legal Decision-making
 Ethical Decision-making
◦ Professional Ethics
◦ Personal Ethics, Values, or Morality

11.  What is the best clinical intervention for this
patient in this situation?
 Am I conceptualizing this patient correctly?
 My patient continues to struggle after eight
sessions. What should I do?

12.  How do I work with a patient to minimize risk
or liability?
 Avoid types of work that have high liability
risks, such as custody evaluations or clinical
complex patients.
 Do I have essential paperwork signed?
Informed Consent or practice policies current

13.  Always have a suicidal patient sign a “no
suicide” contract
 Never touch a patient
 Always remain at a professional distance
emotionally and socially
 Boundary crossings vs. boundary violations

14.  Am I compliant with state laws and
regulations?
 Is my practice HIPAA compliant?
 Am I aware of relevant case law in my state?
 Questions are usually asked of an attorney

15. Professional Ethics
 Do I follow the NASW’s Code of Conduct?
 Am I performing at the minimum or reaching
for the aspirational ceiling?
 Is my behavior linked to a foundational
principle?

16. Personal values, ethics, and morality
 Is what I am doing consistent with my values?
 What is my emotional response to the patient,
lifestyle, or behavioral issue?

17. 1. Religion/Family of Origin
2. Education: College and CE
3. Personal Education: Reading and Experience
4. Honest self-reflection

18.  How did it develop?
 How often do you use it to reflect on
professional life?
 How often do you use it to reflect on personal
life?
 How do you integrate morals into ethics?

19.  Do you use it “before the fact”?
 Is it intuitive and unconscious?
 Is it more cognitive?
 Is it written down?

20.  Is it acceptance of another person’s code in
full?
 If yes, why?
 If not, why?

21.  Do you use it “after the fact”?
 Fundamental Attribution Error
 Actor-Observer Bias
 Motivated Moral Reasoning

22.  Looking at how well a social worker
integrates his/her values and behaviors into
the ethical culture of social workers
 Social Work has a set of normative principles
and behaviors related to ethical behavior and
appropriate conduct

23.  One way of remaining a life-long
learner
 Provides another way to discuss
ethical behaviors and decisions

24. A process to change the cultural behavior of an
individual through contact with another
culture.
The process of acculturation occurs when there
is an adaptation into an organization or
society.

25.  An outgrowth of positive ethics that
integrates personal ethics and professional
obligations.
 Social Work has a system of shared and
distinctive norms, beliefs, and traditions.
 This set of beliefs is reflected in the ethics
code.

26.  Can be a complex process
 Some parts of a social worker’s practice
and lifestyle may be easily acculturated
while others not
 Process that will likely continue throughout
the education or career as a social worker

27. Identification with personal value system
(higher vs. lower)
Identification with value system of psychology
(higher vs. lower)

28. Acculturation Model of ethical
development
Integration Separation
Assimilation Marginalization
Higher on
Professional Ethics
Higher on Personal
Ethics
Lower on Personal
Ethics
Lower on
Professional Ethics

29. Matrix: Lower on professional ethics
Lower on personal ethics
Risks: *Greatest risk of harm
*Lack appreciation for ethics
*Motivated by self-interest
*Less concern for patients

30. Matrix: Higher on professional ethics
Lower on personal ethics
Risks: Developing an overly legalistic
stance
Rigidly conforming to certain rules
while missing broader issues

31. Matrix: Lower on professional ethics
Higher on personal ethics
Risks: Compassion overrides good
professional judgment
Fail to recognize the unique
role of social workers

32. Matrix: Higher on professional ethics
Higher on personal ethics
Reward: Implement values in context
of professional roles
Reaching for the ethical ceiling
Aspirational ethics

33. Autonomy
Beneficence
Nonmaleficence
Fidelity
Justice

34. Ethical Culture of Social Workers
 Service
 Social Justice
 Dignity and worth
of the person
 Importance of
Human
Relationships
 Integrity
 Competence

35.  Social workers elevate service to others above self
interest.
 Social workers draw on their knowledge, values,
and skills to help people in need and to address
social problems.
 Social workers are encouraged to volunteer some
portion of their professional skills with no
expectation of significant financial return (pro bono
service).

36.  Social workers pursue social change,
particularly with and on behalf of vulnerable
and oppressed individuals and groups of
people.
 Social workers’ social change efforts are
focused primarily on issues of poverty,
unemployment, discrimination, and other
forms of social injustice.

37.  These activities seek to promote sensitivity to
and knowledge about oppression and cultural
and ethnic diversity.
 Social workers strive to ensure access to
needed information, services, and resources;
equality of opportunity; and meaningful
participation in decision making for all
people.

38.  Social workers treat each person in a caring
and respectful fashion, mindful of individual
differences and cultural and ethnic diversity.
Social workers promote clients’ socially
responsible self determination.
 Social workers seek to enhance clients’
capacity and opportunity to change and to
address their own needs.

39.  Social workers are cognizant of their dual
responsibility to clients and to the broader
society.
 They seek to resolve conflicts between
clients’ interests and the broader society’s
interests in a socially responsible manner
consistent with the values, ethical principles,
and ethical standards of the profession.

40.  Social workers understand that relationships between
and among people are an important vehicle for
change.
 Social workers engage people as partners in the
helping process.
 Social workers seek to strengthen relationships
among people in a purposeful effort to promote,
restore, maintain, and enhance the wellbeing of
individuals, families, social groups, organizations,
and communities.

41.  Social workers are continually aware of the
profession’s mission, values, ethical
principles, and ethical standards and practice
in a manner consistent with them.
 Social workers act honestly and responsibly
and promote ethical practices on the part of
the organizations with which they are
affiliated.

42.  Social workers continually strive to increase their
professional knowledge and skills and to apply
them in practice.
 Social workers should aspire to contribute to the
knowledge base of the profession.

43.  The means to comply with a standard may
not always be readily apparent
 Two seemingly competing standards may
appear equally appropriate
 Application with of a single standard or set of
standards appear consistent with one or more
aspirational principle, but not another

44.  The social worker is the expert and has
greater power in the relationship
 Patient is vulnerable
 The social worker is ultimately responsible for
what happens in treatment

45.  Identify the competing ethical principles
 Help to determine which principle has
precedence and why
 The importance of emotion in ethical
decision-making and moral judgments
 Cognitive biases are also important to
consider

47. The NASW Code of Ethics does not include a
model of
ethical decision-making
Other resources may aid with decision-
making, but do not highlight how to work
through dilemmas

48. S Scrutinize
H Hypothesize
A Analyze
P Perform
E Evaluate

49. 1. Goal is to define the problem by identifying
the conflicting ethical principles
2. Generate a wide range of possible solutions
and identify pros and cons
3. Merge or knit the possible solutions
together in a way that maximizes the
benefits and limits the disadvantages
4. Implement
5. Look back or evaluate

50. “integrative framework”
steps two and three generate solutions that
maximize your personal values within the
context of your professional role

51. Avoid dichotomous thinking– either I have to
do x or y.
Duty to Warn example: either I have to warn
the potential victim of a threat or I have to
protect confidentiality.

52. 1. We have to train ourselves to think about
larger ethical principles first
2. We need to have the ability to slow
ourselves down prior to making good,
ethical decisions
Why?

53.  Malcolm Gladwell’s book “Blink”
 Jonathan Haidt’s book on Moral Intuition
 David Pizarro’s work on motivated moral
reasoning

54.  Top down approach
 Start with ethical principles
 Work from those principles to make good
decisions about our work

55.  Intuitive
 Automatic
 Emotional
 Rapid

56. Why do psychologists (still and continue to) have
sex with their patients?

57. Negative emotions related to
ethical and moral decision-making
Positive emotions related to our
good decision-making skills and
ethical knowledge
 Fear
 Anxiety
 Disgust
 Disrespect
 Passion
 Calmness/Centered
 Empathy
 Respect/Sympathy
 Elevation

58.  The Fundamental Attribution Error
 Actor Observer Bias
 Availability Heuristic
 Trait Negativity Bias
 Confirmation Bias
 Competence Bias

59.  This cognitive style places an undue
emphasis on the patient’s behavior in the
therapeutic relationship
 Overemphasis on the patient
 Psychologist may lack insight into what s/he
is doing to promote those responses

60.  This cognitive style places an undue
emphasis on external factors for the
psychologist’s behavior
 In an attempt to avoid responsibility, the
psychologist can overemphasize the patient’s
role in the ethical dilemma.

61.  This cognitive error leads one to use
information that readily comes to mind or
easiest to access
 Easiest to go with that which is most
representative of the patient or scenario

62.  When the psychologist more readily recalls
unpleasant characteristics of the patient as
compared with positive characteristics of the
patient
 It is common for psychologists to work with
individuals they do not like or enjoy

63.  The cognitive style in which psychologists
look for evidence to confirm their beliefs
about the patient or the situation.
 Motivated moral reasoning

64.  Dunning-Kruger Effect: a cognitive bias in
which unskilled individuals suffer from
illusory superiority, mistakenly rating their
ability as much higher than average.
 Poor performers fail to learn from their
mistakes.
 And, they fail to internalize direct feedback
from others.

65.  Length of time in treatment
 Patient complexity
 Emotional intensity/therapeutic relationship
 Current focus (or lack thereof) in treatment

66. A Brief Review

67.  Knowledge base: NASW code, foundational
principles, state law, regulation, case law
 Become aware of emotional factors
 Remain aware of cognitive biases/situational
factors
 Patient/relationship factors
 Outcomes are uncertain – Ambiguity remains

68. Emotions
Decision-
making
Skills
Cognitive
Biases
External
Rules
Personal
Ethics
Psychologist
Complexity
Length of
time in
treatment
Current
focus in
treatment
Boundaries
Patient
Variables
Therapeutic Alliance

69. Why study ethics and ethical decision-making
as a part of clinical practice?

70.  Fiduciary Responsibility
 Providing the highest quality of care possible
 Reinforcing doing the best possible for your
patient
 Better treatment outcomes

71. Independent Actions Help from others
 Self Reflection
 Documentation
 Transparency
 Continuing Education
 Self-care
 Consultation
 Supervision
 Psychotherapy
 Continuing Education

72.  Good general basis to contemplate and
discuss ethical issues in psychological
practice
 Look at vignettes as training tools
 Remain aware of ethical issues in your
practice and work on skill building

73. The need for informed consent
Not just for the beginning of psychotherapy

74.  What does the law say?
 What do the ethical principles suggest?
 Usually a conflict between confidentiality and
(community) beneficence
 Child abuse reporting guidelines

75. What is the difference between a boundary
crossing and a boundary violation?

76.  Sexual prohibitions
 Physical prohibitions
 Self-disclosure
 The treatment frame

77.  Between session contacts
 Digital boundaries and virtual ethics
 Multiple roles (therapist, customer, etc.)

78. Ethics and Psychology
www.papsyblog.org