Sometimes, psychologist feel like they are in Ethics Hell. In this presentation, we focus on ethical decision-making, clinical skills, and emotional reactions to patients. The idea is to see how we create our own hell, and some suggestions to avoid it, or how to ascend from it.

1. The road to hell is paved with good intentions - Virgil
In Hell there will be nothing but law and due process will
be meticulously observed. ~ Grant Gilmore
Hell
Samuel K. Knapp, Ed.D., ABPP Psychologist
John D. Gavazzi, PsyD,ABPP Psychologist
Annual Convention of the Pennsylvania PsychologicalAssociation
June, 2015

2. Ethics education in general
Dual Systems/Ethics Code
Foundational Principles & Acculturation
Model
Rings of Hell
Experiential Exercises
Overview

3. 1. Describe fear or avoidance based
theories of ethics
2. Identify ways to incorporate overarching
ethical values in to their practices; and,
3. Apply positive approaches to real life
clinical situations.
Learning Objectives

4. Negative Expectations
Moral emotions like guilt, fear, & shame
Can ethics education pave the way
to ethics hell?

5. Midway in our life’s journey, I went astray
From the straight road and woke to find myself
Alone in a dark wood. How shall I say
What wood that was! I never saw so drear
So rank, so arduous a wilderness!
Its very memory gives shape to fear.
Death could scarce be more bitter than that place!
Canto 1: lines 1-7
Inscription at the entrance to Hell
“Abandon all hope ye who enter here.”
Dante’s Divine Comedy

6. Proscriptive:Those beliefs, behaviors, or
actions that avoid harm
Prescriptive:Those beliefs, behaviors, or
actions that seek beneficial outcomes
Dual Systems & Ethics

7. Aspirational Ethics: Reaching for the ethical
ceiling by promoting patient well-being
Enforcement Ethics: Standing on the
ethical floor as to avoid doing harm
Dual Systems & Ethics Code

8. Research shows that bad has a much
stronger punch than good
Loss aversion
Defensive practice
Bad is stronger than good

9. Respect for Patient Autonomy
Beneficence
Nonmaleficence
Fidelity
Justice
Principle-Based Ethics

10. Autonomy
It encompasses freedom of thought and action.
Individuals are at liberty to behave as they chose.
- Determining goals in therapy
- Making life decisions (e.g., marriage, divorce)
- Scheduling appointments and terminating treatment

11. Beneficence
The principle of benefiting others and
accepting the responsibility to do good
underlies the profession.
- Providing the best treatment possible
- Competency
- Referring when needed

12. Nonmaleficence
The principle is doing no harm.
- Demonstrating competence
- Maintaining appropriate boundaries
- Not using an experimental technique as
the first line of treatment
- Providing benefits, risks, and costs

13. Fidelity
This principle refers to being faithful to
commitments. Fidelity includes promise
keeping, trustworthiness, and loyalty.
- Avoiding conflicts of interests that could
compromise therapy
- Keeping information confidential
- Adhering to therapeutic contract (e.g.,
session length, time, phone contacts, etc.)

14. Justice
Justice primarily refers to treating people fairly
and equally.
-Treating patients equally regardless of
insurance
-Providing high quality of service regardless of
gender, ethnicity, orientation, etc.

15. Setting the Stage for our
Descent into Hell

16. Looking at how well a psychologist integrates
his/her values and behaviors into the ethical
culture of psychology
Psychology has a set of normative principles
and behaviors related to ethical behavior and
appropriate conduct
The Acculturation Model

17. Acculturation
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.

18. Acculturation Model
Provides a model to track our descent
into hell
A different vantage point to address
ethical behaviors and decisions

19. Acculturation as a Process
Can be a complex process
Some parts of a psychologist’s practice and
lifestyle may be easily acculturated while
others not

20. Ethics Acculturation Model
Psychology has a system of shared and
distinctive norms, beliefs, and traditions.
This set of beliefs is reflected in our ethics
code.

21. Ethical Acculturation
Identification with personal value system
(higher vs. lower)
Identification with value system of psychology
(higher vs. lower)

22. 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

23. Rings of hell

24. Assimilation – First Ring of Hell
Matrix: Higher on professional ethics
Lower on personal ethics
Risks: Developing an overly legalistic
stance
Rigidly conforming to certain
rules while missing broader
issues

25. Assimilated Strategies
Assimilated strategies are often “fear based” –
where motive to avoid harming another or incurring
punishment for oneself, causes the psychologist to
adopt legalistic stances.
Assimilated strategy attempts to be prevention
focused
Fail to give adequate attention or weight to the
overarching ethical principles that guide or should
guide professional behavior

26. A psychologist receives a phone message from a former patient. The former
patient is asking for the psychologist to be a “character witness” as he has an
upcoming hearing for a minor criminal offense. His attorney believes that
some good, written character references will really help out with the case.
The psychologist pulls the former patient’s chart. The psychologist has not
worked with the patient for about two years. Additionally, none of the
treatment issues had to do with impulse control or antisocial tendencies.
Therapy lasted about a year and focused on depression and relationship
issues.The psychologist recalls that the patient had always been good-
natured, attended appointments regularly, and worked well in therapy. The
psychologist remembers the former patient as a likeable person.
Vignette 9:
Psychologist as CharacterWitness

27. Second Ring of Hell - Separation
Matrix: Lower on professional ethics
Higher on personal ethics
Risks: Compassion overrides good
professional judgment
Fails to recognize the unique
role of psychologists

28. Separated strategies are often “benefits-based” –
where the motive for promoting the well-being of
the patient causes the psychologist to be blind to
ways that well-meaning people can cause harm
Separated strategy attempts to be promotion
focused
Fails to give adequate attention or weight to the
overarching ethical principles that guide or should
guide professional behavior
Separation

29. A psychologist receives a phone message from a former patient. The former
patient is asking for the psychologist to be a “character witness” as he has an
upcoming hearing for a minor criminal offense. His attorney believes that
some good, written character references will really help out with the case.
The psychologist pulls the former patient’s chart. The psychologist has not
worked with the patient for about two years. Additionally, none of the
treatment issues had to do with impulse control or antisocial tendencies.
Therapy lasted about a year and focused on depression and relationship
issues.The psychologist recalls that the patient had always been good-
natured, attended appointments regularly, and worked well in therapy. The
psychologist remembers the former patient as a likeable person.
Vignette 9:
Psychologist as CharacterWitness

30. Type I Reasoning Type 2 Reasoning
Rule-based
Deliberate
Analytic
Slower
Intuitive
Automatic
Emotional
Rapid
Third Ring: Emotional Reasoning

31. Cognitive Biases Unhealthy Emotional Responses
Fear or Anxiety
Sexual Attraction
Guilt
Disgust
Anger
Availability Heuristic
Confirmatory
Hypothesis Testing
Fundamental
Attribution Error
Actor Observer Bias
Type 1 Reasoning can lead to errors

32. Professional isolation is correlated with:
• Lower quality work
• Job dissatisfaction
• Burnout
• Interpersonal defensiveness
Professional isolation can happen in group
practices.
Fourth Ring: Isolation

33. Denial of Emotions
Lack of self-compassion or adequate self-care
Failure to achieve work-life balance
Working harder than your patients are
Fifth Ring: Emotional Pain/Burnout

34. Sixth Ring: Marginalization
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

35. Upon seeing Satan:
“[Virgil] made me stop, and stepping aside he said
. . .This is the place
Where you must arm your soul against all dread!”
“Do not ask, Reader, how my blood ran cold
And my voice choked up with fear. I cannot write it.
This is the terror that cannot be told.
I did not die, and yet I lost life’s breath,
Imagine for yourself what I became,
Deprived at once of both my life and death.
Canto XXXIV, lines 19-27.

36. Sinners are ironically positioned to demonstrate
their sin
Satan is frozen in waist-deep ice, trying to fly
away from God. The beating of the wings keeps
the water frozen, preventing his escape.
Marginalization is the antithesis of the
psychology’s values and ethics – a professional
who is upside down
In Dante’s Hell

37. Feeling Sufficiently
Uncomfortable?

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

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

40.  Overemphasis on rules or The Code
 Interpreting rules without understanding
overarching ethical principles
 Setting a low bar for professional behavior

41.  Intrusive advocacy
 Lack of understanding boundaries and the
“therapeutic frame”
 Allowing personal values to trump
professional boundaries (without self-
reflection and/or consultation)

42.  In the study of religious persons, a body of research has
identified positive and negative religious coping.
 Positive religious coping could include relying interpreting the
events as a way to improve oneself (or one’s understanding of
the world), seeking out support from the religious
community, viewing relationship with God as a source of
strength, and a willingness to show compassion and
forgiveness towards oneself.
 Negative religious coping would include interpreting the
events as punishment from God, being isolated from the
religious community, feeling shame to the point that it is
paralyzing, or not forgiving oneself.

43.  We can see a parallel process in coping with
stressful professional events. Do we use positive
coping strategies— seeking assistance from others,
being self-reflective (yet forgiving of ourselves if
we made mistakes) or negative (self-condemning,
paralyzed with fear, preoccupied with guilt,
catastrophizing the consequences of our mistakes).
 The Ethics Acculturation model can be used as a
positive coping device if we use it to understand
how we did (or might have) responded to specific
situations.

44.  You can sign up for a one-credit take home
CE credit.
 It consists of a short article about ethics
acculturation, a short quiz, and a diary for
self-reflection
 Flipped classroom concept

45. www.ethicalpsychology.com