Some Principles for Ethics Education: Implementing ...

Training and Education in Professional Psychology 2008, Vol. 2, No. 3, 123–128

Copyright 2008 by the American Psychological Association 1931-3918/08/$12.00 DOI: 10.1037/1931-3918.2.3.123

Some Principles for Ethics Education: Implementing the Acculturation Model Michael C. Gottlieb

Mitchell M. Handelsman

Independent Practice, Dallas Texas

University of Colorado Denver

Samuel Knapp Pennsylvania Psychological Association In 2005, the authors (Handelsman, Gottlieb, & Knapp, 2005) proposed that ethics education be conducted based on a model of ethics acculturation. Here, the authors extend that work by offering some principles that support implementation of an ethics acculturation model (EAM) over the full course of professional preparation. The authors argue that ethics education should be life-long and provide students and trainees with positive, ongoing, experiential, and supportive educational environments and activities. After presenting and explaining each principle, the authors offer a detailed example showing how various exercises from the existing literature may be employed to facilitate students’ ethical development. Keywords: ethics education, ethics acculturation model, principles of ethics education, positive ethics, professional ethics education

as ethics education, ethical decision-making, and risk management, has emerged. Within this line of work, we proposed that ethics should be taught within the framework of an ethics acculturation model (EAM), based on the premise that psychology “represents a discrete culture with its own traditions, values, and methods of implementing its ethical principles” (Handelsman, Gottlieb, & Knapp, 2005, p. 59). To help educators implement the EAM, we propose that they incorporate several basic, interdependent, and synergistic principles into their courses and programs. Specifically, we contend that ethics training may be more effective if it is designed and offered from a positive perspective; process-oriented and experiential; supportive; sensitive to the backgrounds and experiences of each student; and understood as a lifelong process. In this article, we provide a brief overview of the EAM, introduce and explain these principles, and present a detailed example showing how various exercises from the existing literature may be employed to actualize these principles and facilitate students’ ethical development.

The Committee on Accreditation has required professional preparation programs in psychology to include ethics training in their curricula for some time (American Psychological Association [APA], 1979). Also, a recent survey found that 22 states now require continuing education in ethics for licensure renewal (http:// www.apa.org/ ce/mcesurvey03.html). As a result of these requirements and other social forces, ethics education has burgeoned within graduate training and continuing education programs. In response to this trend, a small body of scholarship on matters, such

MICHAEL C. GOTTLIEB, Independent Practice, Dallas, Texas; MITCHELL M. HANDELSMAN, University of Colorado, Denver; and SAMUEL KNAPP, Pennsylvania Psychological Association, Harrisburg, Pennsylvania. The authors made equal contributions to this article. The opinions expressed herein are those of the authors and do not represent those of any organizations with which they may be affiliated. This article is based on a paper presented at the 2006 Annual Meeting of the American Psychological Association, New Orleans, LA (Gottlieb, Handelsman, & Knapp, 2006). MICHAEL C. GOTTLIEB received his PhD in Counseling Psychology from Texas Tech University. He is board certified in Family Psychology (ABPP), is a Clinical Professor at the University of Texas Health Science Center, and served on APA’s Ethics Committee. His research interests include ethical decision making, multiple relations, and risk management. MITCHELL M. HANDELSMAN received his PhD in clinical psychology from the University of Kansas in 1981. He is professor of psychology and a CU President’s Teaching Scholar at the University of Colorado Denver, where he has been on the faculty since 1982. His research areas include ethics and student engagement. SAMUEL KNAPP, EdD, received a doctorate in counseling from Lehigh University. He has been the Director of Professional Affairs for the Pennsylvania Psychological Association since 1987. His research interest is in ethics. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Michael C. Gottlieb, 12810 Hillcrest Rd., Suite 224, Dallas, TX 75230. E-mail: [email protected]

The Ethics Acculturation Model Handelsman et al. (2005) adapted Berry’s model of cultural adaptation and acculturation (Berry, 1980, 2003; Berry & Sam, 1997) to ethics training and proposed that students need to integrate their own ethical and value traditions with those of professional psychology. The model employs two major variables to explain the acculturation process. The first, maintenance, refers to the degree to which people retain the ethical and value traditions of their culture of origin. Students have existing notions of right and wrong professional behavior based upon their family values, ethnicity, national origin, religious traditions, and personal role models. The second variable, contact and participation, refers to the degree to which students adopt the traditions, norms, and values of their new professional culture (Handelsman et al., 2005). Depend123

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ing on the maintenance of values and traditions from their culture of origin and their contact and participation with the new culture of psychology, students may, consciously or unconsciously, choose one of four categories or strategies of ethical acculturation. When students are relatively high on both maintenance and contact, they use an integration strategy. This is the best possible choice because it represents the highest combination of personal and professional identities. Berry and Sam (1997) stated, “Evidence strongly supports a positive correlation between the use of this strategy and good psychological adaptation during acculturation” (p. 298). When applied to professional and ethical acculturation, this means that students can adopt the ethical values of psychology while maintaining much of their own value traditions. Those who adopt the integration strategy may have “a richer, more sophisticated appreciation for the underlying principles of both cultures” (Handelsman et al., 2005, p. 60) and would be more able to use their professional role to realize their personal ideals. For example, consider the practice of informed consent. Psychologists who routinely choose integration strategies will follow the requirements of providing information and documenting consent not simply because they are required to do so by the APA Ethics Code (APA, 2002), state laws, or other sources (Handelsman, 2001). Rather, they will see these procedures as a natural extension and actualization of their personal values of advocacy for patients’ self-determination. As a consequence, they may go beyond what minimum legal and ethical standards require by collaborating with patients in a variety of clinical decisions, such as choosing treatment goals and procedures. Two other acculturation strategies represent less optimal alternatives. A strategy that is high in maintenance but low in contact is called separation (Berry & Sam, 1997). Here students make professional decisions based primarily on their personal morals and value traditions but do not identify as strongly with or inculcate the values of professional psychology. Such students may feel that their own values and ideals are sufficient to deal with the ethical choices they will face and that they do not need any additional rules to govern their professional behavior. For example, students use separation strategies when they do not provide complete information to patients, as required by law and the ethics code because they believe that their own judgment is sufficient, as it has been in their other relationships. Similarly, they may not be sufficiently familiar with how different boundaries in psychotherapy are from those of other personal relationships (Grater, 1985). When practitioners adopt separation strategies over time, they may become uninformed and/or feel disdainful of the ethical/legal constraints placed upon them and become less aware of the potential harm they can cause. The second mismatch is called assimilation (Berry & Sam, 1997), which refers to an overidentification with professional standards to the extent that students may lose too much of their own moral identity. In an effort to develop their professional identities, students may divorce themselves from their personal values in the belief that they are no longer necessary. Assimilation strategies demonstrate literal compliance while lacking moral foundations and “may lead to empty, legalistic, and overly simplistic applications of our ethical principles” (Handelsman et al., 2005, p. 61). To continue with the example of informed consent, psychologists who consistently choose assimilation strategies may follow

legal requirements most conscientiously and obtain signatures on all the required forms. However, if they lose sight of the values that underlie informed consent as a relational process, they may fail to capitalize on opportunities to provide additional clinical benefits such as encouraging the patient to ask questions and involving the patient more fully in decision making. The last acculturation strategy is marginalization. This is the most problematic alternative as it represents low identification with both personal and professional cultures and can lead to an “enduring state of alienation” (Handelsman et al., 2005, p. 61). Individuals using this strategy have neither a well-developed personal moral sense nor have they internalized professional ethics. These individuals may follow the ethics code out of “personal convenience rather than a sense of moral commitment” (Handelsman et al., 2005, p. 61); be lax about the legal requirements of informed consent; and minimize the importance of the clinical or moral implications of respecting patient decision making. Becoming ethical psychologists requires that students be professionally acculturated, and “ethics courses present an excellent opportunity for students to explore their acculturation and to begin developing an ethical identity” (Handelsman et al., 2005, p. 63). In fact, several ethics texts already refer to the acculturation model (e.g., Corey, Corey, & Callanan, 2007; Knapp & VandeCreek, 2006; Sommers-Flanagan & Sommers-Flanagan, 2007). However, a single ethics course is not sufficient to accomplish ethical acculturation. Below, we extend our previous work by offering some general principles designed to facilitate ethical development throughout the process of professional preparation.

Some Principles of Ethics Education Ethics Education Is Positive We have been concerned for some time that ethics education has become too heavily focused on rule adherence in order to help students avoid professional sanctions and civil litigation. In that sense, ethics education can inadvertently reinforce an assimilation strategy. Ethics education should include information regarding the ethics code (APA, 2002); state statutes, regulations, and court decisions; federal statutes and regulations; and risk management principles. Learning this information is essential, but it is not sufficient, in and of itself, to help students reach the goal of using the integration strategy, in which students and professional psychologists maximize their personal virtues and values within the context of what the law and professional standards allow. The advent of the positive psychology movement (e.g., Snyder & Lopez, 2002) provided an opportunity to pursue our view that ethics can and should be taught from a more positive and aspirational perspective. Based on this premise, we proposed that the profession refocus its efforts in the direction of what we termed positive ethics (Handelsman, Knapp, & Gottlieb, 2002). The goal of positive ethics is to shift the primary emphasis from avoiding professional discipline to a “more balanced and integrative approach that includes encouraging psychologists to aspire to their highest ethical potential” (p. 731). For example, psychologists may choose to conform their behavior precisely to the informed consent requirements of professional standards, state law, and federal regulations. But, they may choose to go beyond these minimum requirements to provide a more

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complete consent process because of their basic or prima facie (Ross, 1930); professional obligations to respect patient autonomy (Beauchamp & Childress, 2001); and their higher or supererogatory obligations (Knapp & VandeCreek, 2003) concerning patient welfare and respect. Psychologists who respect patient autonomy and encourage patient involvement in treatment decision making (Beauchamp & Childress, 2001) to the fullest extent possible as a matter of their personal values use the integration strategy. An explicit and comprehensive emphasis on positive ethics can contribute to effective ethics education in several ways. First, a positive emphasis might expand students’ awareness of the ways that the profession’s enforceable rules are based on its higher aspirational principles. Second, a positive emphasis may help students consider ethical issues in a broader context, for example, by more explicitly including their highest personal and professional values, virtues, and motivations into their decision making. Third, positive ethics can contribute to a greater degree of openness so that students and colleagues feel more free to explore difficult issues (e.g., Pope, Sonne, & Green, 2006) and seek the assistance of others. In an atmosphere of increasing anxiety over professional liability, this openness may help professionals avoid feeling that they cannot seek consultation from a trusted colleague precisely at a time when they most need it.

Ethics Education Is a Life-Long Process If we assume that ethics education is complete when it is taught only as a fixed body of knowledge covered in a single academic course, students may be at risk for adopting assimilation strategies. It is as if one were to say, “I had the ethics course; I know all the rules. What else do I need to worry about?” This approach is problematic for at least three reasons. First, contemporary professional practice is far too complex for such an attitude to be adequate. Contemporary risk management procedures (e.g., Bennettet al., 2007) rely on sophisticated clinical and ethical decision making skills that go well beyond simple rule adherence. Second, assimilation strategies ignore the larger context in which future psychologists will function as both professionals and individuals. Assimilation strategies cannot anticipate changes in our personal circumstances, predict social change, or take account of how we will choose to actualize our personal values in a constantly shifting professional context. Alternatively, the acquisition and enhancement of integration strategies may be accomplished more effectively when ethics education is considered a lifelong process in which psychologists continually reconsider their personal and professional values. Therefore, we contend that professional preparation should establish the basis for this lifelong process by integrating ethics education at all levels of training. Third, we hear a great deal about lifelong learning but fear the idea has become trite. Experience is a great teacher, but it is not the only one. We feel that when explicit ethics training is integrated throughout the professional development process we are more likely to model the behaviors we hope to instill in our students and trainees.

Ethics Education Is Experiential Experiential exercises may be a particularly effective way to teach ethics. The experiential principle speaks directly to the need

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to surround oneself with the new culture and its values, traditions, and language. Just as language is effectively taught by immersion, we view experiential exercises as accomplishing a similar purpose. Traditionally, basic concepts in ethical decision making have been developed as a largely intellectual and quasi-legal reasoning process. There is great value in this approach as it helps students explore all relevant sources of knowledge and entertain multiple hypotheses. We support this process and teach it ourselves, but we do not think that it is adequate per se. We disagree with others (e.g., Ford, 2006) who consider emotions to be a distraction to be ignored. Rather, we suggest that emotionally charged experiences are a crucial component of ethical deliberation (Betan & Stanton, 1999) and that students become more fully engaged and effective when they experience the choices they make both intellectually and emotionally. This approach challenges students to go beyond more legalistic reasoning and to consider ways in which they can optimize the good they can do by a reflective balancing of sometimes competing ethical concerns.

Ethics Education Is Social and Supportive Healthy competition in the marketplace of ideas contributes to learning and knowledge. Critiques of journal articles, rejoinders, and intellectual argument demonstrating superior reasoning and methodology have a time-honored place in our scholarly tradition. Although vigorous debate is vital to the scientific enterprise, we submit that ethics education should be different. Here the goal is not to win an intellectual argument by defeating someone else. Rather, it is to cooperatively shape and sharpen the deliberative skills of all involved. This is what we mean when we state that effective ethics training should be social and supportive. Sadly, an “I am right and you are wrong” attitude, combined with the apprehensions created by a litigious environment, may impede the willingness of students and professionals to talk with each other about their ethical concerns. This reluctance may be exacerbated when we teach ethical decision making based only on the reasoned, intellectual, and quasi-legal thinking noted above. Experiential and positive ethics training may help psychologists hone their integration skills by being more open about their values, motivations, conflicts, and aspirations (Pope et al., 2006), which is necessary if they are to develop an integration strategy. Furthermore, supportive environments help engender positive emotions. According to Frederickson’s “broaden and build” theory (2002), individuals who experience positive emotions are better decision makers than those who experience negative ones, and positive emotions can help build a reservoir of strength and resilience that one can draw upon in times of stress. In short, social support fosters sound ethical decision making, good risk management, and attentive self care.

Ethics Education Is Focused on Students’ Backgrounds and Needs Implementing the foregoing principles requires that instructors consider the personalities, backgrounds, and moral/ethical value traditions of the learners. If we are to do this, ethics educators, practicum supervisors, internship and post doctoral trainers have the responsibility of assessing a trainee’s values, reasoning skills, ethical sensitivity, and other relevant attributes to help them inte-

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grate these with the demands of professional practice. Such an assessment can be done quickly and informally in the context of case discussions and/or supervision; it can be the focus of an individual session; or it can include certain exercises such as the ethics autobiography that we discuss below. Progress toward integration may be difficult for some students who are asked to accept professional standards that are confusing or appear counterintuitive to them. Such obstacles may be particularly problematic for students who have worked in other fields that appear to have similar standards to those of professional psychology but upon closer examination do not. For example, a psychology trainee had worked at a shelter for abused women where counselors were encouraged to share their personal abuse history with their counselees. Another was as a nurse who had worked at a nursing home where beneficence was often given a far higher priority than respecting patient autonomy. Therefore, it is not unusual for trainers to find that some of their best students may briefly become stuck in a separation strategy. These students may need help with “culture shedding” (Berry & Sam, 1997, p. 298) or understanding why they must unlearn rules they previously considered to be virtuous. For some students, the “cultural distance” (Berry & Sam, 1997, p. 307) between their ethical culture of origin and the new culture of psychology may be too great. Some of these students will be able to adopt assimilation strategies in order to follow the rules; however, there may be other times when it would be more prudent for such students to be counseled out of the program. Getting to know students and trainees as early as possible may be a good way to determine their degree of cultural distance, their willingness to move toward integration, and their abilities and skills for doing so. Students whose moral and ethical cultures of origin are incompatible with professional psychology—and who show no awareness of it and the work required to bridge the gap—may be poor risks It may be better for the program, and the other students, if such persons were screened out during admissions or shortly thereafter; unfortunately, the data in this regard are not encouraging (Johnson & Campbell, 2004; Johnson, Porter, Campbell, & Kupko, 2005; Pipes, Holstein, & Aguirre, 2005).

Implementing the Acculturation Model: The Case of I. C. Klerely In this section, we illustrate how the principles we have listed can be put into practice. We do this by following the career of a student through various steps in her training. At each one, we provide examples of challenges students face and recommend a variety of experiential and personal exercises gleaned from the literature. Ms. Klerely1 was required by her program to take a full three credit hour course in ethics during her second year of graduate training in clinical psychology. It coincided with her first practicum experience. One goal of the course was to help students reflect on their personal values through an ethics autobiography. As described by Bashe, Anderson, Handelsman, and Kevansky (2007), students were asked to discuss the origins and development of their existing conceptions of moral professional behavior and how those views might influence the manner in which they would practice.

In her ethics autobiography, Klerely wrote, “I am the kind of person who will do whatever it takes to help my patients.” She explained that she came from a strong family and religious tradition that placed great value on social justice and helping others. Prior to enrolling in graduate school, she had worked as a paraprofessional for a publicly funded mental health program that sent workers into the homes of at risk children in underprivileged areas of a large city. Despite the laudable goals of the program, well-developed treatment plans were often lacking, and the supervision was sporadic at best. Klerely quickly decided to “do whatever it took” to win the acceptance of the families, including buying groceries with her own money, babysitting the children, and cleaning house. Once she even had her boyfriend change the oil in the truck of one family. After reading her ethics autobiography, her professor became concerned that Ms. Klerely might have extended herself beyond appropriate professional boundaries. Also, her behavior raised questions regarding the extent to which families may have been consenting to treatment based on an implicit agreement that “I will let you come into my house and do things with my children as long as you provide other nonclinical service to me.” Although in-home services involve unique boundary issues, the extent of Klerely’s behavior appeared to deviate substantially from the more porous boundaries that exist when providing such treatment (Knapp and Slattery, 2004). In psychotherapy situations, Klerely’s approach could undercut the patients’ perceived value of therapy and their investment in the process. Klerely’s description of her attitudes and behavior suggested that she was using a separation strategy. That is, she had acted upon her deeply held personal beliefs regarding the need to be of service to others and did not appreciate the value of establishing professional boundaries. Her professor saw her goal as helping Klerely move toward an integration strategy. The professor’s approach was to use lecture and class discussion in a supportive, strength-based, and experiential manner. Her goal was to create a safe environment that encouraged mutual support and self reflection. In one exercise, the students studied the General (aspirational) Principles and linked them to enforceable Standards in the APA Ethics Code (APA, 2002). Also the students were asked to keep an ethics diary in which they would address a variety of issues, such as how their class readings and clinical experiences affected their personal values. Other exercises included examining paternalistic versus facilitative ethical decisionmaking models as well as reading court cases regarding informed consent (Knapp & VandeCreek, 2004). At the end of the course Klerely expressed her appreciation to he professor for what she had learned, but it was not clear that she had integrated this new knowledge into her clinical practice. Klerely’s third-year practicum class followed a model similar to that of her ethics class the previous year, and it seemed that her attitudes had begun to change. The class was asked to do the provocative statements exercise (Plante, 1995) in which students are given the task of challenging basic professional assumptions, 1 The trainee in this example represents a composite of many students and trainees whom the authors have taught or trained over the years. It does not and is not intended to represent a specific individual.

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such as “The boundaries for professional psychologists are too rigid and are an obstacle to establishing close relationships.” Students broke into two groups to develop arguments defending or challenging the provocative statement, and a spokesperson was selected to argue the group’s position in front of the class. During the class discussion that followed, Klerely related her experiences both as a worker before entering graduate school and with patients she had treated the previous year. She acknowledged finding the work stressful and admitted feeling confused about boundary maintenance to the point that she had reconsidered her goal of becoming a psychologist. In the context of a supportive environment that emphasized positive ethics, she volunteered that some of her patients benefited, but others did not. Some even developed a sense of entitlement, and she felt exploited by them. Klerely was quite self-critical and felt that her work had fallen far short of her own expectations. Nevertheless, the group supported her self-examination, empathized with her struggles, and shared their own progress and frustrations with ethical acculturation. Klerely came away feeling that she could be more open about her struggles without being seen as unethical or intellectually inferior. In Klerely’s fourth year practicum class, the students were asked to reread the ethics autobiography they had written two years earlier, revise it as needed, and then comment on the differences and what they had learned in the interim. This time she wrote, “I am the kind of person who will do whatever it takes to help my patients, within the limits of my professional role.” Her practicum instructor had been briefed about Klerely by his colleagues and found this statement and other comments she had made in class encouraging. He believed that she was well on the way toward adopting an integration strategy and felt she was ready to leave for internship training. It was during this year that Klerely experienced another challenge to her professional acculturation. During graduate school, she had developed an interest in anxiety disorders and had become proficient with cognitive behavior therapy. Upon arrival at her internship site, she was assigned a young woman suffering from panic disorder with some avoidant and mixed personality traits and features. The patient responded well, and treatment was terminated in the fall. Several months later, the patient returned, but this time it was to seek Klerely’s opinion about whether to marry her fiance´. Part of the reason the patient returned to consult Klerely was that she interviewed him as a collateral contact during the patient’s previous treatment. At that time, Klerely felt that he was unhelpful and rather dismissive of her patient’s condition. Her view of the fiance´ was reinforced by other comments the patient had made about his selfishness. When the patient presented her dilemma, Klerely had an immediate and strong desire to tell the patient exactly what she thought about the fiance´, but she also knew that sharing her strong reactions might constitute a clinically contraindicated and perhaps unethical boundary crossing. She knew this intellectually via her readings, but she also recognized it emotionally because she had explored her feelings about boundaries in previous courses and practicum. She managed to suppress her desire to share her feelings and avoided the question by focusing on getting an update on the patient’s progress. They agreed to meet again. After the session, Klerely was troubled by her intense reaction. She immediately went to her supervisor who took a Socratic approach with her. In the course of their discussion, the supervisor

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asked questions such as, “What was it that troubled you so much? If you expressed your feelings, what impact would that have had on the patient? Do you think the patient really wants you to tell her what to do, and even if she does, should you?” Klerely and her supervisor reflected on her reactions, and Klerely quickly realized that some of her reaction was due to the fact that she recently terminated a relationship with an undesirable man herself. At the time, she wished that her friends had been more forthcoming with her regarding their concerns about him. Once this information was explored in supervision, Klerely was better able to consider how she could be of greater assistance to her patient. Klerely concluded that the issue was not so much offering the patient her opinion about marrying this man as it was helping her to clarify her goals for and values about marriage, and whether this man was an appropriate choice for her. As a result of the supervision, Klerely felt far more secure in her professional role, confident that she could set appropriate boundaries around the treatment, and able to help her patient gain insight into her situation.

Conclusions In this article, we propose a set of guiding principles that can contribute to a new and more comprehensive framework for designing and implementing ethics education throughout the course of professional training. To illustrate the principles, we brought together a number of examples from the literature that help teach one or more of these principles. In doing this, we hope to stimulate more thinking and research in order to assess the utility of the principles we proposed; determine if additional principles should be added; and develop additional teaching techniques as needed. If these efforts are fruitful, ethics educators will have more databased techniques to rely upon rather than intuitive heuristics. Some might argue that the responsibilities entailed in this approach are unrealistic given the already considerable time demands on faculty and supervisors. Is it worth it to add more tasks to the applicant selection process; increase course assignments; brief other faculty members on students’ progress; and pursue students’ moral values? Certainly, the answer depends on the motivation and commitment of individual faculty and the training philosophy of the program. For some, our recommendations will represent only small extensions. For example, training programs are already required to assess and monitor the ethical competencies of their trainees (de la Fuentes, Wilmuth, & Yarrow, 2005). In such situation, assigning an ethics autobiography or adding a specific discussion of ethical issues to supervisory session should not be onerous. Furthermore, it may streamline existing training methods and enhance the effectiveness of professional preparation. The incidence of ethical infractions among psychologists is low (Van Horne, 2004), but those data are likely underestimates of the number of patients hurt by incompetent and unethical practice. Our goal is to reduce harm further. One way to do this is to remain mindful that the professional practice of psychology is not a spectator sport. Rather, we intervene in patients’ lives, and what we do is not benign. We hope that the principles we have outlined will help ethics educators to better acculturate students so that they will become both more ethical professionals and better people.


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Received February 2, 2007 Revision received January 22, 2008 Accepted January 30, 2008 䡲