Ethical Dilemmas of South African Clinical Psychologists ...

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Ethical Dilemmas of South AfricanClinical Psychologists: InternationalComparisonsCatherine M. Slack and Douglas R. WassenaarSchool of Psychology, University of Natal, Scottsville, South Africa

This study asked a sample of 487 South African clinical psychologists todescribe situations that they identified as ethically troubling. Forty-ninepsychologists described 51 incidents that were categorized according toPope and Vetter's (1992) system. Psychologists most often described di-lemmas involving confidentiality, followed by dual relationship dilem-mas. These ethical concerns are presented and discussed in the light ofcurrent South African ethical codes and relevant professional literature.

Keywords: Ethics, ethical dilemmas, ethical decision making.

The results are compared with six similar international studies. Resultssuggest that the concerns voiced by South African psychologists resemblethose raised by their international colleagues. Similarities with findingsfrom the United States and Finland may be the most marked. These re-sults are discussed in the light of current professional trends. Implica-tions for the development of specific ethical guidelines and professionaleducation are also discussed.

Recent years have been marked by a rise in the aware-ness of the complex ethical responsibilities of psycholo-gists (Lunt, 1998). Ongoing research in this area willsurely help to sensitize psychologists to the inherentcomplexity of professional practice. Accordingly, surveyresearch has consistently shown that psychologists gen-erally disagree on the most appropriate action in the faceof hypothetical ethical vignettes (Chevalier & Lyon,1993; Haas, Malouf, & Mayerson, 1986; Slack, 1997; Tym-chuk, Drapkin, Major-Kingsley, Ackerman, Coffman, &Baum, 1982). Such diversity in decision making helps inidentifying those professional situations that psycholo-gists are facing without the benefit of clear ethical guide-lines (Chevalier & Lyon, 1993). Yet, because these resultsare based on preselected hypothetical scenarios, theymay fail to capture the complexity of actual situationspsychologists face in their daily practice (Nicolai &Scott, 1994).

Subsequent research has thus focused on the directsolicitation of situations that psychologists and psycho-therapists identify as being personally problematic (An-tikainen, 1997; Colnerud, 1997; Lindsay & Clarkson,1999; Lindsay & Colley, 1995; Odland & Dalen, 1997;

European Psychologist, Vol. 4, No. 3, September 1999, pp. 179-186© 1999 Hogrefe & Huber Publishers

Pope & Vetter, 1992; Sinclair, 1997). Such information cansupport efforts to refine generic professional regulationsso that they are more congruent with the realities ofpractice—and are better able to help psychologists withethical decision making (Lindsay & Colley, 1995; Was-senaar, 1998a). Such data may further guide the devel-opment of specific ethical guidelines to ease decisionmaking in specific ethical areas and guide educative ef-forts at preprofessional and continuing education levels.

South African psychologists have generally failedto subject ethical issues to empirical scrutiny. Certain re-cent studies have, however, investigated psychologists'

Catherine Slack is a clinical psychologist and lecturer in psychologyat the School of Psychology, University of Natal, Pietermaritzburg,South Africa. She is a member of the Ethics Committee of the Psy-chological Society of South Africa. Her interests include ethical issuesin psychological practice, ethical issues in HIV/AIDS, and ethical issuesin recovered memory.

Correspondence concerning this article should be addressed to Cath-erine M. Slack, Department of Psychology, University of Natal, PrivateBag X01, Scottsville 3209, Pietermaritzburg, South Africa (Tel. +27331 260-5373, Fax+27 331 260-5809, E-mail [email protected]).

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Catherine M. Slack and Douglas R. Wassenaar

attitudes toward and practices regarding erotic and non-erotic physical contact with clients (Trent & Collings,1997) and issues associated with client confidentiality(Peel, 1998; Voigt, 1995). Psychologists' preferred resolu-tions to hypothetical ethical vignettes and their primaryreasons for these choices have been documented (Slack,1997), as have complaints and inquiries received bySouth African psychological bodies (Louw, 1997a,b).The present study of situations reported by South Afri-can clinical psychologists comprises a partial replicationof Pope and Vetter's (1992) study and aims to contributeto the international data on dilemmas experienced bypsychological practitioners. International efforts to com-pare data have been coordinated by Sinclair (1997) andto date reflect data from Canada, Colombia, Finland,Great Britain, Norway, Sweden, and the United States.Such international comparisons reflect the growingglobalization of professional issues in psychology, as ex-pressed, for example, in the European Union's work toestablish a Meta-code (EFPPA, 1996).

Method

A survey form and cover letters were posted to a randomselection of clinical psychologists registered with theProfessional Board for Psychology of the Interim SouthAfrican Medical and Dental Council. Of the 487 (32% ofregistered clinicians) clinical psychologists chosen byrandom computer selection, 125 respondents completedand returned their surveys. This amounted to a 25.6%response rate. The invitation to describe an ethical di-lemma formed part of a larger study investigating thechoices psychologists make in the face of ethical dilem-mas (Slack, 1997). Psychologists were asked to respondto the following statement in an "optional" category:

It would be helpful if you could describe an importantethical problem you have encountered. Please includea description of the events, your analysis of the diffi-culty (e. g., which principles it involved), your at-tempts to resolve matters, your reasons for doing so,and the outcome or after-effects of your actions.

Respondents were asked to describe their primary worksetting and the kind of work they conducted in psychol-ogy. Of the 125 respondents who returned their ques-tionnaires, 76 did not volunteer ethical dilemmas. Theremaining 49 respondents described 51 ethical dilem-mas. This response represents about 3% of South Africanclinical psychologists.

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Results

Characteristics of Respondents

55% of respondents who provided ethical dilemmaswere female and 45% were male. Most respondents(84%) identified private practice as their primary worksetting while academic settings comprised the secondlargest milieu (16%). The former group (84%) identifiedindividual psychotherapy as the work they were mostinvolved in, followed by assessment (37%), mari-tal/couple therapy (20%), and academic work (14%).Those who did not respond with an ethical dilemmacomprised the same percentage of males and females(45% and 55% respectively) and were similar to respon-dents in that their primary work settings were identifiedas private practice (78%) and academic settings (21%).Also, the type of work they conducted was similar inthat the majority (84%) were involved with individualpsychotherapy and assessment (39%), followed by mar-ital (24%), and academic work (21%). It would appearthat clinical psychologists who chose to report ethicaldilemmas cannot be differentiated from those who didnot choose to report dilemmas by work setting and thetype of work conducted. As mentioned by Lindsay andClarkson (1999), it is difficult to interpret the nonreport-ing of ethical dilemmas by respondents; it is unclearwhether these respondents did not identify ethical di-lemmas in practice, whether they in fact did identifythem and resolved them with ease, or whether they sim-ply chose not to contribute them to the study.

The 51 ethical dilemmas supplied by respondentswere analyzed and allocated to one of 23 categories usedin a previous study by Pope and Vetter (1992). This cat-egorization system allows dilemmas to be sorted intocategories according to the ethical issue raised by thedilemma or the professional context in which the dilem-ma occurred. These categories are as follows: confiden-tiality; blurred, dual, or conflictual relationships; pay-ment sources, plans, settings, and methods; collegialconduct; sexual issues; questionable or harmful inter-ventions; research, academic/training, competence;medical issues, assessment, ethics and codes/commit-tees; publishing; supervision; advertising and represen-tation; termination; ethnicity; treatment records; helpingthe financially stricken; industrial-organizational psy-chology; forensic psychology; school psychology; andmiscellaneous (Pope & Vetter, 1992).

This system was adopted to allow comparisonsacross international studies. Table 1 presents the per-centages of ethical dilemmas reported in each category

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Ethical Dilemmas of South African Clinical Psychologists

Table 1Categories of most frequently reported ethically troubling incidents: An international comparison.

RANK

1

2

3

4

5

N =

NPA

Confidentiality(26%)

Collegia) Con-duct (10%)

Dual Reins.(8%)

Sexual Issues(7%)

Quest.lntvn.(6%)

131

SPA


Dual Reins.(18%)

Payment (8%)

Collegial Con-duct (8%)

Medical Issues(5%)

161

FPA


Dual Reins.(13%)

Miscellaneous(9%)

Quest. Intvn.(8%)

Assessment(5%)

106

CPA


Dual Reins.(12%)

Payment (8%)

Quest. Intvn.(6%)

Academ-ic/Training (5%)

217

APA


Dual Reins.(17%)


Research (6%)

Forensic Psy-chology (5%)

703

SA


Dual Reins.(14%)

Payment (14%)

Academ-ic/Training (8%)

Sexual Issues(8%)

51

BPS


Research (10%)

Payment (12%)



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Key: NPA = Norway; SPA = Sweden; FPA = Finland; CPA = Canada; APA = America; SA = South Africa; BPS = Britain; N = number ofdilemmas elicited; Dual Reins. = nonsexual dual relationships; Quest. Intvn. = questionable intervention

(in rank order) for South African psychologists with cor-responding data for Norwegian (Odland & Dalen, 1997);Swedish (Colnerud, 1997), Finnish (Antikainen, 1997),Canadian (Sinclair, 1997); US (Pope & Vetter, 1992) andBritish (Lindsay & Colley, 1995) psychologists. Resultssuggest that confidentiality, dual relationships, and pay-ment issues present as the most pressing for SouthAfrican clinical psychologists.

Discussion

This section presents the content of the ethical dilemmasreported within each category. These are discussed in thecontext of South African ethics codes (Steere & Was-senaar, 1985; Wassenaar, 1998a) and relevant theoreticalliterature, in addition, the four largest categories of eth-ical conflict identified by South African psychologistsare compared with international results.

The reliability of all the international comparisonsis limited by the low rate of return for all studies: 51%(Pope & Vetter, 1992); 28% (Lindsay & Colley, 1995);19.2% (Sinclair, 1997); 33% (Antikainen, 1997); 61% (Col-nerud, 1997); 37% (Odland & Dalen, 1997). Also, directcomparison of the South African data with the interna-tional studies is limited by the relatively small size of theSouth African sample. Results must, therefore, be con-


sidered as tentative and any implications of the data assuggestive. Furthermore, the fact that the South Africansample consisted exclusively of clinicians and excludedresearch, educational, and counseling psychologistscompromises comparison with the international sam-ples.

It is, furthermore, possible that researchers have notcoded dilemmas in the same way. As dilemmas oftenpresent at the interface of multiple ethical issues (e. g.,confidentiality concerns within a dual relationship) andmay arise in many contexts (e. g., academic, school),they lend themselves to multiple categories. Althoughmost researchers acknowledge that the coding system isimperfect, this system has been adopted in all previousstudies (Antikainen, 1997; Colnerud, 1997; Lindsay &Clarkson, 1999; Lindsay & Colley, 1995; Odland & Dalen,1997; Pope & Vetter, 1992; Sinclair, 1997) to facilitateinternational comparison.

In most previous studies, no interrater reliability in-formation was presented (Antikainen, 1997; Colnerud,1997; Odlund & Dalen, 1997; Pope & Vetter, 1992; Sin-clair, 1997). The present authors adopted the same ap-proach as Lindsay and Colley (1995) and Lindsay andClarkson (1999) in that dilemmas were analyzed by thetwo authors independently, and the few resulting dis-crepancies were resolved by discussion. It is clear thatmethodological issues need to be addressed more direct-ly in the interests of reliability and validity of data.

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Confidentiality

Dilemmas concerning confidentiality comprised 29% ofthose volunteered by South African survey respondents,making this the largest category of situations perceivedas serious by these respondents.

South African clinical psychologists reported diffi-culties with legal obligations to release client recordsthrough a subpoena or court order. Psychologists wereaware of procedural guidelines regulating the manner inwhich such information should be released (Allan, 1997;Steere & Wassenaar, 1985). They were concerned, howev-er, about the challenge this represented to ethical obliga-tions to maintain client confidentiality and appeared un-aware of available strategies for responding to requeststo release information in the legal context (APA, 1996).

Respondents also described difficulties with at-tempts to establish the parameters of confidentialitywith minor clients. They described attempts to use thechild's "best interests" (Steere & Wassenaar, 1985, p. 35)to determine the degree of parental (or other) involve-ment in treatment. They were, however, attempting tobalance many considerations (such as the child's cogni-tive capacity, the presenting problem, etc.) to decide theappropriate degree of confidentiality with minor clients(Gustafson & McNamara, 1987; Jensen, McNamara, &Gustafson, 1991) in the absence of generic or specialtyguidelines (cf. Koocher & Keith-Spiegel, 1998).

Psychologists also described difficulties establishingthe exact limits of confidentiality in multiperson (maritaland family) therapy. They acknowledged the need toclarify confidentiality limits early in therapy (Steere &Wassenaar, 1985), yet appeared aware that the exact lim-its were at their discretion. Respondents also describedconcerns with legal obligations to report child abuse (cf.Brosig & Kalichman, 1992; Child Care Act 74, 1983, inAllan, 1997; Goldberg, 1997) and obligations to protectthird parties from threatened harm (Steere & Wassenaar,1985). These respondents acknowledged a general obli-gation to break confidentiality in the event of harm toothers, yet described difficulty in recognizing specificallywhen these obligations apply and how to fulfill these ob-ligations in a manner that reduces harm to their clients.

In this category of dilemmas, psychologists ap-peared aware of their general obligations to tailor confi-dentiality to the service recipient(s), or to breach it incertain instances. Respondents were sensitized to theseobligations by current guidelines, yet appeared to findthese regulations unhelpful in determining the exact pa-rameters of these instances or guiding their actions so asto least compromise their responsibilities to clients.

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Confidentiality dilemmas were consistently domi-nant for APA (Pope & Vetter, 1992) and BPS members(Lindsay & Colley, 1995), British psychotherapists (Lind-say & Clarkson, 1999) as well as for members of the SPA(Colnerud, 1997), NPA (Odland & Dalen, 1997), CPA(Sinclair, 1997), and FPA (Antikainen, 1997). These data,therefore, suggest close similarities between the ethicalconcerns presenting in the practice of South African clin-ical psychologists and their international colleagues.

Nonsexual Dual Relationships

Dilemmas surrounding (nonsexual) dual relationshipscomprised 14% of incidents reported by South Africanclinical psychologists.

Psychologists reported conflicting obligations in-herent in dual professional roles, for example, concernthat the confidentiality of service recipients may be com-promised by their role as organizational employees inlaw enforcement/military institutions (Johnson, 1995).They appeared aware of ethical obligations to clarifytheir role (Steere & Wassenaar, 1985), but experienced alack of guidance in how exactly to resolve these dilem-mas. They also described concerns with dual profession-al and nonprofessional roles, for example, concern thatsocial contact with current clients may be harmful tothem. They appeared aware that such situations are eth-ically dubious, but were unclear how to evaluate andmanage them.

Dilemmas concerning the maintenance of clear pro-fessional boundaries formed the second largest categoryfor APA members (Pope & Vetter, 1992), and for mem-bers of the Canadian (Sinclair, 1997), Finnish (Anti-kainen, 1997), and Swedish (Colnerud, 1997) psycholog-ical associations, as well as for psychotherapists in Brit-ain (Lindsay & Clarkson, 1999). While BPS membersindicated that this issue comprised only 3% of dilemmas(Lindsay & Colley, 1995), most of the dual-relationshipdilemmas described by these respondents (concernsabout the legitimacy of their interventions largely due torestrictions placed upon them by the role of an organi-zational employee) appear to have been included in thecategory of "Questionable Intervention." These data,therefore, suggest similarities between South Africanclinical psychologists' ethical concerns and concerns ofthe broader psychological community.

Payment Issues

12% of the dilemmas reported by South African clinicalpsychologists involved payment issues. These dilem-

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mas included concern over requests from clients thatamounted to an abuse of medical aid schemes, and theeffects of nonpayment on the therapeutic relationship.

For American (Pope & Vetter, 1992), Finnish (Anti-kainen, 1997), and Norwegian (Odland & Dalen, 1997)respondents, such concerns comprised the third highestranking. The similarity of these concerns may point tothe long history of prof essionalization in these countries.While tentative, the data from the South African samplemay reflect a similar professional trend. In comparison,the low rate of payment issues reported by BPS mem-bers and Swedish psychologists probably reflects the rel-atively small (but growing) number of privately practic-ing psychologists in those countries (Lindsay & Colley,1995; Persson, 1995).

South African respondents may consider these concernsas troubling as their international counterparts.

The remaining categories contained such a smallnumber of dilemmas that conclusions cannot be drawnfrom them. These were concerns about sexual issues;concerns about the safety and legitimacy of treatmentapproaches used by colleagues and referring psycholo-gists (questionable intervention); the issue of moving be-yond designated areas of expertise (competence); con-cerns about ethics committees and ethical codes; aca-demic or training issues; and medical issues. Categorieswere created to accommodate dilemmas concerned withconsent and reporting practices; however, the number ofvignettes in these categories was negligible.

Collegial Conduct

10% of the South African responses described dilemmasinvolving the unethical conduct of colleagues, such asmisrepresenting their training and registration categoryto potential clients and unprofessional behavior, such asthe subtle coercion of patients, or conducting "rushed"interventions. While many respondents were aware ofthe route to lodging a formal complaint against their col-leagues in the event of a clear breach of the code, manydescribed concern at how to approach colleagues effec-tively in the event of conduct that was less clearly abreach. Most described this scenario as so aversive as tobe consistently avoided.

In total, 27% of the 51 dilemmas comprised situa-tions in which the (mis)conduct of colleagues was ob-served and described, or the reporter perceivedhim/herself to be in a dilemma due to the behavior ofcolleagues. These dilemmas were accommodated in theprimary categories of sexual issues, competence, andquestionable interventions. When accommodated in thecollegial conduct category, these dilemmas comprise thesecond largest category of dilemmas reported by clinicalpsychologists in this study, which corresponds to theranking identified by Odland and Dalen (1997).

In most other studies, collegial conduct concernswere ranked highly. For the Swedish sample such con-cerns provided 8% of dilemmas (Colnerud, 1997), forNorwegian psychologists such issues provided 10% ofreported dilemmas (Odland & Dalen, 1997), and for theCanadian sample these dilemmas showed an incidenceof 11% (Sinclair, 1997). These dilemmas, however, com-prised only 4% and 7% of incidents described by the APA(Pope & Vetter, 1992) and BPS membership (Lindsay &Colley, 1995), respectively. These results suggest that


Conclusions

Although based on a relatively small sample, the generaltrend in this data suggests that South African clinicalpsychologists have ethical concerns that are consistentwith international research. Specifically, confidentiality,dual relationships, payment issues, and collegial con-duct concerns are most troubling for the South Africanclinical psychologists who responded to our queries.

The results suggest that confidentiality concerns forSouth African professionals mirror those of their profes-sional colleagues in every country sampled. Dual-rela-tionship concerns for South Africans seem to reflectthose of Swedish, Finnish, Canadian, and American re-spondents, and payment issues those of Norwegian,Finnish, and American psychologists. These resultsstrongly suggest that certain ethical problems may beendemic to psychology (Colnerud, 1997), and tentative-ly suggest that the ethical issues prominent in othernations are also troubling for South African clinicalpsychologists.

Overall, the South African sample seemed moresimilar to the APA sample than to the BPS sample, per-haps indicative of our longer history of professionaliza-tion and increased focus on private practice.

Relevance

Previous research on this topic has been regarded as use-ful to the planning of ethics education for psychologistsand the updating of ethical guidelines to ensure thatthey are more relevant to the practice realities of psy-chologists (Lindsay & Colley, 1995). In this regard, for

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example, efforts to revise the 1992 APA ethical code(APA, 1992) are currently in progress (APA, 1998). InSouth Africa, there is presently no single uniformly en-dorsed ethical code. It has been recommended that theEFPPAMetacode (EFPPA, 1996) and the ASPPB (ASPPB,1991) code be considered as draft documents by the Pro-fessional Board for Psychology, which is currently en-gaged in a process of transforming professional psychol-ogy in South Africa. It has also been suggested that theAPA (1992) and CPA (1991) codes be considered by thePsychological Association of South Africa (Wassenaar1998a, 1998b). This revision of professional regulationsand ethical codes should take into account empirical da-ta as reviewed and reported above as well as currenttransformational issues in South African psychology.These developments to some extent mirror the processescurrently underway to standardize training, licensing,and ethical codes in the European Union (Lindsay, 1996;Lunt, 1997; Pulverich, 1997).

The data from the present study and the literaturereviewed suggest a number of implications for ethicalguidelines and ethics training for psychologists. Confi-dentiality dilemmas suggest that specific ethical guide-lines regarding confidentiality with minor clients (chil-dren and adolescents) and with multiperson (familyand marital) interventions (Lakin, 1986,1994; Marsh &Magee, 1997) would benefit psychologists who may bestruggling to address the exact parameters of confiden-tiality with these populations. Similarly, guidelines forresponding to subpoenas would assist psychologistswho may be faced with this legal scenario (APA, 1996).

Psychologists may benefit from clear guidelines re-garding legal obligations to protect third parties fromthreatened harm (Monahan, 1993; Monahan & Stead-man, 1996). Educative efforts that are focused on how torecognize the features of the situations that trigger anobligation to protect (such as "foreseeable" harm to anidentifiable victim), options available to psychologists(such as warning victims, treatment intensification, hos-pitalization) and procedures for exercising such optionsin a way that protects clients throughout such a processmay be of assistance. Psychologists may benefit fromeducation concerning legal obligations to report childabuse with attention to features that dictate an obliga-tion to report (such as directly attending to the child inquestion) and procedures for meeting such obligationsthat minimize harm to clients.

Dual relationship dilemmas indicate that ethicalguidelines should sensitize psychologists to factorsspecific to the professional role (such as specific role-responsibilities and role-expectations) that are likely to

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be compromised through any other interaction. Suchguidelines may help psychologists to assess the poten-tial harm to clients posed by any dual relationship(Sonne, 1994).

Payment dilemmas indicate that psychologists maybenefit from education in this area (Koocher, 1994; Peter-son, 1996). Psychologists may benefit from attention tobilling practices, procedures that support frank discus-sion of nonpayment or extended payment plans, andrelationships with third-party reimbursers (Koocher &Keith-Spiegel, 1998).

Descriptions of collegial conduct dilemmas suggestthat ethical guidelines explicitly including the concept of"extended responsibility" (CPA, 1991, p. 8) may sensitizepsychologists to their obligation to approach colleagues.Additionally, ethical guidelines that include a reciprocalobligation to cooperate with a colleague's attempts to in-formally address improper conduct may remedy the cur-rent imbalance in responsibility for peer monitoring(Weinberger, 1988). Education concerning the role non-ethical considerations (such as expediency) can play incompromising the ethical course of action may be of ben-efit to psychologists (Koocher & Keith-Spiegel, 1998).

In certain instances, the ethical dilemmas detailedby respondents contained references to the difficultiespsychologists experienced in interpreting guidelines insuch a way that they could be confident that their behav-ioral choices reflected the spirit of these regulations.These psychologists appeared cognizant of a lack of "cri-teria for interpretation" (Vasquez, 1996, p. 99) thatwould allow them to apply these guidelines to theirspecific situation accurately and consistently.

While not directly supported by the design of ourstudy and others in this area, it is our view that psychol-ogists could benefit from a code of ethics that undertakesto make explicit the reasoning underpinning ethicalguidelines. This would enable psychologists who arefaced with a unique situation not specifically addressedin ethical codes to apply the reasoning underlying val-ued ethical principles to the presenting situation in aconsistent manner (Pettifor, 1989,1998; Seitz & O'Neill,1996; Sinclair, 1996, 1998). This conceptual approach isthe one specifically embraced by the Canadian Psycho-logical Association's code of ethics (CPA, 1991; Sinclair,1998). As the reasoning underlying statements made inthe code is delineated, statements arise on which pro-fessionals can base their decisions (Seitz & O'Neill,1996). This conceptual approach to regulations may pro-vide interpretive criteria for psychologists attempting toextrapolate from imprecise guidelines to specific situa-tions (Vasquez, 1994).



The CPA (1991) code also contains explicit guide-lines on how to resolve complex situations. Psycholo-gists are encouraged to reconcile competing alternativesby selecting a course of action that "loads" strongly onthe principle to be given precedence—respect for per-sons—which delineates confidentiality and consent is-sues stemming from client autonomy (Seitz & O'Neill,1996). Recent attempts to explore the utility of codes indecision-making and resolving dilemmas support thisconceptual approach (Pettifor, 1997,1998). A code of eth-ics structured like the CPA code has intuitive appeal andcould be borne in mind by those charged with increasingthe practical utility of ethical codes (Wassenaar, 1998b).

In conclusion, it is hoped that the data derived fromstudies of psychologists' ethical dilemmas in practicewill contribute to the development of ethical codes thatare clear, practical, and educative. From such codes ed-ucation programs can be developed which can assistpsychologists in their practice. Although based on asmall sample, the data from this study conform largelywith other international studies, which show that situa-tions involving confidentiality and dual relationshipsrequire particularly careful documentation and educa-tional elaboration. Such documentation and educationshould also be subjected to evaluations examining theirimpact on the awareness and practices of psychologists.The comparative data also serves to remind us of theuniversal complexities inherent in psychological work.To this end, on the basis of the current comparative find-ings, the authors are currently developing a study exam-ining ethical dilemmas in relation to the practice con-texts in which they occur.

Acknowledgments

The authors wish to acknowledge the thoughtful com-ments of two anonymous reviewers.

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