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 PsychologistJohn D. Gavazzi, PsyD, ABPP Psychologist

Annual Convention of the Pennsylvania Psychological AssociationJune, 2015

Ethics education in general

Dual Systems/Ethics Code

Foundational Principles & Acculturation Model

Rings of Hell

Experiential Exercises

Overview

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

Negative Expectations

Moral emotions like guilt, fear, & shame

Can ethics education pave the way to ethics hell?

Midway in our life’s journey, I went astrayFrom 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 drearSo 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

Proscriptive: Those beliefs, behaviors, or actions that avoid harm

Prescriptive: Those beliefs, behaviors, or actions that seek beneficial outcomes

Dual Systems & Ethics

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

Research shows that bad has a much stronger punch than good

Loss aversion

Defensive practice

Bad is stronger than good

Respect for Patient Autonomy

Beneficence

Nonmaleficence

Fidelity

Justice

Principle-Based Ethics

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

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

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

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.)

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.

Setting the Stage for our Descent into Hell

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

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.

Acculturation Model

Provides a model to track our descent into hell

A different vantage point to address ethical behaviors and decisions

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

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.

Ethical Acculturation

Identification with personal value system

(higher vs. lower)

Identification with value system of psychology

(higher vs. lower)

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

Rings of hell

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

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

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 Character Witness

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

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

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 Character Witness

Type I Reasoning Type 2 Reasoning

Rule-based

Deliberate

Analytic

Slower

Intuitive

Automatic

Emotional

Rapid

Third Ring: Emotional Reasoning

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

Professional isolation is correlated with:

• Lower quality work

• Job dissatisfaction

• Burnout

• Interpersonal defensiveness

Professional isolation can happen in group practices.

Fourth Ring: Isolation

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

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

Upon seeing Satan:

“[Virgil] made me stop, and stepping aside he said. . . This is the placeWhere you must arm your soul against all dread!”

“Do not ask, Reader, how my blood ran coldAnd 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.

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

Feeling Sufficiently Uncomfortable?

Independent Actions Help from others

Self Reflection

Documentation

Transparency

Continuing Education

Self-care

Consultation

Supervision

Psychotherapy

Continuing Education

Matrix: Higher on professional ethics

Higher on personal ethics

Reward: Implement values in context of professional roles

Reaching for the ethical ceiling

Aspirational ethics

Overemphasis on rules or The Code

Interpreting rules without understanding overarching ethical principles

Setting a low bar for professional behavior

Intrusive advocacy

Lack of understanding boundaries and the “therapeutic frame”

Allowing personal values to trump professional boundaries (without self-reflection and/or consultation)

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.

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.

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

www.ethicalpsychology.com