Welcome to the sixth edition! So much has changed since the 5th edition. The novel coronavirus (COVID-19) pandemic transformed—at least temporarily—psychotherapy and counseling from encounters primarily conducted in-person to virtual meetings convened over Zoom, FaceTime, and other video conferencing and digital tools. Creative innovation, surprising research findings, landmark legal decisions, demographic shifts, and new perspectives continue to bring change to psychotherapy and counseling, and to ethical standards, theory, and practice. To address these trends and changes, we’ve updated all the chapters in this new edition and have created some new chapters.

The authorship of this book has also changed. Ken Pope and Melba Vasquez co-authored the first five editions of this book, and they’re still here. For this sixth edition, they reached out to two distinguished colleagues, Professors Nayeli Y. Chavez-Dueñas and Hector Y. Adames, both of whom are also licensed practitioners. Both Nayeli and Hector agreed to sign on as co-authors with Ken and Melba. The sixth edition benefits from four very diverse perspectives and co-authors who worked collaboratively to create an edition that motivate us all to strengthen and inform our ethical awareness and sense of personal and collective ethical responsibility.

The poor, unloved preface achieved sad notoriety as the least read part of most books. We’ll keep this one short—limiting it to only a note on terminology. We hope the conciseness inspires you to read on, set yourself apart from the crowd, and gain elite status as a reader of the preface.

This book discusses the varied and complex ethical issues that confront psychologists working as psychotherapists, other kinds of therapists (e.g., behavior therapists), and counselors. For brevity and convenience, we often use just one of these terms—rather than some hyphenated form of all three—in a sentence. Similarly, some therapists identify those to whom they provide services as clients; others use the term patients. Again, for brevity and convenience, we have used these terms interchangeably throughout the book.

Psychotherapy holds out the promise of help for people who are hurting and in need. It can save lives and change lives. In therapy, clients can find their strengths and sense of hope. They can change course toward a more meaningful and healthy life. They can confront loss, tragedy, hopelessness, and the end of life in ways that do not leave them numb or paralyzed. They can discover what brings them joy and what sustains them through hard times. They can begin to trust, or to trust more wisely. They can learn new behaviors in therapy and how to teach themselves new behaviors after therapy ends. They can question what they always believed was a given. They can find out what matters most to them, and how to stop wasting time. They can become happier, or at least less miserable. They can become better able, as Freud noted, to love and to work. They can learn how to accept and love themselves just as they are and accept others who are different from them.

Our ethics acknowledge and affirm our profession’s responsibilities. This book was written to help strengthen, deepen, and inform ethical awareness and the sense of personal ethical responsibility. Its job is to help you hold onto the ideals—including ethical ideals—that called you into the profession to begin with, to help you develop and fulfill those ideals. There will be so much—trust us on this—that tends to dull ethical awareness, to make ethics drift out of focus, to create barriers between you and your ideals, to replace ethics with pseudo-ethics and ethics placebos. Fatigue, endless paperwork, unrealistic expectations, illness, family crises, not being able to make ends meet, burnout, threats of job loss, insurance coverage that doesn’t come close to meeting the needs of our clients, biases that have not been addressed, and so many other forces can pressure us into cutting ethical corners. This book is intended to help you develop a strong and healthy resistance to such forces, to help you weather them without losing your ethical awareness and ideals.

We can often help, but if our ethics slip, we can needlessly hurt. Mishandled, the process of therapy and counseling can waste time and opportunity. It can betray clients’ hope, good faith, hard work, and trust. It can leave them worse off than before they reached out for our help. It can erode trust in the health system and prevent people from seeking help in the future.

Realizing how much our ethical decisions can affect the lives of those who come to us for help is central to our ethical awareness. What we do can make a difference in whether a client loses hope and commits suicide or chooses to live, whether a battered partner finds shelter or returns to a toxic and dangerous relationship, whether a teenager with anorexia gets help or starves to death. Such stark examples tell only part of the story. So many people come to us facing what seem to be minor, hard-to-define problems, yet the hard, risky, unpredictable twists and turns of their therapy can lead to more meaningful, effective, and fulfilling lives.

Few therapists take these responsibilities lightly. Few forget about a suicidal client between sessions. Few sit unmoved while a client talks, perhaps for the first time, about what it was like to survive an atrocity. Few turn away untroubled when a managed care company refuses to authorize treatment for someone in desperate need of help, someone who lacks enough money to put food on the table, let alone to pay for therapy.

Recognizing these responsibilities as they appear in our day-to-day work and deciding how to respond can be stressful, sometimes overwhelming. We may feel short of time, resources, or wisdom. We may feel pulled in different directions, stretched to or beyond the breaking point. The responsibilities can weigh us down, make us feel discouraged, rattle us, and make us want to run and hide. They can make us more vulnerable to other sources of stress and leave us prone to make flawed ethical decisions.

Uncertainty causes stress for some of us. We can’t find that magical book that will tell us what to do, especially in a crisis. Research, guidelines, manuals, our own experience, and consultation help, but we can’t know the best course in all situations, or even how the “best” course will turn out. We are constantly thrown back on our own judgment. If we believe a client might kill someone but there is no explicit threat or other legal justification under the state’s law to hospitalize the client or breach confidentiality, what do we do? What diagnosis should we write down if we know that the insurance company won’t cover treatment for the client’s condition and believe that the client’s need for treatment is urgent, a matter of life or death? Will using stress-reducing imagery techniques help a client (reducing stress and increasing the client’s effectiveness) or cause harm (enabling the client to adapt to an abusive job or relationship) is a question without an instantly clear, infallible answer. Does informed consent make sense if all it accomplishes is to cause a patient to turn away from life-saving treatment or stop them from sharing information critical to their treatment? The inescapable responsibility of making careful, informed professional judgment regarding issues of enormous complexity and potentially life-and-death implications can push even the most resourceful therapists to and beyond their limits.

Fearing that formal review agencies will hold us accountable, after the fact, scares, stresses, and distresses some of us. Some agencies focus specifically on the ethical aspects of our work. Others, such as state licensing boards and the civil courts, enforce professional standards of care that may reflect ethical responsibilities. The prospect of review agencies second-guessing us—and perhaps falling prey to both outcome bias and hindsight bias—can make difficult judgments a nightmare for some therapists. They may suffer debilitating performance anxiety, dread going to work, and discover that the focus of their work has changed from helping people to avoiding a malpractice suit.

Managed care stresses some therapists. For example, capitation contracts provide a limited sum of money to cover all services for a group of patients (e.g., a business that has contracted coverage for its employees with an agency). The agency providing services, having estimated the average number of sessions needed for each patient, must limit the total number of sessions to make a profit. Strict guidelines may limit how many sessions a therapist can provide. Therapists may feel pressure to terminate before the limit, even if they think services are still needed. Even if clinicians follow agency procedures, they may face charges before an ethics committee, licensing board, or malpractice court for patient abandonment, improper denial of treatment, or similar issues. Therapists may fear not only that a formal review agency will sanction them but also that the limited sessions fall far short of what their clients need.

Teaching or learning therapy is practiced on the living—this can stress us. As supervisors, we may grow uncomfortable with how the supervisee responds to the client differently from how we would, with our responsibility to evaluate the supervisee’s work, and with the demands of our role as teacher, mentor, and gatekeeper. As supervisees, we may doubt our ability to carry out clinical responsibilities (especially when they involve suicidal or homicidal risks), dread making mistakes, feel uneasy about differences in values or theoretical orientation between ourselves and our supervisor, wonder if racial (or gender or sexual orientation or religious or political, or, or, or) differences between us and our supervisor are causing us to be viewed in a negative light, and figure that if we are completely honest in describing to our supervisor what we actually thought, felt, and did with our clients, we might be advised to look for another line of work.

Learning to work competently with clients from various identity groups can be challenging. Understanding and integrating racial and cultural issues and context is fundamental to our professional responsibilities. We can complete workshops, read, get supervision, take continuing education courses, but the challenge in gaining knowledge about various social groups will be an ongoing task. Knowledge about the various social identities that our clients represent will be necessary in assessing the degree to which we integrate various values, behaviors, and expectations in the course of treatment. Those potential identities include but are not limited to race, ethnicity, generation, gender, ability status, sexual orientation, gender identity, caste, religion, spirituality, immigration, employment, and the like. Working competently requires awareness, knowledge, and skills about people’s identities and the ways in which overlapping forms of oppression (e.g., gendered-racism, gendered anti-Semitism) impact people’s lives (for further reading on the theory of intersectionality as originally created by Black Women see Combahee River Collective, 1995; Crenshaw, 1991; for intersectionality in clinical practice see Adames et al., 2018; Chavez-Dueñas et al., 2019).

A fundamental stress that confronts therapists is the urgent, complex, inescapable question: “What do I do now?” Consider these scenarios:

Doing psychotherapy confronts us with constant challenges. Each ethical challenge, large or small, subtle or staring us in the face, brings a tangle of questions. Is there a “right” thing to do? If so, how do I find out what it is? How do I actually go about doing it? What makes it right? Who says so? If I do it, what will happen to the patient? to me? to innocent—and not-so-innocent—bystanders?

We wrestle with personal questions that are hard to admit to ourselves or others. What am I tempted to do? What could I get away with? Would doing the right thing cost too much? make people mad at me? get me sued? get me fired? Would doing the wrong thing be all that bad? Would anyone find out? What would happen to me if they did? What if I’m not strong enough, not “good” enough to do the right thing? Can I duck this one and stick someone else with it?

These stinging questions always lead back to the basic question: What do I do now?

Strong, deep, informed ethical awareness helps us answer that question. It brings into focus how our choices affect the lives of our patients, our colleagues, and the public. It frees us from the sticky webs of habit, fatigue, fallacy, dogma, carelessness, hurry, and stress. It wakes us to new possibilities.

If this book helps you to strengthen, deepen, and inform your ethical awareness, it will help you find better answers to that basic question: What do I do now? This book will disappoint those looking for an ethics cookbook, an authority pointing out the right answer for every scenario, a substitute for ethical consideration, decision-making, and personal responsibility. We believe that approach fails in the real world, leading us to blunder with confidence.

Each of us must bring our own ethical awareness to the challenges, pitfalls, and opportunities that we face in each unique, constantly changing situation, to make the best choices. We emphasize eight basic assumptions about ethical awareness.

1. Ethical awareness is a continuous and active process that involves constant questioning and personal responsibility.

Our work requires constant alertness and mindful awareness of the ethical implications of what we choose to do and not do. Ethical awareness helps us to shoulder personal responsibility for our ethical choices, for what we choose to do and not do. We face the consequences for what we choose or not choose to do.

Ethical awareness helps us avoid quick certainties that shut down further questioning. It prompts us to rethink what seems to be a “given,” to continuously look for more creative, more ethical, more effective solutions to problems.

Ethical awareness means setting aside arrogance and complacency. All of us have weaknesses, vulnerabilities, and blind spots—it comes with being human. The stark differences are not so much between those with many flaws and those with few but between those who are freely open to themselves and others about how their own shortcomings affect their work and those who tend to hide such shortcomings and see others as their inferiors.

Ethical awareness depends on our ability to take care of ourselves, to recognize when exhaustion, personal problems, or feelings like fear, anger, boredom, resentment, sadness, hopelessness, or anxiety hurt our work, and to do something about it.

2. Awareness of ethical codes is crucial, but formal codes cannot take the place of an active, thoughtful, creative approach to our ethical responsibilities.

Ethical awareness is strengthened and informed by pouring over the ethics codes that bear on our work. But formal standards and guidelines¹ are no substitute for an active, deliberative, and creative approach to our ethical responsibilities. Codes prompt, guide, and inform our ethical considerations; they do not shut it down or take its place.

Ethical awareness never allows us to follow a code in a rote, thoughtless manner. Each new client, whatever their similarities to previous clients, is unique. Each situation is unique and constantly changing—time and events never stand still. Our theoretical orientation, our community and the client’s community, our race and culture and the client’s race, culture, and so many other contexts and factors shape what we see and how we make sense of what we see. Each ethical choice must take these complexities and contexts into account.

Codes can steer us away from clearly unethical approaches. They can shine a light on key values and concerns. But they cannot tell us what form these values and concerns will take. Standards and guidelines can set forth essential tasks or point to aspirational goals but they never show us the best way to carry out those tasks and realize those goals with a unique client facing unique problems in a specific time and place with limited resources. Ethical decision-making is a process and codes are only one part of that process.

3. Awareness of laws is crucial, but legal standards should not be confused with ethical responsibilities.

A risk in the emphasis on legal standards is that meeting legal standards, which for some can mean finding ways around those standards (e.g., looking for loopholes), can start to replace ethical behavior. This practice is a high art in the political arena. Caught betraying the public trust, politicians often insist they did nothing wrong because no law was broken. When it turns out that a law was broken, politicians admit that their enemies are harping on a mere “technical violation of the law.” Ethical awareness avoids the comfortable trap of aiming low, of striving only to get by without breaking any law.

Ethical awareness stays alert to possible conflicts between our ethical and our legal duties.

An overly exclusive focus on legal standards discourages ethical responsibility. Practicing “defensive therapy”—making risk management our main focus—can cause us to lose sight of our ethical responsibilities and the ethical consequences of what we say and do. When we originally discussed this tendency to confuse legal and ethical issues over 30 years ago in this book’s first edition, the tendency had already begun to spread widely. It shows no signs of slowing down.

4. We believe that the overwhelming majority of therapists and counselors are conscientious, dedicated, caring individuals, committed to ethical behavior. But none of us is infallible.

All of us can—and do—make mistakes, overlook something important, work from a limited perspective, reach conclusions that are wrong, hold tight to cherished beliefs that are misguided or biased. We’re aware of many barriers between us and our best work, but we may underestimate or overlook some of those barriers. Part of our responsibility is to question ourselves: What if I’m wrong about this? Is there something I’m overlooking? Could there be another way of understanding this situation? Are there other possibilities? Can I come up with a more creative, more effective, better way of responding?

5. Many of us find it easier to question the ethics of others than to question what we ourselves value, believe, and do. It is worth noticing if we often find ourselves stewing over just how ethically weak, dense, or shady others are while sparing ourselves from critical self-assessment.

It is a red flag if we spend more time trying to point out other people’s weaknesses, flaws, mistakes, ethical blindness, destructive actions, or hopeless stupidity than we spend questioning and challenging ourselves in positive, effective, and productive ways that awaken us to new perspectives and possibilities. Questioning ourselves is at least as important as questioning others.

6. Most of us find it easier to question ourselves on those intriguing topics we know we don’t understand, that we stumble onto with confusion, uncertainty, and doubt. The harder but more helpful work is to question ourselves about our casual certainties. What have we taken for granted and accepted without challenge? Nothing can be placed off limits for this questioning.

Certainties are hard to give up, especially when they feel like they are part of who we are. They become landmarks, helping us make sense of the world, guiding our steps. But perhaps an always-reliable theoretical orientation begins distorting our view of a new patient, leading us to interventions that make things worse. Or having always prided ourselves on the soundness of our psychological evaluations, we keep rereading our draft report in a case in which an unbiased description of our findings may bring about a tragic injustice, harming many innocent people, and begin to wonder if our feelings for the client led us to shade the truth. Or the heart of our internship has been the supervision, and we’ve made it a point to tell the supervisor everything important about every patient, except about getting so turned on with that one patient, the one who is not very vulnerable at all and does not really need therapy, the one we keep having fantasies of asking out after waiting a reasonable time after termination and then, if all goes well, proposing to.

Questioning our certainties means actively and repeatedly seeking out and listening respectfully to those who disagree with us and engaging them in openly exchanging views. It means actively searching out articles and books that challenge—and sometime attack—our assumptions, beliefs, and practices.

We must follow this questioning wherever it leads, even if we venture into territories that some might view as politically incorrect or—much harder for most of us—“psychologically incorrect” (Pope et al., 2006).

7. We often encounter ethical dilemmas without clear and easy answers.

As we try to help people who come to us because they are hurting and in need, we confront overwhelming needs unmatched by adequate resources, conflicting responsibilities that seem impossible to reconcile, systems that work against the best interests of our clients, frustrating limits to our understanding and interventions, and countless other challenges. We may be the only person a desperate client can turn to, and we may be jerked every which way by values, events, limited time, and limited options. Our best efforts to sort through such challenges may lead us to a thoughtful, informed conclusion about the most ethical path that is in stark contradiction to the thoughtful, informed conclusions of a best friend, a formal consultant, our attorney, or the professional groups we belong to.

In the midst of these limitations, conflicts, disagreements, and complexities, we must make the best choices we can. We must each struggle to answer the question: What do I do now? And each of us must take responsibility for the decisions we ultimately make. We cannot shift personal responsibility for what we decide and what we do to another person, group, law, code, or custom. There is no escape from these struggles. They are part of our work.

8. We and our clients do not live in a vacuum. We live and develop in sociocultural contexts.

We are called to act in accordance with an ethic of human rights and social justice. We open our eyes and hearts to how discrimination, hatred, injustice, beatings, xenophobia, slavery, jail, starvation, torture, or genocide—based on factors like race, religion, immigration, culture, gender, sexual orientation, disability, politics—affect us, our clients, their families and communities, our supervisees, and the world we live and work in. We search for the most ethical response to social injustice. We don’t shrug our shoulders and turn away. We face these issues with courage, honesty, caring, and a sense of personal responsibility to respond ethically.

Even the simplest ethical concept, standard, or guideline can fool us. We hear it in class. We read it in the code. We understand it. We can explain it in a test, give a lecture on it, or explain it to a jury. We know the concept, standard, or guideline, but it fools us when it shows up unexpected in the messiness of real life. It comes dressed in different clothes—and sometimes camouflage—and we don’t recognize it.

Therapy offers countless challenges to recognizing how a specific ethical concept, standard, or guideline might be helpful or vital. One reason is that concepts, standards, and guidelines tend to be abstract, general, and sometimes ambiguous. Another reason is that psychotherapy can be such a complex set of interactions between unique people. Yet another is that psychotherapy can serve as the intense focus of need, hope, risk, and expectation. Lives can be at stake.

In the midst of this work, as it actually happens in real life, it can be hard to recognize those moments when we need to consider an abstract ethical concept, standard, or guideline.

This chapter provides examples of those moments as they happen in the messy textures of real life. None is based on a specific case (and none of the people are based on an actual clinician or patient), but each represents the kinds of challenges that therapists and counselors face in their day-to-day practice.

In each of the following fictional scenarios, the clinicians were trying to do their best. Readers may disagree over whether each clinician met the highest or even minimal ethical standards, and such disagreements can form the focus of classroom discussions, case conference presentations, or supervision consultation. In at least one or two instances, you may conclude that what the clinician did was perfectly reasonable and perhaps even showed courage and profound ethical awareness. In some cases, you may feel that significant relevant information is missing. But in each instance, the professional’s actions (or failures to act) become the basis of one or more formal complaints.

As you read each scenario, consider the situation from the point of view of each person mentioned as well as a member of an ethics committee, licensing board, or jury hearing the complaint.

After a full day of Zoom and Facebook sessions with her clients, Dr. Soo sits down at the computer to update her clinical files, making sure all the notes, billing information, digital copies of the day’s Zoom and Facetime sessions (recorded with the full informed consent of her clients), and other records are current. She turns on the computer and … nothing. Just a blank screen. That’s never happened before. Wait: A message scrolls into view:

Greetings, Dr. Soo! I was able to hack into your computer—obviously!—and copy all your files. Yes, even your video files, which I found quite interesting. I even accessed those files you stashed in the cloud as backups. Your passwords weren’t much of a challenge for my software and finding your key to unencrypt your encrypted files was something I did while multitasking. I left your files on your computer, but I used a much more sophisticated program to encrypt them so that you can’t access them.

I’ll bet you’re upset, even angry, but you needn’t be. All can be set right as rain in just a step or two. All you need do is deposit $25,000 U.S. in bitcoin into the account specified at the bottom of the page within 72 hours, I’ll send you the key that will unencrypt your files, and you’ll never hear from me again.

Easy, isn’t it? A simple quid pro quo.

Oh, one more thing, Dr. Soo. What if you don’t pay within 72 hours? What if you think you don’t even need to pay because you’ve got another copy of all your records hidden somewhere on a disk that is not connected to the internet and so inaccessible to me and my merry band of fun-loving rascals? Well, you should know that were I not to receive the bitcoin within 72 hours—and I have full confidence you won’t let that happen—unencrypted copies of all your files will start appearing on all sorts of anonymous websites, and your clients and all others in your address book will receive notification along with links to some of those websites.

In closing, allow me to wish you well, Dr. Soo, especially next Tuesday, where I see in your scheduler and notes you’re expected to testify as an expert witness on the clinical records you reviewed and the tests you administered. It would be such a shame if the judge and attorneys in that case were to be notified before you testified that you had guarded the confidentiality of all those records so well that they were now available for all to see on a whole array of websites. Bet that would lead to an interesting cross-examination? Might even lead to a little chat with the licensing board.

Bye-bye, doc! And thank you for making me feel so welcome. No two-factor identification when signing in to your computer, no ransomware protection, not even a virtual private network when you connect to the internet. I felt you were inviting me in.

To avoid having her clients’ records and videos flashed across the web, Dr. Soo manages to get together $25,000 by emptying her savings and borrowing the rest, and sends off the bitcoin under the deadline. However, the files are never returned to her—They show up on a variety of anonymous websites. Several clients sue.

Josefina was a Black Cuban high school student. She worked part time as a cook. During the first session with Dr. Marcus she poured out a heart full of pain from the discrimination and racist abuse she’d endured at her mostly-White high school and at her job. Just being able to talk about it made her hurt less, she said. She didn’t feel so suicidal as she had the last few weeks. The next session she showed up extremely distressed. She’d lost her job as a cook and could no longer pay for therapy.

Dr. Marcus, who did pro bono work conducting asylum assessments at a legal aid clinic, had never offered free therapy. He believed that patients would not value or work hard if therapy cost nothing. So, he suggested various ways they might barter for the fee. Josefina had nothing tangible to barter with but Dr. Marcus suggested that, since she had been a cook, if she were to cook him a meal and bring it with her to each session, he would accept that as payment. She gladly accepted, thrilled she’d be able to continue therapy.

After four more weekly sessions, Josefina failed to show up for her appointment. Instead Dr. Marcus was served notice of a malpractice suit filed by Josefina’s parents. They alleged that he had taken advantage of and mistreated a minor. Josefina had been suffering from racial prejudice, discrimination, and abuse at her high school and job, and instead of respecting her and providing valid treatment, he had treated her in the most stereotypical manner possible and turned a minor into his personal maid, telling her she must bring him his lunch. Both the subsequent therapist and the expert witness hired by the family agreed that treating Josefina in this way was unethical and damaging.

Ms. Huang, whose family had moved from mainland China to the United States 15 years ago, is a 45 year-old automobile mechanic. She agreed, at the strong urging of her employer, to seek psychotherapy for difficulties that seem to affect her work performance. She has been showing up late at her job, has often phoned in sick, and frequently appears distracted. She complains to her new therapist, Dr. Jackson, of the difficulties she is having coping both with psychomotor epilepsy, which has been controlled through medication, and with her progressive diabetes, for which she is also receiving medical care.

Although she has no real experience treating people of Chinese descent or patients with chronic medical conditions such as epilepsy, Dr. Jackson begins to work with Ms. Huang. She meets with her on a regular basis for three months, but never feels that a solid working alliance is developing. After three months, Ms. Huang abruptly quits therapy. At the time, she had not paid for the last six sessions.

Two weeks later, Dr. Jackson receives a request to send Ms. Huang’s treatment records to her new therapist. Dr. Jackson notifies Ms. Huang that she will not forward the records until the bill has been paid in full.

Some time later, Dr. Jackson is notified that she is the complainee in a licensing case and that she has been sued for malpractice. The complaints allege that Dr. Jackson had been practicing outside of her areas of competence because she had received no formal education or training and had no supervised experience in treating people of Chinese descent or those with multiple serious and chronic medical diseases. The complaints also alleged that Ms. Huang had never adequately understood the nature of treatment as evidenced by the lack of any written informed consent. Finally, the complaints alleged that “holding records hostage” for payment violated Ms. Huang’s welfare and deprived her subsequent therapist of having prompt and comprehensive information necessary to Ms. Huang’s treatment.

Ms. Cain brings her two children, ages four and six, to Dr. Durrenberger for a psychological evaluation. She reports that they have become somewhat upset during the last few months. They are having nightmares and frequently wet their beds. She suspects that the problem may have something to do with their last visit with their father, who lives in another state.

Dr. Durrenberger schedules three sessions in which he sees Ms. Cain and her two children together and three individual sessions with each of the children. As he is preparing his report, he receives a subpoena to testify in a civil suit that Ms. Cain is filing against her ex-husband. She is suing for custody of her children. During the trial, Dr. Durrenberger testifies that the children seem, on the basis of interviews and psychological tests, to have a stronger, more positive relationship with their mother. He gives his professional opinion that the children would be better off with their mother and that she should be given custody.

Mr. Cain files an ethics complaint, a civil suit, and a licensing complaint against Dr. Durrenberger. One basis of his complaint is that Dr. Durrenberger had not obtained informed consent to conduct the assessments. When Mr. and Ms. Cain had divorced two years previously, the court had granted Mr. Cain legal custody of the children but had granted Ms. Cain visitation rights. (Ms. Cain had arranged for the assessments of the children during a long summer visit.) Another basis of the complaint was that Dr. Durrenberger had made a formal recommendation regarding custody placement without making any attempt to interview or evaluate Mr. Cain. Additionally, Mr. Cain’s attorney and expert witnesses maintained that no custody recommendation could be made without interviewing both parents.

In therapy for one year with Dr. Franks, Mr. Edwards experienced alcoholism and drank heavily for four years prior to therapy. Dr. Franks uses a psychodynamic approach but also incorporates behavioral techniques specifically designed to address the drinking problem.

Two months into therapy, when it became apparent that outpatient psychotherapy alone was not effective, Mr. Edwards agreed to attend Alcoholics Anonymous (AA) meetings as an adjunct to his therapy. During the past nine months of therapy, Mr. Edwards had generally been sober, suffering only two relapses, each time falling off the wagon for a long weekend.

Now, a year into therapy, Mr. Edwards suffers a third relapse. He comes to the session having just had several drinks. During the session, Dr. Franks and Mr. Edwards conclude that some of the troubling material that has been emerging in the therapy had led Mr. Edwards to begin drinking again. At the end of the session, Mr. Edwards feels that he has gained some additional insight into why he drank. He decides to go straight from the session to an AA meeting.

One month later, Dr. Franks is notified that he is being sued. On his way from the therapy session to the AA meeting, Mr. Edwards had run a red light and had killed a mother and her child who were crossing the street. The suit alleged that the therapist knew or should have known his patient to be dangerous since he was driving while inebriated, and should have taken steps to prevent him from driving that day, specifically, as well as until his alcoholism no longer constituted a danger to the public.

Dr. Larson is an executive director and clinical chief of staff at the Golden Internship Health Maintenance Organization. For one year, he closely supervises an excellent postdoctoral intern, Dr. Marshall. The supervisee shows great potential, working with a range of patients who respond positively to her interventions. After completing her internship and becoming licensed, Dr. Marshall goes into business for herself, opening an office several blocks from Golden Internship Managed Care Organization. Before terminating her work at the organization, Dr. Larson tells Dr. Marshall that she must transfer all patients to other center therapists. All of the patients who can afford her fee schedule, however, decide to continue in therapy with Dr. Marshall at her new office. The patients who cannot afford Dr. Marshall’s fee schedule are assigned to new therapists at the center. Dr. Larson hires an attorney to take legal action against Dr. Marshall, asserting that she unethically exploited the health maintenance organization (HMO) by stealing patients and engaging in deceptive practices. He files formal complaints against her with the state licensing board, charging that she had refused to follow his supervision in regard to the patients and pointed out that he, as the clinical supervisor of this trainee, had been both clinically and legally responsible for the patients. He refuses to turn over the patients’ charts to Dr. Marshall or to certify to various associations to whom she has applied for membership that Dr. Marshall has successfully completed her postdoctoral internship.

Dr. Marshall countersues, claiming that Dr. Larson is engaging in illegal restraint of trade and not acting in the patients’ best interests. The patients, she asserts, have formed an intense transference and an effective working alliance with her; to lose their therapist would be clinically damaging and not in their best interests. She files formal complaints against Dr. Larson with the licensing board, charging that his refusal to deliver copies of the patients’ charts and to certify that she completed the internship violates ethical and professional standards.

Some of the patients sue the Golden Internship Managed Care Organization, Dr. Larson, and Dr. Marshall, charging that the conflict and the legal actions (in which their cases are put at issue without their consent) have been damaging to their therapy.

When George, a 19 year-old college student, began psychotherapy with Dr. Hightower, he told the doctor that he was suffering from a fatal disease. Two months into therapy, George felt that he trusted his therapist enough to tell her that the disease was AIDS (acquired immune deficiency syndrome).

During the next 18 months, much of the therapy focused on George’s losing battle with his illness and his preparations for the end of life. After two stays in the hospital for pneumonia, George informed Dr. Hightower that he knew he would not survive his next hospitalization. He had done independent research and talked with his physicians, and he was certain that, if pneumonia developed again, it would be fatal due to numerous complications and that it would likely be a long and painful death. George said that when that time came, he wanted to die in the off-campus apartment he had lived in since he came to college—not in the hospital. He would, when he felt himself getting sicker, take some illicitly obtained drugs that would ease him into death. Dr. Hightower tried to dissuade him from this plan, but George refused to discuss it and said that if Dr. Hightower continued to bring up the subject, he would quit therapy. Convinced that George would quit therapy rather than discuss his plan, Dr. Hightower decided that the best course of action was to offer caring and support—rather than confrontation and argument—to a patient who seemed to have only a few months to live.

Four months later, Dr. Hightower was notified that George had taken his life. Within the next month, Dr. Hightower became the defendant in two civil suits. One suit, filed by George’s family, alleged that Dr. Hightower, aware that George was intending to take his own life, did not take reasonable and adequate steps to prevent the suicide, that she had not notified any third parties of the suicide plan, had not required George to get rid of the illicit drugs, and had not used hospitalization to prevent the suicide. The other suit was filed by a college student who had been George’s partner. The student alleged that Dr. Hightower, knowing that George had a partner and that he had a fatal sexually transmitted disease, had a duty to protect George’s partner. The partner alleged ignorance that George had been suffering from AIDS.

Mr. Alvarez, a 45 year-old professor of physics, has never before sought psychotherapy. He shows up for his first appointment with Dr. Brinks. He shares with Dr. Brinks that his life is in chaos. Dr. Brinks was granted full professor status about a year ago and about one month after that, his wife suddenly left him to live with another man. He became very depressed. About four months ago, he began to become anxious and to have trouble concentrating. He feels he needs someone to talk to so that he can figure out what happened. Mr. Alvarez and Dr. Brinks agree to meet twice every week for outpatient psychotherapy.

During the first few sessions, Mr. Alvarez says that he feels relieved that he can talk about his problems, but he remains very anxious. During the next few months, he begins talking about some traumatic experiences in his early childhood. He reports that he is having even more trouble concentrating. Dr. Brinks assures him that this is not surprising, that problems concentrating often become temporarily worse when a patient starts becoming aware of painful memories that had been repressed. She suggests that they begin meeting three times a week, and Mr. Alvarez agrees.

One month later, Mr. Alvarez collapses, is rushed to the hospital, but is dead upon arrival. An autopsy reveals that a small but growing tumor had been pressing against a blood vessel in his brain. When the vessel burst, he died.

Months after Mr. Alvarez’s death, Dr. Brinks is served notice that the licensing board is opening a formal case against her based upon a complaint filed by Mr. Alvarez’s relatives. Furthermore, she is being sued for malpractice. The licensing complaint and the malpractice suit allege that she was negligent in diagnosing Mr. Alvarez in that she had failed to take any step to rule out organic causes for Mr. Alvarez’s concentration difficulties, had not applied any of the principles and procedures of the profession of psychology to identify organic impairment, and had not referred Mr. Alvarez for evaluation by a neuropsychologist or to a physician for a cognitive and medical examination.

Angelica, who was born in Bolivia and migrated to the US two years ago, is a 55 year-old mother of three. Following the advice of her physician and sister, she decides to seek psychotherapy to deal with insomnia, lack of appetite, and uncontrollable crying spells. Angelica only speaks Spanish and there are no bilingual therapists available at the clinic; however, Dr. Jones agrees to work with Angelica. Wanting to help Angelica, Dr. Jones agreed to do therapy with an interpreter, although this is the first time she is providing therapy services with an interpreter. She is sure that all interpreters know what to do. Dr. Jones proceeds to schedule Angelic’s intake. During the clinical interview Angelica seemed to be worried and went back and forth with the interpreter. Dr. Jones, not speaking Spanish, is unable to follow what’s happening and when she inquires, the interpreter only says that Angelica feels ashamed of speaking about her family’s business. Dr. Jones, via the interpreter, tells Angelica not to worry and goes on to discuss informed consent and confidentiality. Angelica does not return to her second session and several months later, Dr. Jones receives a letter indicating that a civil law suit had been filed against her. According to the letter, Dr. Jones assured Angelica that all of the information that was shared in therapy would remain confidential, but somehow her husband, who has a long history of domestic violence, found out all of the details that Angelica disclosed to Dr. Jones during the intake interview. He became so violent toward Angelica that she spent several days in the intensive care unite (ICU) recuperating from the physical abuse.

What happened to these therapists was so traumatic that, even though they are fictional characters and never existed, they have fled into other lines of work, do not want to be recognized, and demand anonymity in this hypothetical scenario. The catastrophes seemed to start when one of them hit the “send” button on his computer.

For many years they had maintained a small and very successful group practice. Then they modernized, bringing in state-of-the-art computers, elegantly networked and equipped with wonderful software that made the therapists’ work so much easier.

Until one day the first therapist hit the send button. He had carefully collected all the electronic records of one of his patients, who was involved in litigation, to e-mail to the patient’s attorney. There were the billing records, results of psychological testing, records of therapy sessions, as well as the background records (employment, disability, etc.) that the therapist had on file. The therapist gave one last look and then hit the send button.

It was only after watching his computer send off the records that the therapist realized he had used the wrong address on the e-mail. The patient records were on their way, not to the patient’s attorney, but to a large internet discussion list that the therapist belonged to. This unfortunate series of events led to a formal complaint against the therapist.

By a far-fetched coincidence typical of hypothetical scenarios, the second therapist walked into the first therapist’s office just when the first therapist was hitting the send button. Here’s what the second therapist said: “Can you believe it!? I’m being sued, and it’s all because of my computer! When my patient temporarily moved to the east coast for a sabbatical, we thought it best to continue treatment, but because of the time difference and our heavy schedules, we couldn’t find a time when we could both talk, so we decided to communicate by e-mail. But then she got mad at me about something and filed complaints against me in the other state! So now they’re saying I was providing psychological services in that state without being licensed in that state, and that I failed to follow that states rules and regulations about…well you’d have to read the complaints her attorney has filed with the licensing board, the courts, and the ethics committee. It’s terrible!”

As if sensing that another wild coincidence was needed to keep the story moving, the third therapist rushed into the first therapist’s office at that moment and said: “You won’t believe what just happened! I just got a formal notice that I’m being sued! I just found out what happened: Somehow a virus or Trojan or Worm or one of those things got into my computer and took my files—you know, all my confidential case files—and sent them to everyone listed in my address book and to all the other addresses in my computer’s memory. What do I do now?”

On cue, the fourth therapist ran into the room and cried, “Help! I’m in such trouble! One of my patients is involved in a nasty law suit, and I received a court order to produce all my records. The patient had given me consent to turn them over because she and her attorney believe they will be the key to their winning the case. So, I sat down to print them out and … they’re gone! My hard drive crashed and when I hired a company to rescue what they could, they retrieved some of the files but all the files for that patient are gone. What do I do now?”

Although the room was getting crowded, the fifth therapist slouched in, collapsed in a chair, and said, “I’m doomed. I kept all my records on my laptop. But while I was at lunch today, someone broke into my car and stole it. Then I got worse news. I thought at least the files would be safe because I encrypted them, but I just found out from a colleague that since the program I used to encrypt and unencrypt them is on that computer and since many thieves have software that enables them to get past passwords and gain use of the encryption program, it would be pretty easy for a hacker to unencrypt my files.”

When the final member of their group practice failed to show up with bad news, they grew concerned and went down the hall to her office. She was sitting at her desk with a big smile on her face. She said, “I can’t tell you how good I feel. I’ve been so concerned about keeping records on my computer that I finally decided it just wasn’t worth the worry. I printed out all my records, made extra copies that I put in my safe deposit box, and got rid of my computer. It was such a good move for me. I haven’t felt this good in days.”

It was only months later that she discovered, when reading the complaint filed against her, that she had done a poor job of trying to erase her hard drive before selling her computer, and that the person who had bought it had little trouble retrieving the supposedly erased files and reading all the details about her patients.

▪ ▪ ▪

These scenarios remind us of the need for constant alertness, constant awareness of the ways that seemingly simple and abstract ethical principles in the ethics codes can find their way into our work, often in unexpected ways and at unexpected times. Anticipating potential problems like these begins with our understanding of the ethics codes themselves, the topic of the next chapter.

The work we do as therapists is complex, difficult, and emotional. Yet, as a mental health profession we have often struggled to capture with words exactly what we do and even what we profess to do as therapists. The challenge of describing what we do has been debated from the start of our profession.

In 1949, the Boulder Conference tried to define psychotherapy in a way that it could be used to train clinical and counseling psychologists. Carl Rogers, then president of the American Psychological Association (APA) in 1947, appointed David Shakow to chair a committee on defining and teaching psychotherapy. The Shakow Report, adopted at the 1947 APA convention, resulted in the Boulder Conference two years later.

On August 28, 1949, the recorder for the Boulder Task Force for defining both psychotherapy and the criteria for adequate training provided the following summary: “We have left therapy as an undefined technique which is applied to unspecified problems with a nonpredictable outcome. For this technique we recommend rigorous training” (Lehner, 1952, p. 547).

Since the Boulder Conference, other conferences and various groups have tried to define psychotherapy and the practice of psychology. For example, the 2002 Competencies Conference: Future Directions in Education and Credentialing in Professional Psychology (Kaslow et al., 2004), identified competencies in professional psychology and discussed effective strategies for teaching and assessing these competencies (Kaslow, 2004; see also Belar, 2009; Fouad et al., 2009; Hatcher, 2015; Hatcher et al., 2013; Rodolfa et al., 2013). Similarly, the European Association of Clinical Psychology and Psychological Treatment (EACLIPT) Task Force on Competences of Clinical Psychologists (2019) developed “a list of competences that should be acquired during regular studies of psychology with a clinical specialisation” (EACLIPT Task Force, 2019; see also Prado-Abril et al., 2019).

The difficulty reaching agreement on a definition of therapy is echoed in the difficulty agreeing on a basic theory of ethics. In this section we briefly review four theories of ethics to illustrate the vast diversity of ethics theories, which can be viewed as a strength. Put succinctly, having multiple lenses through which we can examine and question professional ethics codes and our own ethical decision-making is an advantage.

Utilitarianism, developed by Epicurus, Jeremy Bentham, John Stuart Mill, Katarzyna de Lazari-Radek, and Peter Singer among others, holds that a guiding principle of ethics involves choosing whatever brings the most happiness and produces the least pain to the majority. According to Bentham (1780):

Nature has placed mankind [humankind] under the governance of two sovereign masters, pain and pleasure. It is for them alone to point out what we ought to do, as well as to determine what we shall do. On the one hand the standard of right and wrong, on the other the chain of causes and effects, are fastened to their throne. They govern us in all we do, in all we say, in all we think …. The principle of utility recognizes this subjection, and assumes it for the foundation of that system, the object of which is to rear the fabric of felicity by the hands of reason and of law …. By the principle of utility is meant that principle which approves or disapproves of every action whatsoever … according to the tendency it appears to have to augment or diminish … happiness …. (p. 232–245).

Similarly, Mill (1863) wrote:

The creed which accepts as the foundation of morals, Utility, or the Greatest Happiness Principle, holds that actions are right in proportion as they tend to promote happiness, wrong as they tend to produce the reverse of happiness. By happiness is intended pleasure, and the absence of pain; by unhappiness, pain, and the privation of pleasure (p. 9).

This may seem like a fairly simple, almost easy, approach to ethics. However, de Lazari-Radek and Singer (2017) emphasize that figuring out what promotes the most happiness in every situation may present more of a challenge than following a set of rules.

The core precept of utilitarianism is that we should make the world the best place we can. That means that, as far as it is within our power, we should bring about a world in which every individual has the highest possible level of well-being. Although this may seem like mere common sense, it is often in opposition to traditional moralities. Most communities prescribe rules to be followed irrespective of whether the outcome will make the world better or worse. It is much easier to follow rules than to try to assess, each time one acts, which of the available options will have the best consequences (p. 711–717).

Utilitarianism focuses on results, consequences. Kantian ethics focuses on will and intention. Kant (1785/1998) wrote:

Nothing can possibly be conceived in the world, or even out of it, which can be called good, without qualification, except a good will. Intelligence, wit, judgement, and the other talents of the mind, however they may be named, or courage, resolution, perseverance, as qualities of temperament, are undoubtedly good and desirable in many respects; but these gifts of nature may also become extremely bad and mischievous if the will which is to make use of them, and which, therefore, constitutes what is called character, is not good …. A good will is good not because of what it performs or effects, not by its aptness for the attainment of some proposed end, but simply by virtue of the volition; that is, it is good in itself …. and considered by itself is to be esteemed much higher than all that can be brought about by it …. (p. 115–127).

Kant believed that we must always treat others as an end in themselves and never as simply a means to an end.

Brabeck and Ting (2000) open a discussion of feminist ethics by quoting the striking claim that feminism itself cannot exist separate from ethics: “In 1991, the political scientist Jean Bethke Elshtain wrote, ‘feminism without ethics is inconceivable’ … According to Elshtain, all feminisms offer an ethical position that accompanies a political, activist agenda to achieve social justice and improve women’s lives” (Brabeck & Ting, 2000, p. 17). They then summarize five major themes running through feminist ethics, including:

While ethics is an inextricable part of feminism, multiculturalism is an inextricable part of feminist ethics. Gartrell (2014) wrote that “any discussion of feminist ethics must incorporate diverse experiences due to race, ethnicity, class, and sexual orientation” (p. 137; see also Greene & Flasch, 2019; Hayden & Crockett, 2020; Powell et al., 2020).

Lerman (2014) discussed the work of the Feminist Therapy Institute in creating their own ethics code based on their conclusions about traditional ethics codes. Their view that most of the current ethics codes were not a good fit for feminist therapists included:

The recognition that most codes are reactive rather than proactive, that ethics is frequently viewed as a good-bad dichotomy rather than as a continuum of actions generated by the complex nature of human interactions, that ethics codes do not customarily teach how to make ethical decisions, that ethics codes have usually ignored issues especially pertinent to minorities and women and that complaint procedures most frequently focus on legally protecting the professional rather than displaying compassion toward the client.

In a commentary on the APA Ethics Code, The Society of Indian Psychologists (SIP; Garcia & Tehee, 2014) emphasized that:

Indigenous people have a holistic and inter-relational view of health. This view means that the Western-based concepts of body, emotions, mind, spirit, community, and land cannot be separated and that an individual cannot be separated from their relationships, including the generations before them and the generations to come. There are no distinctions between physical health, mental health, and spiritual health, which also means that my physical health, mental health, and wellbeing are related to yours (“we are all related”).

* They set forth 12 essential concepts, including:

Difficulties defining psychotherapy with precision or agreeing on a basic philosophy of ethics do not free the profession from setting forth its own ethics. The hallmark of a profession is the recognition that the work its members carry out affects the lives of their clients, sometimes in direct, profound, and immediate ways. The powerful nature of this influence makes the customary rules of the marketplace—often resting on variations of the principle “Let the buyer beware”—inadequate.

Society asks and expects the profession to create and set forth a code of ethics that holds its members accountable. At its heart, this code calls for professionals to protect and promote the welfare of clients and avoid letting the professional’s self-interests place the client at risk for harm.

Perhaps because society never completely trusts professions to enforce their own standards and perhaps because the professions have demonstrated that they, at least occasionally, are less than effective in governing their own behavior, society has established its own means for making sure that professions meet minimal standards in their work and that their clients are protected from incompetent, negligent, and dishonest practitioners. As a result, four major mechanisms have been developed to hold therapists and counselors accountable: (1) professional ethics committees; (2) state licensing boards; (3) civil (e.g., malpractice) courts; and (4) criminal courts. Each of these four mechanisms uses different standards, though they may overlap. Behavior may be clearly unethical and yet not form the basis for criminal charges.

In some cases, therapists and counselors may feel that these different standards clash. They may, for example, feel that the law compels them to act in a way that violates the welfare of the client and the clinician’s own sense of what is ethical. A national survey of psychologists found that a majority (57%) of the respondents had intentionally violated the law or a similar formal standard because, in their opinion, not to do so would have injured the client or violated some deeper value (Pope & Bajt, 1988). The actions reported by two or more respondents included refusing to report child abuse (21%), illegally divulging confidential information (21%), engaging in sex with a patient (9%), engaging in nonsexual dual relationships (6%), and refusing to make legally required warnings regarding dangerous patients (6%).

That almost 1 out of 10 of the respondents reported engaging in sex with a client using the rationale of patient welfare or deeper moral value highlights the risks, ambiguities, and difficulties of us evaluating the degree to which our own individual behavior is ethical.

Pope and Bajt (1988) reviewed the attempts of philosophers and the courts to judge those times when a person decides to go against the law (e.g., engage in civil disobedience). On one hand, for example, the US Supreme Court emphasized that in the United States, no one could be considered higher than the law: “In the fair administration of justice no man can be judge in his own case, however exalted his station, however righteous his motives, and irrespective of his race, color, politics, or religion” (Walker v. City of Birmingham, 1967, p. 1219–1220).

Conversely, courts endorsed Henry David Thoreau’s (1849/1960) injunction that if a law “requires you to be the agent of injustice to another, then … break the law” (p. 242). The California Supreme Court, for example, tacitly condoned violation of the law only when the principles of civil disobedience are followed

If we were to deny to every person who has engaged in … nonviolent civil disobedience … the right to enter a licensed profession, we would deprive the community of the services of many highly qualified persons of the highest moral courage (Hallinan v. Committee of Bar Examiners of State Bar, 1966, p. 239).

As Pope and Bajt note, civil disobedience (Gandhi, 1948; King, 1958, 1964; Plato, 1956a, 1956b; Thoreau, 1849/1960; Tolstoy, 1894/1951) is useful in many contexts for resolving this dilemma. The individual breaks a law considered to be unjust and harmful but does so openly, inviting the legal penalty both to demonstrate respect for the system of law and to call society’s attention to the supposedly unjust law. King (1963) explained why civil disobedience can only be done openly, publicly, and never covertly:

I hope you are able to see the distinction I am trying to point out. In no sense do I advocate evading or defying the law, as would the rabid segregationist. That would lead to anarchy. One who breaks an unjust law must do so openly, lovingly, and with a willingness to accept the penalty. I submit that an individual who breaks a law that conscience tells him is unjust, and who willingly accepts the penalty of imprisonment in order to arouse the conscience of the community over its injustice, is in reality expressing the highest respect for law (p. 8–9).

However, counselors and therapists often find this avenue of openness unavailable because of confidentiality requirements. If we as individuals and a profession are to address the possible conflicts between the law and our ethical responsibilities, one of the initial steps is to engage in frequent, open, and honest discussion of the issue. The topic needs open and active discussion in graduate courses, internship programs, case conferences, professional conventions, and informal meetings with colleagues.

Founded in 1892 and incorporated in 1925, the APA first formed the Committee on Scientific and Professional Ethics in 1938. As complaints were brought to its attention, this committee improvised solutions on a private, informal basis. There was no formal or explicit set of ethical standards, and the committee’s work was done on the basis of consensus and persuasion.

A year later, the committee was charged with determining whether the organization needed a formal ethics code. In 1947, it decided that a formal code was necessary, stating “The present unwritten code is tenuous, elusive, and unsatisfactory” (“A Little Recent History,” 1952, p. 425). The board of directors established the Committee on Ethical Standards for Psychology to determine what methods to use in drafting the code. Chaired by Edward Tolman, the committee members were John Flanagan, Edwin Ghiselli, Nicholas Hobbs, Helen Sargent, and Lloyd Yepsen (Hobbs, 1948).

Some members strongly opposed creating formal ethical standards, and many of their arguments appeared in the American Psychologist. Calvin Hall (1952), for example, wrote that any code, no matter how well formulated,

plays into the hands of crooks …. The crooked operator reads the code to see how much he can get away with, and since any code is bound to be filled with ambiguities and omissions, he can rationalize his unethical conduct by pointing to the code and saying, “See, it doesn’t tell me I can’t do this,” or “I can interpret this to mean what I want it to mean” (p. 430).

Hall endorsed accountability, but he believed that it could be enforced without an elaborate code. He recommended that the application form for APA membership contain this statement:

As a psychologist, I agree to conduct myself professionally according to the common rules of decency, with the understanding that if a jury of my peers decides that I have violated these rules, I may be expelled from the association (p. 430–431).

Hall placed most of the responsibility on graduate schools. He recommended that “graduate departments of psychology, who have the power to decide who shall become psychologists, should exercise this power in such a manner as to preclude the necessity for a code of ethics” (p. 431).

The APA Committee on Ethical Standards (APA Committee) determined that because empirical research was a primary method of psychology, the code itself should be based on such research and should draw on the experience of APA members. As Hobbs (1948, p. 84) wrote, the method would produce “a code of ethics truly indigenous to psychology, a code that could be lived.”

The board of directors accepted this recommendation, and a new committee was appointed to conduct the research and draft the code. Chaired by Nicholas Hobbs, the new committee members were Stuart Cook, Harold Edgerton, Leonard Ferguson, Morris Krugman, Helen Sargent, Donald Super, and Lloyd Yepsen (APA Committee, 1949).

In 1948, all 7,500 members of the APA were sent a letter asking each member “to share his [their] experiences in solving ethical problems by describing the specific circumstances in which someone made a decision that was ethically critical” (APA Committee, 1949, p. 17). The committee received reports of over 1,000 critical incidents. During the next years, the incidents, with their accompanying comments, were carefully analyzed, categorized, and developed into a draft code.

The emerging standards, along with the illustrative critical incidents, were published in the American Psychologist (APA Committee, 1951a, 1951b, 1951c). The standards were grouped into six major sections:

The draft sparked much discussion and several revisions. Finally, in 1952, it was formally adopted as the Ethical Standards of Psychologists, and it was published in 1953.

In 1954, information on the complaints that the committee had handled for the past 12 years, during most of which there had been no formal code of ethics, was published in the American Psychologist (“Cases and Inquiries,” 1954). During this period, the ethical principles most frequently violated were:

APA pioneers provided an array of reasons to use an empirical approach to create the code of ethics for psychologists. But a critical incident survey of APA members could also serve other purposes. For instance, the actuarial data of ethics committees, licensing boards, and civil and criminal courts can reveal trends in ethical or legal violations as established by review agencies, empirical critical incident studies. They can also reveal ethical dilemmas and concerns that are encountered in day-to-day practice by a diverse range of psychologists and not just those who are subject to formal complaint.

The APA critical incident study undertaken in the 1940s was replicated in the 1990s and published in the American Psychologist (Pope & Vetter, 1992). In this study, 1,319 randomly sampled APA members were asked to describe incidents that they found ethically challenging or troubling. Table 3.1 describes 703 incidents in 23 categories provided by 679 psychologists.

Table 3.1. Ethical Problems Reported by a National Sample of APA Members.

Here is a sample of the ethical concerns that the psychologists described in this anonymous survey:

The most recent version of the ethical principles (APA, 2017a), the Ethical Principles of Psychologists and Code of Conduct With the 2010 Amendments, is the 12th version. APA published versions of the code or amendments in these years: 1953, 1959, 1963, 1968, 1977, 1979, 1981, 1990, 1992, 2002, 2010, 2016. The current version consists of an introduction, a preamble, five general principles, and specific ethical standards. The preamble and general principles, which include beneficence and nonmaleficence, fidelity and responsibility, integrity, justice, and respect for people’s rights and dignity, are aspirational goals to guide psychologists toward the highest ideals of psychology. The specific ethical standards are enforceable rules of conduct.

The APA Ethics Code Task Force is in the process of revising the code, and has developed eight initial draft principles (APA Ethics Code Task Force, 2020, July 31). Additional principles seem to reflect attempts to incorporate evolving awareness of human rights and social responsibility. The aspirational guiding principles include beneficence and nonmaleficence, human and civil rights, integrity, interrelatedness of people, systems and the environment, professionalism and responsibility, respect for the welfare of persons and peoples, scientific mindedness, and social justice.

The CPA was organized in 1939, incorporated under Part II of the Canada Corporations Act in 1950, and received its Certificate of Continuance under Canada’s Not-for-profit Corporations Act in 2013. In the mid-twentieth century, Canada was a geographically large country with relatively few psychologists. Because it would have been hard to bring these psychologists together to create an ethics code, “the Canadian Psychological Association … decided to adopt the 1959 … APA code for a three-year trial. This was followed by adoptions (with minor wording changes) of the 1963 and 1977 APA revised codes” (Sinclair & Pettifor, 2001, p. i).

Discontent with the APA code and the perception that it was not a good fit for Canadian psychologists led the CPA to create its own code. Prior to developing its own code, there was evidence of periodic discontent by CPA members with the APA code. For example, in a 1976 document titled “Alternative Strategies for Revising CPA’s Code of Ethics,” the statement was made that the 10 APA ethical principles were “clearly designed for the current American social and moral climate and geared to American traditions and law.” However, it was not until the 1977 revision of the APA code that the discontent became serious.

Of particular concern was the fact that, in response to US court applications of antitrust law to professional activities, the APA had removed some of its restrictions on advertising. Many Canadian psychologists believed such application of antitrust laws ran the risk of changing the nature of the professional relationship from a primarily fiduciary contract to a commercial one (Sinclair et al., 1996, p. 7).

To create an ethics code, CPA began with a critical analysis of the international and interdisciplinary literature to determine the primary purposes of codes of ethics and their perceived strengths and weaknesses. This was followed by sending out 37 ethical dilemmas to psychologists who were asked how they would act in these situations and, equally important, to describe their reasoning (Sinclair et al., 1987). The responses yielded four basic ethical principles (CPA, 1986):

The original CPA ethics code opened with a Preamble, which included a model of ethical decision-making in which the four ethical principles are to be considered and balanced. The Preamble was followed by four sections. Each section included an ethical principle, identified the values that give definition to the ethical principle, and list the standards that illustrate the application of the principle to the activities of psychologists.

Although the code was revised in 1991 and 2000, its original structure and emphases on the four ethical principles and ethical decision-making remains (Sinclair, 1998, 2011).

The third revision of the Canadian Code of Ethics for Psychologists (CPA, 2017a) maintains the structure and emphases of previous editions of the Code, but with clarification, updates, and additions related primarily to the following themes:

In 1985, the CPA Board approved a framework for re-directing to a regulatory body any complaint against a CPA member who is registered with that regulatory body. Although CPA would review the outcome of adjudication of the complaint, this review is to determine whether the individual’s CPA membership should be terminated or whether any conditions should be placed on the membership. The complaint is not re-adjudicated. This practice has remained in effect to the present. However, CPA does accept and adjudicate complaints about CPA members who are not registered, as well as complaints that regulatory bodies believe do not come under their jurisdiction.

In 2019, the APA issued the following statement:

Complaints Regarding APA Members

APA has made changes to its adjudication program to better serve individuals who believe they have been harmed by a psychologist. Our focus now will be on providing information on other potential avenues for resolution that have a greater ability to take a desired action against an unethical psychologist. We only accept complaints against an APA member psychologist if there is no alternative forum to hear the complaint. If another forum takes an action against the member, the APA can review the matter at that time.

Is the Psychologist You Would Like to Complain About Licensed?

If a state psychology licensing board has jurisdiction, we will not accept a complaint against them. (In the event that the licensing board makes a significant finding against the member psychologist, we will be informed and will review the behavior under a different process).

If you have a complaint against a psychologist, you should contact your local, state, provincial, or territorial psychology licensing board to determine if the psychologist is licensed and obtain information on filing a complaint with that licensing board. These state regulatory agencies control the ability of a psychologist to practice and are separate entities from APA. A complete list can be found at The Association of State and Provincial Psychology Boards.

There also may be other avenues for you to consider, even if the psychologist is not licensed. If you are a student wishing to complain about a faculty member, you should explore your school’s grievance procedures. Similarly, faculty members can explore their institution’s faculty grievance procedures. If the matter involves child custody issues, another avenue beyond filing with the licensing board would be to work with your lawyer to present your concerns to the judge.

Why Is This the Focus?

As a membership organization, APA cannot revoke a psychologist’s license or restrict a psychologist from practicing. We cannot obtain a monetary award for you or require that a psychologist do something you request. As with most membership-based organizations, the most serious action that APA can take is expelling the member from the association with notifications. We also do not have powers of investigation that governmental bodies and others possess. In most situations, there is a licensing board or other body that can review your complaint in greater depth and provide you greater relief for unethical behavior.

If you would like to receive additional assistance in identifying another forum better suited to hear your complaint, please contact us. In the event you have a record of a significant finding against a member by a forum other than a licensing board, you may contact us to give us that information (APA, 2019a, para. 1–6).

As emphasized in Chapter 1 and throughout this book, knowing the professional codes is important to ethical decision-making but it is not sufficient. Codes cannot stand alone and do the thinking and deciding for us, freeing us from our personal responsibility. The next few chapters focus on some other concepts—Dignity, Respect, Trust, Power, Caring, Culture, Social Justice, and Human Rights—that are key to ethical awareness, choice, and action.

Recognizing the inherent value of our clients and treating them with deep regard for their humanity is fundamental to the work that we do as psychotherapists. It is striking and strange that key concepts like “dignity” and “respect” are absent from so many discussions of ethical decision-making. Perhaps it’s because we assume that we are drawn into this field because we see the inherent worthiness of people. Perhaps it’s because the terms seem vague, abstract, and hard to define. Perhaps it’s because we assume that dignity and respect look the same across cultures. Perhaps it’s because violations of dignity and respect rarely serve as the explicit focus of ethics complaints, licensing board actions, and malpractice suits. Perhaps it’s because we clinicians get caught up navigating the laws, rules, procedures, and paperwork related to carefully regulated areas like informed consent, insurance coverage, and confidentiality. And perhaps it’s because we are socialized in a society that works against treating each person with dignity and respect.

Despite such absence, associations like the Canadian Psychological Association (CPA) and the American Psychological Association (APA) emphasize dignity and respect as fundamental. CPA makes “Respect for the Dignity of Persons and Peoples” the first of four basic principles and the one generally given the most weight:

This principle, with its emphasis on inherent worth, non-discrimination, moral rights, distributive, social and natural justice, generally should be given the highest weight, except in circumstances in which there is a clear and imminent danger of bodily harm to someone (CPA, 2017b).

The Canadian Code goes beyond an emphasis on moral rights to embrace human rights, civil rights, and an array of other basic principles that recognize the importance of treating every person with dignity and respect

[Psychologists would] not promote, contribute to, nor engage in any activity that contravenes international humanitarian law (e.g., declarations, treaties, or conventions regarding: human rights; torture and other cruel, inhumane, or degrading treatment or punishment; economic, social and cultural rights; civil and political rights; rights of indigenous peoples; children’s rights; weapons of mass destruction; destruction of the environment) (CPA, 2017a, IV.26).

For APA, “Respect for People’s Rights and Dignity” is one of the five basic principles, which are aspirational and inform the standards. APA’s ethics code states that:

Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision-making. Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status, and consider these factors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices (APA, 2017a, Principle E).

An initial draft of the revision of the next APA Ethics Code includes eight draft aspirational principles, including “Respect for the Welfare of Persons and People.” A definition incorporates and expands the previous principle above:

A new, additional related principle has been added as well, “Human and Civil Rights.” The description of the new proposed principle follows:

Note:

While Human Rights serve as the basis of many goals and aims that relate to the way humans should interact, they must be deemed aspirational and dependent upon the good will of humankind. Because of human nature there will always be the risk for violations of Human Rights. Civil Rights and Civil Liberties however are defined and ensured by (codified within) the laws of a governing or constitutional body to its citizens. They are rights designed to ensure/guarantee fairness and protect/guard against discrimination or repression without regard to particular attributes of the citizenry. They are basic freedoms or rights enjoyed by all the citizens of a government by law without any further specificity. Although they may require legal or legislative intervention in order to be secured or obtained, civil rights and civil liberties are protected and cannot be taken away without due process.

Therefore, in the conduct of their activities, it is important that psychologists recognize both the basis for and the characteristics of human rights, civil rights, and civil liberties, their protections and their vulnerability for violation.

Clearly, the evolution of awareness in society of the importance of promoting dignity and respect, including human and civil rights, has influenced the profession of psychology.

When we strengthen, deepen, and broaden our ethical awareness, we hone our skills at catching ourselves whenever we fail to fully respect the dignity of our patients, perhaps by not paying careful attention to them. Most of us learn about this failure when we are on the receiving end. For instance, have you led a charmed life free of the sinking realization that the other person, who supposedly is there to help, was either not showing you the basic respect of paying attention or seemed intent on slowing or blocking you from getting the help you need? Consider the following scenarios to see if any feel familiar:

You walk into the store to buy a new coat and (good!) there are no other customers—just four sales clerks near the back of the store telling each other jokes—so you should be able to get in and out of there without standing in line to check out. You go over to the coats but no sales person comes over to ask if you need help. You pick out the coat you want, try it on to make sure it fits, and walk over to the register. The sales clerks seem blissfully unaware of your existence, even after you clear your throat a couple of times. Finally, you say, “I’d like to buy this coat. Would one of you be able to check me out?” The sales clerk nearest you turns around to see who’s talking, looking at you as if you’d burped loudly at a formal dinner. The clerk holds up an index finger, indicating that your opportunity to give the store your money will come soon and you should show some patience. Finally, one of the longest jokes in recorded history reaches its long-anticipated punch line, and not too long after, you have left the store with your new coat. Another “satisfied” customer.

▪ ▪ ▪

You walk into another store and this time a manager, their face full of concern, practically runs over to you and asks, “Can I help you?” When you say, “just browsing,” they follow you around the store, a look of disdain on their face. It’s clear they didn’t think you belonged in the store, didn’t want you in the store, thought you came to shoplift, or cause some kind of trouble. Why would they think that? Did they think you couldn’t afford what the store had to sell? Was it your skin color? Your Rainbow Coalition pin? Your yarmulka? Your burqa? Your Black Lives Matter shirt? Why did the manager decide, just by looking, that you were not to be treated with dignity and respect?

▪ ▪ ▪

You (calling a clinic near closing time to reach your child’s pediatrician before he leaves the country on a 2-week vacation): Hi, I’m hoping to reach Dr. Guzman before he heads for the airport. My child has come down with something and no one knows her like Dr. Guzman. Any chance he’s still there?

Receptionist: Oh, I just saw him packing his briefcase in his office. Let me run to catch him before he leaves, and I have to chase him across the parking lot! [puts you on hold]

[You wait. And wait. You see in your mind’s eye the old movie convention of clock hands whirring around to show the passage of time. Then you see calendar pages flying off the wall. And then finally!]

Receptionist: What were you waiting for? Oh, I’m sorry, he left a while ago.

▪ ▪ ▪

You’re on the phone with tech support: Hi, I’m hoping you can help me get my internet connection up and running again quickly because I’ve got a Zoom session scheduled for a patient in crisis in 5 minutes. Let me tell you what I’ve already tried so that we can save time not going through those initial steps. I’ve tried disconnecting everything from my router, unplugging it from the wall socket, waiting 10 seconds, then plugging it again, and reconnecting everything. Then I tried checking all the settings on my computer to make sure they were correct. Then I made sure my computer didn’t have a virus that was messing things up. Anything else we could try?

Tech support: I am so sorry you are having trouble with our company’s services, but I am sure that I will be able to help you reconnect to the internet. Let’s start with this: First, please disconnect everything from your router, unplug it from the electrical socket, and wait about 10 seconds before we plug everything back in to see if that works.

▪ ▪ ▪

Anyone who speaks to you using sentences that begin with: “No offense intended but …”, “I hope you won’t take this the wrong way but …”, “With all due respect …”, or “You know I love you but …”

For most of us, realizing when others cut us short on respect and dignity comes easier than realizing when we do it to others. What may be completely understandable under the circumstances and hardly worth noticing when we do it, becomes very clear when it is done to us—arrogance, intentional disrespect, veiled hostility, a personality disorder, a lack of human decency, unforgivable, and part of a clear and consistent pattern of high crimes and misdemeanors.

This ethical responsibility often slips easily from our awareness. Even if treating others with full respect for their dignity is our goal and our custom, we are likely to face countless obstacles. Here are a few examples:

We work in a world in which most of us must manage the DSM (Diagnostic and Statistical Manual of Mental Disorders), the ICD (International Classification of Diseases), insurance forms, and other forces that draw our attention to diagnostic categories and invite us to think of our patients in terms of which diagnostic labels apply. The powerful language of labels can distort or blot out completely the person behind the label. Some clinicians, particularly in inpatient and forensic settings, may stop using the patient’s name entirely and use only the label, often in a way that seems to lack respect or dignity (e.g., “Time to see if that schizophrenic is ready for a home visit. You gotta be careful with schizos”).

We also work in a world where most of us must pay the bills and many of us face financial pressures. If we are in independent practice, the gain or loss of one patient, particularly one who promptly pays our full fee, can mark the difference in whether we’re in the red or black that month and whether we can pay the office rent and our other bills on time. When each patient’s fee can produce such an immediate powerful impact, it is hard not to have financial issues weighing on our mind as we decide whether this long-term patient is ready for termination or whether we’re truly competent to work with that new patient we just screened.

When we’re tired, it’s hard to pay full attention to our patients, to take in what they may be telling us between the lines of what they say, and to respond sensitively. When we’re dragging through the day, it’s easy to be short with others, to take things the wrong way, and to miss what’s important.

We all have them—certain things we like and, of course, dislike about other people. Each of us could get a good start on our own private list of negative reactions by completing the following sentences, as many ways as possible, with complete honesty and without censoring ourselves:

Our personal list may include negative emotional reactions evoked solely by someone’s membership in certain social categories based on

These negative emotional reactions based solely on such categories have the potential to choke off our respect for the dignity of that person.

This chapter is a reminder that treating others with respect for their dignity is a basic ethic of our profession, one easily overlooked but facing countless challenges. None of us is perfect in this area. All of us will fall short more than once over the course of a career. It will suddenly strike us that we’ve been sitting with a patient for most of a therapy session and for most of that time our mind has been elsewhere; we’ll breathe a deep sigh of relief as we terminate a patient, realizing that we never liked the person, never invested much in the therapy, and feel joy that we’re rid of that person; a patient will say something that somehow breaks through our shell and we’ll discover that some time ago we’d lost our sense of shared humanity with someone who’d started to seem like a stranger. The Golden Rule is useful here, no less so for being a cliché: We must strive to treat our patients and others with the same respect for their dignity that we wish to receive from others.

Psychotherapy is a remarkable venture. It harnesses three forces—trust, power, and caring—to help people heal. In our work, we face the ethical challenge of understanding, respecting, and handling carefully all three.

When we apply to states and provinces for professional status via licensure and certification, we accept the responsibility that comes with that status. Society expects us to be trustworthy, to avoid abusing the trust that people place in us. Society depends on us to fulfill that trust for the good of our clients as well as society. Ethical dilemmas can arise from the clash between the client’s interests and society’s interests, or between the client’s interests and the therapist’s interests. In return for assuming a role in which the safety, well-being, and ultimate good of clients is to be held as a sacred trust, we are entitled to the roles, privileges, and power that governments and society entrust to professionals.

This concept of trust is key to understanding the context in which clients enter into a working relationship with us. Clients expect or desperately hope that they can trust us. Many fear we might betray their trust. Some agonize over trust issues. Others find barriers to trust almost insurmountable. And others, like Black, Indigenous People of Color (BIPOC) clients come to therapy knowing that the profession we represent has violated their trust many times throughout history. Still others come to therapy unaware of how their problems trusting others have made it hard for them to love, work, and enjoy life.

Trust is at the core of therapy and clinicians put it to good use. In therapy we expect clients to walk into the consulting room of an absolute stranger and say things that they would say to no one else. We therapists may ask questions that would get us slapped, punched, or sued if we asked them outside of therapy. What patients tell us in confidence carries potential to be therapeutic or harmful depending how we use that information and/or, whether we violate the client’s trust by breaking the sacredness of confidentiality. This potential to help or hurt has led virtually all states and provinces to recognize some form of professional confidentiality and therapist–patient privilege. Laws prevent therapists, with some specific exceptions, from talking to others about what clients share with them during therapy.

Therapy, like surgery, relies on trust. Surgery patients allow themselves to be physically opened up in the hope that their condition will improve. They trust or may reluctantly trust surgeons not to take advantage of their vulnerability to harm or exploit them. Therapy patients undergo a process of psychological opening up in the hope that their condition will improve. They trust us or want to trust us not to harm or exploit them. Freud (1952) noticed this similarity. He wrote that the newly developed “talking therapy” was “comparable to a surgical operation” (p. 467) and emphasized that “the transference especially … is a dangerous instrument … If a knife will not cut, neither will it serve a surgeon” (p. 471). Recognizing and respecting the potential harm that could result from psychotherapy was, according to Freud (1963), essential:

It is grossly to undervalue both the origins and the practical significance of the psychoneuroses to suppose that these disorders are to be removed by pottering about with a few harmless remedies … Psychoanalysis … is not afraid to handle the most dangerous forces in the mind and set them to work for the benefit of the patient.

As patients, only if we trust the therapist and their intentions are we likely to speak truthfully about—or even disclose at all—events and topics that make us feel fear, shame, guilt, anxiety, or all the other forms of discomfort and apprehension. Research by Farber et al. (2019) found that trust played a “role for clients concealing depression symptoms; 42% of respondents saw it as a way to foster honesty. Increasing trust was also important to clients concealing mistreatment in relationships and even for those lying about self-harm” (p. 3203–3204).

Our ethical responsibility includes respecting our clients’ trust that we will do nothing that places them at risk for harm. When we betray the client’s trust, they may lose hope in the system and profession we represent and not just in us as individual providers. When we betray our clients’ trust, we can sometimes cause deep, pervasive, lasting damage. The poet Adrienne Rich wrote a vivid description of the effects of shattered trust:

When we discover that someone we trusted can be trusted no longer, it forces us to reexamine the universe, to question the whole instinct and concept of trust. For awhile, we are thrust back onto some bleak, jutting ledge, in a dark pierced by sheets of fire, swept by sheets of rain, in a world before kinship, or naming, or tenderness exist; we are brought close to formlessness (1979, p. 192).

Research by psychology professor Jennifer Freyd and her colleagues (e.g., Freyd, 1998; Freyd et al., 2005; Gobin & Freyd, 2014; Platt & Freyd, 2015; Smith, 2017) has explored and described how betrayal trauma can result when our trust is violated. Freyd emphasized:

Psychologically, betrayal is toxic to the mind and body. We know this from decades of research on betrayal trauma. People who are betrayed are likely to suffer mentally and physically. This is true whether the betrayer is a trusted person—like a psychotherapist or supervisor—or a trusted institution—like a clinic, hospital, or university. In the case of institutional betrayal, the harm can be particularly acute and even associated with increased thoughts of suicide (personal communication, August 7, 2020).

We all face the challenge of understanding what inspires and validates trust and what misreading, misunderstanding, or mishandling trust can mean for the client. For some of us, advanced degrees from prestigious universities, diplomate status and other certifications (often framed in the office), awards and honors (often framed even more prominently in the office), publications in respected journals on topics related to what we want to work on in therapy, fame, and even an office in an impressive building may inspire our initial trust in a therapist. Surely someone with all those accomplishments must know what they’re doing, some of us might think, rightly or wrongly. For others the realities of intergenerational trauma and institutionalized forms of oppression experienced many times at the hands of those deemed experts rightfully detract from our ability to trust us. Clients may think that we may not know what to do with them. Others know that we too have biases that affect how we treat them; yet, despite these valid concerns, clients hope to be proven wrong. They hope we can be of help so they can feel better.

But for some prospective patients, these markers may be warning signs and even barriers to trust (Alire, 2019; Okun et al., 2017; Sue et al., 2019). These markers may suggest to members of historically oppressed communities that the therapist is a member of the establishment that has inflicted prejudice, discrimination, hate, oppression, and injustice. For instance, some BIPOC may understandably assume that a White therapist holds the same racist views and practices that so many White people have held for generations, given the many ways in which systems and institutions provide unearned advantages (privilege) to White people. Some of these privileges include: hiring and promotion practices favoring Whites; juries less likely to convict White defendants or, after conviction, to impose the death penalty on White defendants for comparable crimes; and traffic stops being much less risky for White drivers than for Black drivers. BIPOC may believe that White therapists have accepted those views and enjoyed those benefits without acknowledging the taint, wrongness, and injustice of such unearned advantages, let alone working to dismantle racist or other oppressive systems.

A White therapist who reacts defensively to a client holding a version of such views—an extreme version might be “Why, there’s not a racist bone in my body. I have no racist views”—or tries to block or shunt side dealing with such trust issues honestly and openly, is on the wrong track. A well-intentioned response to an experience about discrimination, such as “Oh, I am sure they didn’t mean it that way” invalidates the reality and perceptions of the BIPOC client.

Many minorities may perceive that the therapist cannot be trusted unless otherwise demonstrated. Again, the role and reputation that the therapist has as being trustworthy evidenced in behavioral terms. More than anything, challenges to the therapist’s trustworthiness will be a frequent theme blocking further exploration and movement until they are resolved to the satisfaction of the client (Sue et al., 2019, p. 109).

Similarly, not talking or addressing issues related to racism, anti-Semitism, sexism, heterosexism, cis-sexism, gendered-racism and other forms of oppression may signal to the client that the therapist does not see these social problems as significant, real, or important to how they impact clients who are members of various minoritized groups. This lack of attention to the lived experiences of BIPOC and those who experience other forms of oppression may further negatively impact a client’s ability to trust that the therapist will hear, understand, and respect their experiences. The heart of trust is not about our telling clients to trust us, the credentials on our walls, or the buildings where we practice—the heart of trust is about who we are, about whether we treat our clients with dignity and respect, and about our actions and inactions.

The trust that society and individual clients give to therapists is one source of power—for example, the power to respect and value that trust or to abuse and betray it. The role of therapist holds power ranging from superficial to profound, from fleeting to lasting. The following sections look at seven forms of power including: (1) power given by the state; (2) power to name and define; (3) power of testimony; (4) power of knowledge; (5) power of expectation; (6) power created by the therapist; and (7) the inherent power differential.

State and provincial licensing confers power. Licensed professionals can do things that people without a license cannot. With patients’ consent, surgeons can cut human beings wide open and remove internal organs, anesthesiologists can drug clients until they are unconscious, and some therapists can recommend or administer mind or mood altering drugs to clients, all with the law’s authorization. People will take off their clothes and willingly (well, somewhat willingly) submit to all sorts of indignities during a medical examination. They let physicians to do things to them that they would not dream of letting anyone else do.

Similarly, clients will open up and allow us as therapists to explore private aspects of their thoughts, feelings, and social lives, including their history, fantasies, hopes, and fears. Clients will tell us their most guarded secrets, material shared with literally no one else. We can ask questions off-limits to others. States and provinces recognize the importance of protecting clients against the misuse of this power to violate privacy. Except in certain instances, we are legally required to keep confidential what we have learned about clients through the professional relationship. Holding private information about our clients gives us power.

Through licensing, governments also invest us with the power of state-recognized authority to affect our clients’ lives. We have the power to make decisions (subject to judicial review) about our clients’ civil liberties. In some cases, we have the power to determine whether a person constitutes an immediate danger to the life of someone else and should be held against their will for observation or treatment. Alan Stone (1978), professor of law and psychiatry at Harvard University and a former president of the American Psychiatric Association, noted that in the 1950s the United States incarcerated more of its citizens against their will for mental health purposes than any other country, and that the abuse of this power later led to extensive reforms and formal safeguards.

The state has sometimes used the power of involuntary hospitalization to enforce social injustice. For example, in 1958, Black pastor and civil rights activist Clennon King “tried in vain to enrol at the all-White University of Mississippi” (Negro pastor pronounced sane, demands Mississippi apologize, 1958, p. 3). State troopers took him to a mental health institution where he was imprisoned against his will. Where he had been committed was kept secret from everyone for 48 hours. After being confined in the mental health institution for 12 days, he was released when a panel of 17 doctors declared him sane. He regained his freedom only to face charges of disturbing the peace by trying to enrol in an all-White university and resisting arrest. He said, “My only fear of jail is what might happen to me in that jail—the authorities are the only ones who have threatened me” (Negro pastor pronounced sane, demands Mississippi apologize, 1958, p. 3).

In the 1940s and 1950s, the government of Quebec falsely diagnosed 20,000 Canadian children as mentally ill and imprisoned them in psychiatric institutions to enable the misappropriation of government funds (Boucher et al., 2008; Clément, 2016; Duplessis orphans seek proof of medical experiments, 2004). The children became known as the Duplissis Orphans, named after Mauric Duplessis, who governed as Premiere of Quebec for five non-consecutive terms between 1936 and 1959. These are only a few of the countless examples in which the field of mental health and therapists have acted in unjust ways causing harm to vulnerable populations, and engendering distrust in the mental health system.

We hold the power of naming and defining. To diagnose someone is to exercise power. In an ingenious study, Lam et al. (2016) showed clinicians a video of a woman describing how she experienced uncomplicated panic disorder. They then asked the clinicians to rate her problems and describe her prognosis. Research participants had been randomly assigned to three groups. One was given the woman’s personal details and background information, the second was also given a behavioral description consistent with borderline personality disorder, and the third was given one piece of additional information that included the label of a borderline personality diagnosis. The results showed the power of a diagnosis to affect perception and judgment. Their study found that “the BPD label was associated with more negative ratings of the woman’s problems and her prognosis than both information alone and a behavioural description of BPD ‘symptoms’” (p. 253).

In one of the most widely cited psychological research studies, “On Being Sane in Insane Places,” Rosenhan (1973) wrote, “Such labels, conferred by mental health professionals, are as influential on the patient as they are on his relatives and friends, and it should not surprise anyone that the diagnosis acts on all of them as a self-fulfilling prophesy. Eventually, the patient himself accepts the diagnosis, with all of its surplus meanings and expectations, and behaves accordingly” (p. 254).

Caplan’s description (1995) of psychiatrist Bruno Bettelheim’s analysis of student protesters reveals the potential power of diagnosis and other forms of clinical naming to affect how we view people:

In the turbulent 1960s, Bettelheim … told the United States Congress of his findings: student anti-war protesters who charged the University of Chicago with complicity in the war machine had no serious political agenda; they were acting out an unresolved Oedipal conflict by attacking the university as a surrogate father (p. 277).

The power of naming and defining has been particularly harmful to BIPOC and members of other oppressed social groups. For instance, naming “homosexuality” as a mental illness, being gatekeepers of gender-affirming terms for transgender people, over-diagnosing Black children with externalizing behavioral disorders and Black adults with more severe forms of mental illness (e.g., bipolar disorder, schizophrenia) has contributed to the pathologizing of communities who are already suffering as a result of discrimination and hatred.

We possess authority to change the course of lives when we testify as experts in the civil and criminal courts and through similar judicial or administrative proceedings. Our testimony can help determine whether someone convicted of murder is executed. It can be the deciding factor in whether a parent gains or loses custody of a child. It can shape a jury’s view of whether a defendant was capable of committing a crime, was likely to have committed it, was legally sane at the time the crime was committed or is likely to commit similar crimes in the future. It can lead a jury to believe that an uncle sexually abused a young child or that the child either imagined the abuse or was coached as part of a custody dispute. It can help immigrant and asylum-seeking individuals regularize their status in the United States so they can live and work free from the fear of being separated from their families or deported to countries where their lives may be at risk. Our testimony can convince a jury that the plaintiff is an innocent victim of a needless trauma who is suffering severe and chronic harm or is a chronic liar, gold digger, or malingerer.

Our role as therapist holds power beyond the power that a license creates. We hold power that comes from knowledge. We study human behavior, mental processes, and the intrapsychic and social factors that affect motivation, decision, and action. We learn methods to bring about change. Our research, writing, and our very words have the power of providing language and validation to experiences that have been marginalized, made invisible, silenced, and disregarded. Maintaining a constant, respectful awareness of the power flowing from knowledge and expertise is essential to avoid the subtle ways of manipulating and exploiting clients through our interaction with them or through our clinical documentation (treatment plans, progress notes, assessment report) and scholarship.

The process of psychotherapy itself creates and uses different forms of power. Most therapies recognize the force of the client’s expectation that the therapist’s interventions will be able to induce beneficial change. One aspect of this expectation is the placebo effect, a factor that must be considered when studying the efficacy and effectiveness of interventions. The client’s investing the therapist with power to help bring about change can become a significant part of the change process itself. Conversely, the therapist’s expectations, including optimism and belief in the client’s capacity to change, are powerful as well. Miller et al. (1995) reviewed the research and noted that

As a factor in outcome, technique matters no more than the “placebo effect” … The creation of such hope is greatly influenced by the therapist’s attitude toward the client during the opening moments of therapy. Pessimistic attitudes conveyed to the client … are likely to minimize the effect of these factors. In contrast, an emphasis on possibilities and a belief that therapy can work will likely counteract demoralization, mobilize hope and advance improvement.

On the basis of their research, Connor and Callahan (2015) reported:

Psychotherapists were found to hold significantly higher expectations for client improvement than anticipated, based on existing literature, and these high expectations were found to be positively correlated with clinically significant change in clients. Moreover, psychotherapists’ expectations were found to explain 7.3% of the explainable variance in whether or not clients experienced clinically significant change during psychotherapy (p. 351).

Similarly, research conducted by Swift et al. (2018) found that student therapists’ expectations were a “significant unique predictor of change. These results suggest that therapists should be aware of their own expectations when working with clients in order to make sure that any negative beliefs do not impact the quality of care that they provide” (p. 84).

In some approaches, the therapist works to create specific kinds of power. A family therapist may unbalance the equilibrium and disrupt alliances among family members. A behavior therapist may create a hospital unit or halfway/transitional house in which desirable behaviors bring a rewarding response from the staff (perhaps in the form of tokens that can be exchanged for goods or privileges); the power of the therapist and staff is used to control, or at least influence, the client’s behavior.

Psychologist Laura Brown (1994) describes another domain of the therapist’s power:

The therapist also has the power to engage in certain defining behaviors that are real and concrete. She sets the fee; decides the time, place, and circumstances of the meeting; and determines what she will share about herself and not disclose. Even when she allows some leeway in negotiating these and similar points, this allowance proceeds from the implicit understanding that it is within the therapist’s power to give, and to take away, such compromises (p. 111).

Power differential is inherent in psychotherapy. Although some approaches emphasize egalitarian ideals in which therapist and client are equal, such goals are viewed only within a narrowly limited context of the relationship. In truly equal relationships, in which there is no appreciable power differential, there is no designation of one member as “therapist” in relation to the other member, there is no fee charged by one member to the other for the relationship itself, there is no designation of the activity as “professional” (and falling within the scope of a professional liability policy), there is no license possessed by one member allowing initiation of a 72-hour hold on the other, and so on. A defining attribute of the professional is the recognition, understanding, and careful handling of the considerable power—and the personal responsibility for that power—inherent in the role. Regardless of how mutual, genuine, or egalitarian a therapist may choose to be, often utilizing humanistic, feminist (e.g., relational), multicultural orientations, some degree of power difference is unavoidable.

Both the individual client and society recognize the diverse powers of the professional role and place their trust in us to use those powers to help—never to harm, oppress, or exploit. We must match with our caring the trust that society and the individual client invest in us. Only within a context of caring and healing—specifically, caring about the client’s well-being, and working to not just help cope or adjust to intolerable circumstances but actually helping clients heal their pain—are our professional status and powers justified.

Historically, professional status was not created or defined by charging high fees, spending long years in training, or reaching a high level of skill. The professional’s defining characteristic was an ethic of placing the client’s well-being foremost and not allowing professional judgment or services to be drawn off course by one’s own needs and wants. A major purpose of professional ethics codes is to help us use our knowledge, skills, status, and other forms of powers to help our clients and not to take advantage of, endanger, cheat, undermine, abuse, or otherwise mistreat or harm them. “Professional ethics protect the public against the abuses of professional power, specialized knowledge, and prominent positions. They place protecting the public interest above advancing the profession’s self-interest” (Pope, 2019, p. 186). Professional ethics help keep us from being biased or blinded by our own self-interest so that we can no longer see clearly or care about our clients, their legitimate interests, and our responsibilities to them.

The touchstone for the approaches discussed in this book is caring for and about our clients. This book’s concept of caring avoids passive, empty sentimentality. Caring includes responding to a client’s legitimate needs and recognizing that the client must never be exploited. Caring also includes assuming personal responsibility for working to help and to avoid harming or endangering our clients. Caring involves learning to contextualize experiences and realities that may be completely different from our own so that we do not pathologize, misdiagnose, or misattribute behaviors that may be culturally congruent or blaming our clients for their reactions to oppression. Furthermore, caring means that we work on addressing our biases and prejudices as a way to ensure that we are able to treat all of our clients with the same level of respect and dignity. Caring is being a healing presence in the lives of those we serve.

Unfortunately, the concept of caring may not receive adequate attention in graduate training programs. As Seymour Sarason (1985) wrote:

On the surface, trainees accept the need for objectivity—it does have the ring of science, and its importance can be illustrated with examples of the baleful consequences of “emotional over-involvement”—but internally there is a struggle, as one of my students put it, “between what your heart says you should say and do and what theory and your supervisor say you should say and do.” Many trainees give up the struggle but there are some who continue to feel that in striving to maintain the stance of objectivity they are robbing themselves and their clients of something of therapeutic value. The trainee’s struggle, which supervisors gloss over as a normal developmental phase that trainees grow out of, points to an omission in psychological-psychiatric theories. Those theories never concern themselves with caring and compassion. What does it mean to be caring and compassionate? When do caring and compassion arise as feelings? What inhibits or facilitates their expression? Why do people differ so widely in having such feelings and the ways they express them? It is, of course, implicit in all of these theories that these feelings are crucial in human development, but the reader would be surprised how little attention is given to their phenomenology and consequences (positive and negative) (p. 168).

Sarason made some excellent recommendations for how to encourage and develop caring, compassion, and empathy in clinical training programs, and more recently other innovative approaches have begun to emerge (see, for example, Condon & Makransky, 2020; Fragkos & Crampton, 2020; Han & Kim, 2010).

We still have a long way to go in ensuring that clinical training programs, internships, professional organizations, clinics, hospitals, and other settings are doing all they can to support caring, compassion, and empathy among clinicians. Unfortunately, there is evidence that such qualities may actually decline in some settings (see, for example, Hegazi & Wilson, 2013; Hojat et al., 2004, 2009). In “Empathy Decline and Its Reasons: A Systematic Review of Studies with Medical Students and Residents,” Neumann and her colleagues noted that the evidence of declines of empathy over the course of medical training, they describe:

Some of the studies included in our review reported significant increases in cynicism among medical students. Crandall et al. also found students’ commitment to caring for medically underserved patients to be greater when they entered medical school than at graduation. This result was independent of gender and curriculum type (problem-based versus traditional; Neumann et al., 2011).

Caring about clients and what happens to them is at the heart of the formal rules and regulations that are society’s attempt to hold us accountable, of our professional ethics codes, and of our personal ethical responsibilities to each patient.

When patients seek our services, they hope we know how to help them. Ethical practice hinges on competence, including our ability to use our skills effectively to help our clients heal and cope with the challenges they face. Society gives us the power and privileges to help our clients, while holding us accountable for competence through the courts and licensing boards.

Cynthia Belar (2009) discusses our ethical responsibility to train competent psychologists and to maintain our own competence as our “social contract.” She emphasizes that a central question for our training programs

is whether we are producing what we say we are producing—a psychologist competent for entry to practice. This question comes from prospective students, prospective employers, and the public. Indeed our social contract with the public as an independent profession requires that we self-regulate in these matters (p. S63).

The importance of that social contract was emphasized by The European Association of Clinical Psychology and Psychological Treatment (EACLIPT) Task Force on Competences of Clinical Psychologists (2019): “Politicians, societies, stakeholders, health care systems, patients, their relatives, their employers, and the general population need to know what they can expect from clinical psychologists” (p. 1).

Some patients may expect magic. For them, competence means that we can guarantee results, act flawlessly, and meet all needs. While this superhero, shero, or theyro role can be tempting, and some of us find it difficult to turn down potential worshippers, it is not realistic. We don’t have a magic wand that can disappear our clients’ distress, pain, and difficulties. Unfortunately some therapists indulge their ego and take up residence in this delusional state.

This chapter is a reminder that as therapists, we are all human and imperfect. We all have weaknesses, blind spots, and biases, as well as strengths, abilities, and insights. Hence, it is important for us to keep a healthy dose of humility.

Failures of competence often spring from our human vulnerabilities. We face temptations, pressures, distractions, demands, and countless other forces. These forces can weaken our ability to know the limits of our competence and can sometimes block our ability to act effectively altogether. Consider, for example, the ways in which we have been socialized to respond to members of various groups. Unless challenged, this socialization affects our attitudes, beliefs, biases, and prejudices which may impact our competence to provide therapy or counseling to members of diverse groups. In addition, each of us has our own personal history, individual experiences, and an array of group-based reactions which can also impact our competence. See if the following self-assessment turns up any challenges to competence for you. Imagine you are in your office and a new patient walks in. Set aside for the moment whether you have training to work with a member of the group. Focus only on whether the patient’s membership in a specific group evokes any reactions in you that might weaken your competence to welcome, become interested in, listen openly to, empathize with, and create a positive working relationship with them. Also, consider how you may respond if you are a member of a social group that has a history of being harmed by the new client’s social group (Chapters 7 and 23 provide more discussion). The array of patients you meet may include:

How did you do? Turn up any potential challenges to competence? Achieving awareness of these challenges puts us in a better position to handle them carefully, knowledgeably, and ethically, and to approach each situation with humility.

Our own values and experiences as members of different groups contribute to our biases, blind spots, and other limitations. Our ethical awareness depends on us becoming aware of these limitations. Despite our best efforts to spot problem areas, some of these challenges may stay hidden from our awareness for quite a while yet manifenst themselves in our moment to moment interactions with our patients, supervisees, mentees, and colleagues. We may pride ourselves on our lack of biases toward certain groups and yet our behaviors may seem somehow “off.” Others may view what we say or do in regard to members of that group as avoidant, passive-aggressive, subtly hostile (words and behaviors sometimes termed “microaggressions”), or more openly biased—all of which may escape our attention. In addition, we may be well aware of the biases and prejudices that we have toward particular groups, but we may excuse them or view them as valid.

One tipoff that we may need to examine our competence to work with a particular group is if we talk about members of that group differently when they are present than when they are not within earshot. This difference in behavior, depending on whether members of a group are present, can be much more subtle than simply telling certain jokes, imitating accents, making generalizations about the group, and the like.

The theme of blind spots and biases affecting our competence on the individual level runs throughout this book and is a focus of Chapters 7 and 23—but a parallel theme is the way they affect the competence of organizations. For example, think of the different clinics, hospitals, and other agencies you’ve been to. Imagine the array of patients listed above each entering that agency, walking to the reception desk, and asking about getting help there. To what extent do you think each person would actually feel welcomed and get the help they need?

The opening chapters of this book rejected views of ethics as rigid rule following and presented an approach in which professional codes, administrative directives, legislative requirements, and other givens mark the start of a process of creative questioning and critical thinking. We search for the most ethical and positive way to respond to each unique patient with unique needs and resources in a unique context.

We carry on this creative questioning and critical thinking with a sense of humility as fallible human beings, vulnerable to fatigue, discouragement, frustration, anger, fear, and feeling overwhelmed. Our work depends on not just intellectual competence (knowing about and knowing how) but also what might be called emotional competence for therapy (Pope & Brown, 1996).

Competence is hard to define. Licensing boards and civil courts sometimes specify defining criteria for areas of practice. More often, they require only that in whatever area of therapy and counseling the clinician is practicing, they should possess demonstrable competence. Demonstrable competence requires clinicians to produce evidence of their abilities. Usually this evidence comes from formal education, professional training, and supervised experience, followed by continuing education.

A competence requirement often appears in ethical, legal, and professional standards. Here are some examples:

The ethical requirement of competence recognizes that the therapist’s power and influence (see Chapter 5) should not be handled in a careless, ignorant, and thoughtless manner. The complex, hard-to-define nature of therapy tends to cloud why this requirement makes sense. It becomes clearer by analogy to other fields. A physician who is an internist or general practitioner may do excellent work, but would any of us want that physician to perform coronary surgery or neurosurgery on us if they did not have adequate education, training, and supervised experience in these forms of surgery? A skilled professor of linguistics may have a solid grasp of a variety of Indo-European languages and dialects but be completely unable to translate a Swahili text.

Pulled by patients holding exaggerated beliefs about our abilities and pushed by our own impulse to step in and help, our humility may fail us and we may resist admitting to ourselves and the client that we lack competence for a particular situation. We may need new clients to pay the bills and fear shutting off a valued referral source. Managed care may require us to take the patient. Nevertheless, extensive education, training, and supervised experience in working with adults does not qualify us to work with children; solid competence in providing individual therapy does not qualify us to lead a therapy group; and expertise in working with people who are profoundly depressed does not qualify us to work with people who have developmental disabilities.

At times, complex situations require great care to determine how to respond to a client’s needs while staying within our areas of competence. For example, a counselor may begin working with a client on issues related to depression, an area in which the counselor has had considerable education, training, and supervised experience. Much later the therapeutic journey leads into a problem area—bulimia—for which the counselor has little or no competence.

Alternatively, a client starts meeting with a counselor to deal with problems concentrating at work. Soon, the client says they suffer from agoraphobia. Can the counselor ethically assume that the course on anxieties and phobias that they took 10 years ago in graduate school makes them competent? The counselor must decide whether they have the time, energy, and interest in gaining competence through continuing education, study, or consultation to provide up-to-date treatment for agoraphobia or whether they need to refer the client or find some other way for the client to get competent help for agoraphobia.

Clinicians who work in isolated or small and rural communities often face this dilemma. They take workshops, consult long distance with experts, and come up with creative strategies to make sure that their clients receive competent care. Despite the clear ethical and legal mandates to practice only with competence, some of us suffer lapses. A national survey of psychologists, for example, found that almost one-fourth of the respondents indicated that they had practiced outside their area of competence either rarely or occasionally (Pope et al., 1987).

Intellectual competence involves one’s fund of knowledge or “knowing about.” In our graduate training, internships, supervised experience, continuing education, and other contexts, we learn about the research, theories, interventions, and other topics that we need to do our work. We learn to question the information and assess its validity and relevance for different situations and populations. We learn to create and test hypotheses about assessment and interventions. We find ways to keep up with the latest therapy research.

Part of intellectual competence is learning which clinical approaches, strategies, or techniques show evidence or promise of effectiveness and for whom do such techiques work. If clinical methods are to avoid charlatanism, hucksterism, and well-meaning ineffectiveness, they must work (at least some of the time). The practitioner’s supposed competence means little if their methods lack competence. In his provocative article The Scientific Basis of Psychotherapeutic Practice: A Question of Values and Ethics, Jerry Singer (1980) emphasized the ethical responsibilities of clinicians keeping up with the emerging research basis of the methods they use.

Intellectual competence also means learning what approaches have been shown to be invalid or perhaps even harmful. George Stricker (1992) wrote:

Although it may not be unethical to practice in the absence of knowledge, it is unethical to practice in the face of knowledge. We all must labor with the absence of affirmative data, but there is no excuse for ignoring contradictory data (p. 544).

Intellectual competence is not frozen in time. David Barlow showed how quickly well-designed research can change our views of which interventions are effective, worthless, or even detrimental. “Stunning developments in health care have occurred during the last several years. Widely accepted health-care strategies have been brought into question by research evidence as not only lacking benefit but also, perhaps, as inducing harm” (Barlow, 2004, p. 869; see also Sue, 2015).

Intellectual competence also means admitting what we do not know. We may know about depression in adults but not depression in kids. We may be familiar with the culture of one Asian population but not others. We may understand the degree to which the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) can assess malingering among criminal defendants but not whether it can identify leadership strengths among job candidates in the tech industry.

Intellectual competence also involves knowing how to do certain clinical tasks. We gain this kind of competence, the development of skills, through carefully supervised experience. We can’t learn how to do therapy just by reading a book or sitting in a classroom; therapy is a set of skills that is learned through practice. The APA Ethics Code Standard 2.01c (APA, 2017a) encourages properly trained psychologists planning to provide services new to them to achieve competence in those new services through relevant education, training, supervised experience, consultation, or study. Both the APA Ethics Code (Standard 2.03) and the CPA’s Ethics Code (Standards IV.3 and IV.4) recognize that knowledge becomes obsolete and that psychologists don’t stop developing and maintaining competence when they become licensed.

Emotional competence for therapy, as described by Pope and Brown (1996), reflects our awareness and respect for ourselves as unique, fallible human beings. It includes self-knowledge, self-acceptance, and self-monitoring. We must know our own emotional strengths and weaknesses, our needs and resources, our abilities and our limits for doing clinical work.

Therapy can stir strong emotions in both therapist and client. Some clinical work places great emotional demands on us. For example, working with people who survive torture can evoke intense reactions that can lead to secondary trauma, despair, helplessness, and burnout (Allden & Nancy Murakami, 2015; Comas‐Diaz & Padilla, 1990; Long, 2020; Pope, 2012; Pope & Garcia-Peltoniemi, 1991).To the degree that we are unprepared for the emotional stressors and strains of therapy, our attempts to help may be futile and perhaps even harmful.

Table 6.1 presents research findings about intense emotions experienced in therapy. The numbers indicate the percentage of therapists in each study who reported at least one instance of each behavior. Readers who have had experience as therapists or patients may wish to compare their own experience to these findings.

Table 6.1. Percentages of Intense Emotions and Other Reactions in Therapy.

Therapists, of course, bring something to the work they do. Each of us has a unique personal history. Table 6.2 presents national survey results showing therapists’ self-reports of their experiences of various kinds of abuse during childhood, adolescence, and adulthood (Pope & Feldman-Summers, 1992). These results suggest that almost one-third of male therapists and over two-thirds of female therapists have experienced at least one of these forms of abuse over their lifetimes.

Table 6.2. Percentages of Male and Female Therapists Reporting Having Been Abused.

While these experiences may—or may not—affect emotional competence for any of us as individuals, it is important not to assume a one-size-fits-all theory about how forms of abuse (or any other experience) may affect an individual therapist. No research supports the notion that all those who have a history of abuse are more competent or less competent as therapists, or that those who have no history of abuse are more or less competent as therapists. Each instance must be evaluated on an individual basis, with the full range of available information and without stereotypes. What is key is for us to be aware of how such events affect us and what role, if any, they play in our emotional competence and our ability to respond effectively to clients.

Our work requires continuous awareness to prevent compromised performance, especially when we go through hard or challenging personal times. Chapter 17 discusses common consequences when a therapist or counselor is distressed, drained, or demoralized. These common consequences include disrespecting clients, disrespecting work, making more mistakes, lacking energy, using work to block out unhappiness, pain, and discontent, and losing interest.

Emotional competence includes the process of constantly questioning ourselves. Consider the following: Do the demands of the work we do as therapists, or other factors, suggest that the we need therapy in order to maintain or restore emotional competence? For many of us, creating self-care strategies that fit us as unique individuals and that sustain, replenish, and give meaning are an essential part of our work to maintain competence (see Chapter 17), particularly to maintain “emotional competence for therapy” (Pope & Brown, 1996; Pope, Sonne et al., 2006).

The psychology profession emphasizes the ethical aspects of self-care. General Principle A, Beneficence and Nonmaleficence, and Standard 2.06 of the APA Ethics Code (APA, 2017a) encourage psychologists to be aware of the possible effects of their own physical and mental health on their ability to help those with whom they work. The new proposed General Principle of Beneficence and Nonmaleficence also encourages psychologists to safeguard, protect, and contribute to the well-being, welfare, and rights of Persons and Peoples. Psychologists are also encouraged to maximize benefit and avoid or minimize harm in ways that respect the dignity of Persons and Peoples (APA Ethics Code Task Force, 2020, July 31).

The Canadian Code of Ethics for Psychologists, Standard II.11 (CPA, 2017a), states that psychologists “seek appropriate help and/or discontinue scientific or professional activity for an appropriate period of time, if a physical or psychological condition reduces their ability to benefit and not harm others.” Standard II.12 states that psychologists “engage in self-care activities that help to avoid conditions (e.g., burnout, addictions) that could result in impaired judgment and interfere with their ability to benefit and not harm others.”

The National Association of Social Workers (2017) and the American Counseling Association (2014) are among the other major mental health professions whose ethics codes highlight the role of self-care in supporting competence and preventing impairment.

Table 6.3 presents the results of a national study of therapists as therapy patients (Pope & Tabachnick, 1994). Eighty-four percent of the therapists in this study reported that they had been in personal therapy. Only two respondents indicated that the therapy was not helpful, but 22% reported that their own therapy included what they believed to be harmful aspects (regardless of whether it also included positive aspects).

Table 6.3. Therapists’ Experiences as Therapy Patients.

This research suggests that most therapists experience, at least once, deep distress. For example, 61% reported experiencing clinical depression, 29% reported suicidal feelings, and 3.5% reported attempting suicide. About 4% reported having been hospitalized. Readers may wish to consider their own experiences in the light of these findings.

Emotional competence in therapy is no less important than intellectual competence, and it is for that reason that we have included, beginning with Chapter 15, clinical scenarios at the end of each chapter. These scenarios describe hypothetical situations that this book’s readers might encounter. Each is followed by a handful of questions designed to provide practice in the processes of the critical thinking explored in detail in Chapters 10–14. The first question in each sequence is a variant of “What do you feel?” Emotional competence leaves little room for denying, discounting, or distorting how we respond emotionally to the challenges of clinical work.

To the extent that these scenarios and questions form the basis of class or group discussion in graduate school courses, internships, in-service training, continuing education workshops, or other group settings, their value may be in direct proportion to the class’s or group’s ability to establish as safe an environment as possible in which participants are free to disclose responses that may be politically incorrect or “psychologically incorrect” (Pope, Sonne et al., 2006) or otherwise at odds with group norms or with what some might consider the “right” response. Only if participants are able to speak honestly with each other about responses that they might be reluctant to speak aloud in other settings and to discuss these responses with mutual respect, will the task of confronting these questions likely prove helpful in developing emotional competence (Pope, Sonne et al., 2006).

Learning to discuss these sensitive topics and our personal responses to them with others can help to strengthen our emotional competence and develop resources for maintaining competence throughout our careers (see Pope, Sonne et al., 2006, for a more thorough discussion of understanding taboos that hurt therapists and clients). Our colleagues also constitute an invaluable source of help to avoid or correct mistakes, identify stress or personal dilemmas that threaten to overwhelm us, and provide fresh ideas, new perspectives, and second and third opinions. A national survey of psychologists, in fact, found that therapists rated informal networks of colleagues as the most effective resource for prompting effective, appropriate, and ethical practice (Pope et al., 1987). Informal networks were seen as more valuable in promoting ethical practice than laws, ethics committees, research, continuing education programs, or formal ethical principles. Our colleagues can help sustain us, replenish us, enrich our lives, and play an important role in our self-care (Chapter 17).

In the last few decades, the United States (US) and Canada have become more multiracial, multiethnic, and multilingual. As of 2019, 40% of the US population was Black Indigenous and People of Color (BIPOC) including: 18.5% Latinxs, 13.4% African American, 5.6% Asian American, and 1.3% American Indians (U.S. Bureau of the Census, 2019). Approximately 20% of the US population or 40 million are immigrants (Pew Research Center, 2020). In Canada, 22.3% of the total population in 2016 identified as People of Color and 21.9% of the population as immigrant. The largest ethnic minority community in Canada was composed of people of South Asian descent (5.6%), followed by Chinese (4.6%), First Nations (4.4%), and people who identify as Black (3.5%; Statistics Canada, 2016).

In the field of mental health, several foundational publications (see Comas-Díaz, 2012; Helms & Cook, 1999; Sue et al., 2019; Vasquez, 2007; White & Henderson, 2008) and professional guidelines (see American Psychological Association [APA], 2017b, 2019c; Canadian Psychological Association [CPA], 2017b) underscore the importance of ethnicity and culture in the therapeutic process. These important documents aim to assist therapists in providing culturally responsive services to individuals and communities. Culture, defined as the “complex constellation of [learned] mores, values, customs, traditions, and practices that guide and influence people’s cognitive, affective, and behavioral response to life circumstances” (Parham et al., 1999, p. 14) is an important aspect of the work that we do as therapists. Culture shapes how clients: (a) narrate and make sense of their presenting problems, describe the causes, signs, and symptoms of their problems; (b) discuss what they believe heals or prevents the problems from getting worse; and (c) envision their relationship with healthcare providers including their therapist (Adames & Chavez-Dueñas, 2017; Gallardo et al., 2012; Kleinman et al., 1978; Vasquez, 2007). Culture always shapes how therapists view problems and issues, as well as what we consider to be healthy and unhealthy processes and functional and dysfunctional coping strategies (Vasquez & Johnson, in press). Culture is always in the therapeutic space, even when we fail to honor its presence and significance.

The concept of culture is sometimes misleadingly used interchangeably with race. However, the consensus among scientists, including social scientists, is that both concepts are distinct, albeit closely related (see Alvarez et al., 2016; Chavez-Dueñas et al., 2019; Helms & Cook, 1999). Specifically, race describes how individuals are grouped according to their shared phenotype (e.g., skin-color, eye-color, hair texture) and the social, educational, health, and political implications of this method of grouping (e.g., choosing to divide people up according to the color of their skin; see Bonilla-Silva, 2014; Carter & Pieterse, 2005; Chavez-Dueñas et al., 2014; Gannon, 2016; Helms & Cook, 1999; Ifekwunigwe et al., 2017; Jones, 1997). Said differently, race is a social construct and not a biological one. However, this social construct has real life and social consequences such as its impact on health and access to opportunities. The role of race, racism, colorism, and other forms of oppression (e.g., anti-Semitism, sexism, heterosexism) in ethics will be discussed in Chapter 23. In this chapter we focus on culture and its implications for our work as therapists—we provide some steps to recognize and overcome barriers to ethical practice in the context of different cultures.

Psychotherapy as a healing practice has existed for centuries in different cultures. However, the current practice of psychotherapy is often rooted in a Western philosophy with origins in Europe and the United States. Wampold (2001) explains that

The idea of sitting in a room with the healer, confiding in the healer, responding to questions, and following the implicit or explicit ritualistic expectations of the psychotherapeutic protocol, whether it is expressing one’s feelings, monitoring one’s thoughts, forming a contingency contract, or looking at the rapidly moving hands of the therapist, would be an absurdity in 99% of the societies past or present. On the other hand, participating in some healing practice is universal. As a healing practice, psychotherapy shares commonalities with medicine, but also with laying-on-of-hands, theriac, and shaman rituals. Psychotherapy is not universal; it has existed, in widely different forms, in some (but not all) Western cultures for about 100 years (p. 79).

There is also evidence that the Indigenous people of the Americas were using talk as a form of treatment for mental illness centuries before colonization. Padilla (1984) describes how the Aztecs had a well-developed system of public health that included healing services for mental health-related concerns where conversation was used to heal and care for others. He also wrote that

In essence it was believed that the tonalpouhqui [healer] had the knowledge and more authority to assist the patient by means of lengthy conversations designed to liberate them [from their ailments]. The personal characteristics and language of the tonalpouhqui were the major determinants for a successful outcome…The tonalpouhqui possessed concepts of ego formation and catharsis, as well as techniques of dream interpretation and psychotherapy similar to those developed later by Freud and Jung (p. 7).

These two passages exemplify the ways in which distinct cultural groups around the world used dialogue and other methods to connect and build relationship to address the problems of living. However, the common ways in which psychotherapy is currently practiced are not culturally universal. Consider current counseling practices prevalent in the US, Canada, and many other Western countries: 45 to 55-minute sessions, once a week, often taking place in an office setting or using a Zoom connection, typically between two people. Few would argue that these practices are universal or free of cultural influence. To a great extent, they reflect Western standards and values. If so, how do we form healing relationships with clients of other cultures for whom such practices are a barrier? What do we need to learn about ourselves, the groups we belong to, and other cultures in order to communicate and work more effectively with those from other cultures? The following sections provide some ways to address these complex, arduous, but crucial questions.

Psychotherapists are like all people. We too are shaped and influenced by many factors including our cultural heritage and our multiple social group memberships (e.g., race, ethnicity, gender, sexual orientation, religion, ability status). Subsequently, we navigate the world with a set of attitudes and ideologies that shape how we see ourselves and others. Indeed, you and I are “cultural beings,” all of our interactions are cross-cultural, and all of our life experiences are perceived and shaped from within our own cultural stance—the mantra and bedrock of cross-cultural and multicultural practice. As psychotherapists, our culture provides a rich context for becoming more aware of how our mores, values, customs, and traditions influence our own professional practice, ethical views, and reasoning. Ronald Francis (2009) wrote:

One of the singular merits of ethical considerations in a cross-cultural context is the way in which it forces us to confront our own values, to develop them, and to defend them. Cross-cultural comparisons afford a marvelous opportunity to examine the bases of our ethical codes in a manner which does not invite the heat more commonly attending intercultural value debates. Ethics is essentially about human values. Since not all values are shared, we are compelled to consider the issues we have in common; and those on which we divide. For instance, what may seem self-evident in one culture may be ethically repugnant to another. Ethics affords an opportunity to discuss and resolve these human values in a non-threatening frame of reference (pp. 182–193).

Ethical assessment and intervention also depend on our ability to understand culture beyond the surface level and popular culture (see Chapter 20). When considering the role of culture in psychotherapy, scholars have discussed and illustrated ways to examine and understand culture at the deep structural level, address how it impacts the psychotherapeutic process, and plan how to best integrate it into our practice (see Adames & Chavez-Dueñas, 2017; Gallardo et al., 2012; Parham et al., 1999; Vasquez, 2007). Five domains of culture at the deep structural level introduced and described by Ani (1994) include: ontology (nature of reality); axiology (value system); cosmology (relationship to the divine); epistemology (system of knowing and believing what is the truth); and praxis (systems of human interaction). Conversely, examples of surface level culture include food, holidays, celebrations, clothing, visual and performing arts, sports, dancing, language, and the like. The model in Figure 7.1 illustrates culture at both the deep and surface levels, with questions to guide us to explore, unpack, and understand culture in nuanced ways.

Our cultural competence influences the experience that clients have in therapy. For instance, Smith and Trimble (2016) conducted a meta-analysis focused on therapists’ cultural competence and its connection to clients’ experiences in treatment. They concluded that

Diverse clients tend to see therapist multicultural competence as highly related to, yet distinct from, other positive counselor attributes. In addition, culturally diverse clients are moderately more likely to prematurely discontinue treatment when their therapists do not demonstrate multicultural competence. Client outcomes improve when their therapists are able to competently attend to and value the varying experiences of culturally diverse clients (p. 64).

More recent decades have seen an increase in scholarship describing and centering the role of culture in treatment outcomes. For instance, the evidence-based practice movement in psychology frames evidence as the “best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (APA, Presidential Task Force on Evidence-Based Practice, 2006, p. 273). This expansive description of evidence underscores the pivotal role of culture in psychotherapy outcomes. To illustrate, meta-analyses provide support for the effectiveness of culturally adapting psychotherapies for different groups (see Benish et al., 2011; Bernal & Domenech Rodríguez, 2012; Griner & Smith, 2006; Smith & Trimble, 2016; Zane et al., 2016).

The abundance of evidence supports the need to consider the client’s culture and our own cultural competence in the therapeutic process—not doing so can result in unintentional harm to clients (Vasquez, 2009, 2012; Sue, 2019). Thus, the inclusion of cultural factors in psychotherapy is not just a desirable practice, it is a fundamental ethical responsibility outlined in standards.

The CPA Code of Ethics Standard II.10 encourages psychologists to:

“evaluate how their own experiences, attitudes, culture, beliefs, values, individual differences, specific training, external pressures, personal needs, and historical, economic, and political context might influence their interactions with and perceptions of others, and integrate this awareness into their efforts to benefit and not harm others” (2017b, p. 19). Standard IV.15 requires that psychologists “acquire an adequate knowledge of the culture, social structure, history, customs, and laws or policies of organizations, communities, and peoples before beginning any major work there, obtaining guidance from appropriate members of the organization, community, or people as needed” (p. 33).

APA Ethics Code Standard 2.01b, Boundaries of Competence, states:

Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies (2017b, p. 5).

Several psychological associations in the US have published documents that articulate and augment our ethical responsibilities within different cultural worldviews. Pope, Chavez-Dueñas, and Adames (in press) report that:

members representing the four Ethnic Minority Psychological Associations (EMPAs) in the United States including the Asian American Psychological Association (AAPA), Association of Black Psychologists (ABPsi), the National Latinx Psychological Association (NLPA), and the Society of Indian Psychologists (SIP) met with the APA Ethics Committee at the 2011 annual APA convention. During this meeting the EMPAs and APA agreed to review whether the ethics code addresses issues of culture adequately, appropriately, and knowledgeably. Specifically, the EMPAs shared their thoughts on how the ethical code both “assists or hinders their work as Psychologists of Color” with the goal of broadening knowledge on “how culture intersects with ethical dilemmas” (APA, 2012a, para. 15). Several EMPAs have developed and published their own set of ethical commentaries. (see SIP, 2014), guidelines (see NLPA, 2018), or standards (see ABPsi, n.d.).

A focus on the role of culture in psychotherapy as practiced and regulated by state or provincial licensing laws is a relatively recent phenomenon. Historically, the field of mental health has been slow at recognizing the significance of culture in psychological science, practice, and ethics (see Hall, 1997; Guthrie, 2004; Pickren & Burchett, 2014; Sue et al., 2019; Vasquez, 2007, 2012). The first mention of culture as a factor in therapy took place at the Vail Conference of 1973 (Korman, 1974). Sixteen years later, in 1990, the APA published its first guidelines that addressed culture titled, The Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations (APA, 1990). That same decade, the CPA approved and published their Guidelines for Non-Discriminatory Practice. Since then, both APA and CPA guidelines have been revised. In 2003, the new APA guidelines were published with a new title, The Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change (see APA, 2003) and in 2017 they were revised once again (see APA, 2017b). The CPA guidelines were updated in 2001 and in 2017.

The 2017b version of the APA Multicultural Guidelines more broadly addresses the importance of attending to various identities and

encourage psychologists to consider how knowledge and understanding of identity develops from and is disseminated within professional psychological practice. Endemic to this understanding is an approach that incorporates developmental and contextual antecedents of identity and how they can be acknowledged, addressed and embraced to engender more effective models of professional engagement (APA, 2017b, p. 6).

Similarly, the 2017 CPA Guidelines for Non-Discriminatory Practice

promote non-discriminatory care in therapeutic work with clients, as well as to provide guidelines for evaluating the extent to which one’s work falls within the parameters of non-discriminatory practice. As our society and culture become more diverse, and as we become more aware of specific diversities, it is important that psychologists gain an awareness of the need for non-discriminatory practice. As the need arises, guidelines can be developed for use of specific diversities (CPA, 2017b, p. 1).

The APA Guidelines on Race and Ethnicity in Psychology (2019c) more specifically focus on race and ethnicity

and describe how clinicians, educators and researchers can develop racial and ethnocultural responsiveness and discuss the importance of understanding bias and recognizing the influence of race and ethnicity in society (APA, 2019c).

These guidelines encourage psychologists to understand and consider the role of culture in practice, research, consultation, and education. Unfortunately, we have a long way to go in the field of mental health to move beyond just highly encouraging people to consider the role of culture in assessment and interventions to requiring the integration of culture as a standard in practice.

Building cultural competence in clinical practice often begins with effective training. Many programs in psychology and related fields historically have not provided adequate training on how to effectively integrate cultural knowledge into assessment and therapy. Adames et al. (2013) posit that

While psychology as a discipline maintains that diversity and multiculturalism training is important, some departments do not adequately address it as a central topic, emphasize its importance by making it a requisite, or provide a sound framework for effectively addressing diversity and multiculturalism (p. 3).

To what degree is culture and diversity respected, valued, welcomed, and its potential, approached in positive and creative ways? To what extent is it approached in ways that divide, isolate, set people against each other? For instance, several studies support how conversations about culture, ethnicity, and race provoke and exacerbate uncomfortable feelings including defensiveness, anxiety, anger, helplessness, blame, and invalidation (Bell, 2003; Helms & Cook, 1999; Sue et al., 2011; Utsey et al., 2005). Other scholars posit that when culture is addressed it is at the cost of Students of Color. Franklin (2009), for example, wrote:

Ethnic minority students often felt trapped between, if not victimized by, the roles of cultural educator and student. However, students as cultural brokers in class are often educators without a portfolio in the eyes of professors and fellow classmates. Challenging psychological information being presented that did not accurately represent our experiences could bring … a label as an impudent student. Parenthetically, it was not uncommon to have our personal insights as members of the community also challenged or dismissed by professors or researchers who had no experience with our communities other than their readings in psychology. This was infuriating to many colleagues and students, given their lived experiences … These in class and work experiences were frustrating, intimidating, humiliating, and discouraging to students and subsequently early career professionals in particular. This circumstance continues to contribute to the attrition of Students of Color in training programs and later becomes a deterrent to participation in organized psychology (p. 419; see also Kaduvettoor et al., 2009).

When we neglect how our own worldviews and cultural values influence the ways in which we navigate the world and interact with others—or when we fail to understand and appreciate the role of culture in our clients’ lives and in the work that we do as therapists—we end up straying from the appropriate and helpful to the useless or even oppressive. We cannot operate from a one-size-fits-all approach to training and psychotherapy by applying frameworks and interventions grounded solely in the experiences of the dominant group (Burkard & Knox, 2004; Gómez, 2015; Sue, 2015). The road toward cultural competence, or the ability to develop interventions that are culturally responsive begins by looking inward toward the self and outward toward others.

We encounter people who practice different cultures and who differ from us in many ways as we go about our lives. We learn about cultural diversity in our studies, we work on developing ethical awareness in approaching it in our clinical work, but often we forget that we also carry our own private—and sometimes not so private—views and feelings about specific cultures, races, religions, and so on. Most readers would have no trouble naming areas in the world in which people are fighting each other in part because of religion, culture, ethnicity, and similar factors. Most could name groups in their own countries that view members of another group with suspicion, unease, resentment, disdain, or hate.

It is impossible for us as therapists to be completely free of the prejudices that afflict the rest of humanity; after all, we are socialized in societies that have long histories of racism, colorism, nativism, ethnocentrism, and many other forms of othering (Chavez-Dueñas et al., 2019). Life is remarkable in so many ways, but not that one. For any of us, various cultural, racial, ethnic, political, religious, and other groups—or topics related to these groups—may evoke an intense emotional response. The response may be subtle or powerful. We may be ashamed of it or embrace it as important. We may be reluctant to mention it to certain people. We may view it as not politically correct or—a more forbidding barrier for many of us—as not emotionally correct (Pope, Sonne et al., 2006).

These psychological reactions may block or diminish our cultural competence to work with specific groups or certain topics. Thus, it is vital to assess not only our intellectual competence but also what Pope and Brown (1996) termed emotional competence for therapy. We invite each of us to take a moment now to ask ourselves the following set of questions:

Becoming aware of the ways we may fail to recognize and respect a group that is different from our own challenges all of us. It is easy to recognize in theory, the influence of our own culture and context, but it often escapes our notice in practice. A remarkable book, The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures (Fadiman, 1997), illustrates the potential costs of overlooking the influence of culture and context on everyone involved. The book describes the efforts of a California hospital staff and a Laotian refugee family to help a Hmong child whose American doctors had diagnosed with epilepsy. Everyone involved had the best of intentions and worked hard to help the girl, but a lack of awareness of cultural differences had tragic effects. The book quotes medical anthropologist Arthur Kleinman:

As powerful an influence as the culture of the Hmong patient and her family is on this case, the culture of biomedicine is equally powerful. If you can’t see that your own culture has its own set of interests, emotions, and biases, how can you expect to deal successfully with someone else’s culture? (p. 261).

Several models have been created to help us operate from a culturally responsive stance (see Adames & Chavez-Dueñas, 2017 CREAR-CE Model; Park-Taylor et al., 2009 Multicultural Competency Training Model). A well-established framework is White and Henderson’s (2008) multicultural competency building model which includes an actionable plan to develop and maintain cultural competency throughout our mental health careers and beyond. This model is divided into four levels including: (1) conceptual/theoretical/intellectual which underscores the importance of learning about our client’s culture at the deep structural level obtained by reading textbooks and journals, attending lectures and courses, and watching movies/documentaries; (2) engaging in challenging cross-cultural dialogues that provide the opportunity for emotional grow through active participation in difficult dialogues around individual differences; (3) behavioral engagement which emphasizes the importance of immersing ourselves in the context/community of the people we serve; and (4) building practical skills that enhance the therapeutic relationship which focuses on developing healing approaches that are tailored to the unique and complex needs of our clients (also see Adames et al., 2016; Henderson et al., 2014). According to White and Henderson, when we engage in activities at each of the four levels, we end up developing and deepening our cultural competency and improving the psychological services we provide.

You share a suite of offices with several other therapists. The name of each therapist is on the door to that therapist’s office. One morning you find that the door to one of the offices has been broken in and the office vandalized. The name on the door was Jewish. Swastikas along with epithets have been spray-painted on the walls, desk, floor, and bookshelves. You have no evidence but believe the vandal may have been one of your patients—someone who has expressed strong anti-Semitic views during therapy sessions, embraces the view that the Holocaust is fiction, and has described fantasies of vandalizing synagogues. But if you were to ask him during the next therapy session whether he had anything to do with vandalizing your colleague’s office, he would deny it.

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You are a Latino psychotherapist who speaks Spanish only moderately well. Your policy is to try to refer all those who speak only Spanish to fluent Spanish speakers, but you will see Spanish speakers who also speak English if they wish. A South American client who speaks fluent English and Spanish sees you because you are the only Latino available on her HMO list. At the first session, she insists that you should be ashamed for not speaking better Spanish and that you therefore have no culture.

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You have been leading a therapy group at a large mental health facility. As one of the sessions begins, a group member interrupts you and says, “I want to ask you about something. Have you noticed how none of the doctors here are People of Color but almost all the cleaning crew are? Why do you work in a system like that? Don’t you think that has any effects on us patients?”

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You work in a large office building. As your therapy client, a person of the Sikh faith, is getting ready to leave your office, the police show up at the door, handcuff him, and say they are taking him to the station for questioning. When they leave, the accountant across the hall comes over and says that someone saw your client in the lobby, thought he was acting suspiciously, and called the police to report someone who seemed up to no good.

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A married couple comes to you for counseling. Both believe that men are the natural leaders in a marriage and that a woman’s rightful place is to be obedient to her husband. However, they often have what they describe as “slips,” when he seems to look to her for guidance or when she finds it hard to accept his decisions. They are seeking marital counseling to help them eliminate these “slips.”

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You work as a counselor in a high school where the majority students are African American and Latinx. You see clients in a small space right next to the principal’s office. Most of your clients have been referred to you for “acting out” behaviors—they are often described by their White teachers as “lazy, unmotivated, and trouble-makers.” In therapy your clients often talk about how the school is “not for them.” They often discuss feeling not smart and that the teachers don’t like them. During one of your sessions with a client who is crying while sharing a traumatic event, a teacher barges into your office and blurts out, “gosh, why do these kids have to be so loud, can you keep them quiet for once?”

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You work with a geriatric population that is composed predominately of first-generation immigrants from Asia and Latin America. One of your Mexican clients, an 80 year-old woman comes to your session looking very serious. She begins her session by sharing that she wants to talk to you about what happened last night. She described having a conversation with her dead mother who came to give her a message. The message was that the mother was “not resting in peace” because your client was separated from her abusive husband. Your client states that her mother wants her to forgive her husband from whom she has been separated for over a decade. You have been working with this client for two years now to help her cope with the traumatic experience of living with a husband who abused her for decades.

You are a therapist at an agency with a policy that says that if a client misses two appointments without calling, the therapy automatically terminates. A client who is a single mother, uses public transportation, has no telephone, and is often distressed by a babysitter who does not show up, misses her appointment for the second time. Your supervisor insists that you terminate by letter, given the long waiting list of potential clients.