The Ethics of Building Trust - A PsyD Research Project

Drew Wilson - August 06, 2014

A Carlow University study explores the decision-making of Pennsylvania’s licensed clinicians, and lays the groundwork for future research.

A client and a therapist walk into an office.  

What sounds like a twist on the beginning of an old joke, should really be the beginning of building lasting trust between client and therapist.

"Confidentiality is at the core of our profession," said Joy Krumenacker, a second year student in the Doctor of Psychology (PsyD) program at Carlow University. "People tell us their deepest, darkest secrets. We need to make sure we are offering them a safe place, where they can share their secrets and not be worried that we will break their confidence."

Most times the confidences that are shared between client and therapist are sacrosanct. Sometimes, however, what the client relates during therapy can cause the therapist to wrestle with a difficult ethical or moral dilemma. Criminal activity — be it drug use, theft, assault, or worse — is often at the center of the gray area for most therapists.

"Ethical and moral ambiguity is so inherent in counseling," said Angela Harrington, a first-year student in Carlow's PsyD program. "I was curious to see how others deal with these difficult issues."

That curiosity spurred Krumenacker and Harrington to become part of a research project, with Joseph Roberts, PhD, an assistant professor of psychology at Carlow. 

"A solid foundation of knowledge and skills is essential for the scientifically informed professional practice of psychology, and Carlow's PsyD program is committed to students advancing the knowledge in the profession through research as they seek to become better clinicians," said Robert Reed, PsyD, chair of the Department of Psychology and Counseling at Carlow, and interim dean of the Graduate School. "This is one of the bases for accreditation from the  American Psychological Association (APA), and Carlow was recently awarded the program maximum seven-year accreditation,"

Krumenacker, Harrington, and Dr. Roberts, along with 2010 undergraduate alumna, Vanessa Vudy, and master's of professional counseling students Jenna Dlugos and Zia Sultan surveyed more than 150 of Pennsylvania's licensed clinicians, exploring what factors most help them decide when to report criminal activity that comes to their attention during a counseling session. The research phase of their study, titled "Peripheral Criminal Activity: Implications for Practice and Supervision in Mental Health Settings," is complete, and they are working toward getting their results published this spring.

"Most forms of criminal behavior are not required to be reported by a therapist, but how they respond can be the difference between jeopardizing a therapeutic relationship or not," said Harrington. "It's often a decision to immediately act versus not do anything."

A landmark case, Tarasoff vs. Regents of the University of California, decided by the California Supreme Court in 1974, held that mental health professionals have a duty to protect individuals who are being threatened with bodily harm by a patient.  The case, which involved the murder of a female graduate student, Tatiana Tarasoff, by another graduate student who had disclosed his intentions to murder Tarasoff to his therapist several months before.  The therapist had not reported the threat outside of the university, Tarasoff was murdered, and, when the whole story came out, Tarasoff's family sued.

Thankfully, not every ethical or moral dilemma faced by a mental health professional involves a threat to murder, but it can still be quite serious. The study revealed that therapists most frequently receive a verbal report of child abuse, driving under the influence, selling drugs (either prescription or street drugs), child neglect or sexual abuse, shoplifting or theft, and rape. Therapists who visit clients' homes frequently observe many of those activities - or evidence of those activities - during the therapy session.

"In Pennsylvania, mental health professionals are mandated to report child abuse or neglect," said Dr. Roberts. "Most other activities are simply not reportable, regardless of a clinician's value-based reaction to a criminal revelation."

However, the study found that even with suspected child abuse, consensus of how to act was difficult to attain.

"In a separate study, 144 counseling psychologists could not reach consensus after reading a vignette of alleged child abuse," said Krumenacker. "They tended to examine non-legal factors in making their decisions, such as: agency or practice protocols, the level of experience with such cases, effects on the ongoing counseling relationship, or whether or not the client was the perpetrator."

All of which means that if criminal activity is revealed or observed during a session, it does not make it any less vexing for the therapist. In fact, many of the situations involve a conflict between professional ethical standards and personal moral beliefs.

"If the ethical guidelines aren't in line with your personal belief system, ethics are often the first things to go," said Harrington — the implication being that when professional ethics are sacrificed, consistent, competent therapeutic practice for the client often suffers. 

To address this issue, Krumenacker says that the study demonstrates several important goals.

"There needs to be a bigger push in all levels and helping professions around ethics," she said.

"Clearly naming ethical guidelines around certain issues is important," agreed Harrington, who cited a difference in the quality and quantity of ethical training among in-home therapists and office based therapists as a problem to be addressed. "After they've had their ethical training, what does continuing ethical training look like?

But even under the best of training, Krumenacker and Harrington acknowledge that gray areas abound in therapeutic practice.  So what should a mental health professional do when in doubt?

"Consult with another colleague," said Krumenacker. "That's huge. Consult, consult, consult."

"And document, document, document," said Harrington.