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Introduction: Case Studies in the Ethics of Mental Health Research

Joseph millum.

Clinical Center Department of Bioethics/Fogarty International Center, National Institutes of Health, Bethesda, MD

This collection presents six case studies on the ethics of mental health research, written by scientific researchers and ethicists from around the world. We publish them here as a resource for teachers of research ethics and as a contribution to several ongoing ethical debates. Each consists of a description of a research study that was proposed or carried out and an in-depth analysis of the ethics of the study.

Building Global Capacity in Mental Health Research

According to the World Health Organization (WHO), there are more than 450 million people with mental, neurological, or behavioral problems worldwide ( WHO, 2005a ). Mental health problems are estimated to account for 13% of the global burden of disease, principally from unipolar and bipolar depression, alcohol and substance-use disorders, schizophrenia, and dementia. Nevertheless, in many countries, mental health is accorded a low priority; for example, a 2005 WHO analysis found that nearly a third of low-income countries who reported a mental health budget spent less than 1% of their total health budget on mental health ( WHO, 2005b ).

Despite the high burden of disease and some partially effective treatments that can be implemented in countries with weaker healthcare delivery systems ( Hyman et al., 2006 ), there exist substantial gaps in our knowledge of how to treat most mental health conditions. A 2007 Lancet Series entitled Global Mental Health claimed that the “rudimentary level of mental health-service research programmes in many nations also contributes to poor delivery of mental health care” ( Jacob et al., 2007 ). Its recommendations for mental health research priorities included research into the effects of interactions between mental health and other health conditions ( Prince et al., 2007 ), interventions for childhood developmental disabilities ( Patel et al., 2007 ), cost-effectiveness analysis, the scaling up of effective interventions, and the development of interventions that can be delivered by nonspecialist health workers ( Lancet Global Mental Health Group, 2007 ). All of these priorities require research in environments where the prevailing health problems and healthcare services match those of the populations the research will benefit, which suggests that research must take place all around the world. Similarly, many of the priorities identified by the Grand Challenges in Mental Health Initiative require focus on local environments, cultural factors, and the health systems of low- and middle-income countries. All the challenges “emphasize the need for global cooperation in the conduct of research” ( Collins et al., 2011 ).

Notwithstanding the need for research that is sensitive to different social and economic contexts, the trend of outsourcing to medical research to developing countries shows no sign of abating ( Thiers et al., 2008 ). Consequently, a substantial amount of mental health research will, in any case, take place in low- and middle-income countries, as well as rich countries, during the next few years.

The need for local research and the continuing increase in the international outsourcing of research imply that there is a pressing need to build the capacity to conduct good quality mental health research around the world. However, the expansion of worldwide capacity to conduct mental health research requires more than simply addressing low levels of funding for researchers and the imbalance between the resources available in rich and poor countries. People with mental health disorders are often thought to be particularly vulnerable subjects. This may be a product of problems related to their condition, such as where the condition reduces the capacity to make autonomous decisions. It may also result from social conditions because people with mental disorders are disproportionately likely to be poor, are frequently stigmatized as a result of their condition, and may be victims of human rights abuses ( Weiss et al., 2001 ; WHO, 2005a ). As a result, it is vitally important that the institutional resources and expertise are in place for ensuring that this research is carried out ethically.

Discussion at a special session at the 7th Global Forum on Bioethics in Research revealed the perception that many mental health researchers are not very interested in ethics and showed up a lack of ethics resources directly related to their work. This collection of case studies in the ethics of mental health research responds to that gap.

This collection comprises six case studies written by contributors from around the world ( Table 1 ). Each describes a mental health research study that raised difficult ethical issues, provides background and analysis of those issues, and draws conclusions about the ethics of the study, including whether it was ethical as it stood and how it ought to be amended otherwise. Three of the case studies are written by scientists who took part in the research they analyzed. For these cases, we have asked scholars independent of the research to write short commentaries on them. It is valuable to hear how the researchers themselves grapple with the ethical issues they encounter, as well as to hear the views of people with more distance from the research enterprise. Some of the ethical issues raised here have not been discussed before in the bioethics literature; others are more common concerns that have not received much attention in the context of international research. The case studies are intended to both expand academic discussion of some of the key questions related to research into mental health and for use in teaching ethics.

Case studies are an established teaching tool. Ethical analyses of such cases demonstrate the relevance of ethics to the actual practice of medical research and provide paradigmatic illustrations of the application of ethical principles to particular research situations. Concrete cases help generate and guide discussion and assist students who have trouble dealing with ethical concepts in abstraction. Through structured discussion, ethical development and decision-making skills can be enhanced. Moreover, outside of the teaching context, case study analyses provide a means to generate and focus debate on the relevant ethical issues, which can both highlight their importance and help academic discussion to advance.

People working in mental health research can benefit most from case studies that are specific to mental health. Even though, as outlined below, many of the same ethical problems arise in mental health research as elsewhere, the details of how they arise are important. For example, the nature of depression and the variation in effectiveness of antidepressive medication make a difference to how we should assess the ethics of placebo-controlled trials for new antidepressants. Moreover, seeing how familiar ethical principles are applied to one's own research specialty makes it easier to think about the ethics of one's own research. The cases in this collection highlight the commonalities and the variation in the ethical issues facing researchers in mental health around the world.

The current literature contains some other collections of ethics case studies that may be useful to mental health researchers. I note four important collections here, to which interested scholars may want to refer. Lavery et al.'s (2007) Ethical Issues in International Bio-medical Research provides in-depth analyses of ethically problematic research, mostly in low- and middle-income countries, although none of these cases involve mental health. Cash et al.'s (2009) Casebook on Ethical Issues in International Health Research also focuses on research in low- and middle-income countries, and several of the 64 short case descriptions focus on populations with mental health problems. Two further collections focus on mental health research, in particular. Dubois (2007) and colleagues developed short and longer US-based case studies for teaching as part of their “Ethics in Mental Health Research” training course. Finally, Hoagwood et al.'s (1996) book Ethical Issues in Mental Health Research with Children and Adolescents contains a casebook of 61 short case descriptions, including a few from outside the United States and Western Europe. For teachers and academics in search of more case studies, these existing collections should be very useful. Here, we expand on the available resources with six case studies from around the world with extended ethical analyses.

The remainder of this introduction provides an overview of some of the most important ethical issues that arise in mental health research and describes some of the more significant ethics guidance documents that apply.

Ethical Issues in Mental Health Research

The same principles can be applied in assessing the ethics of mental health research as to other research using human participants ( Emanuel et al., 2000 ). Concerns about the social value of research, risks, informed consent, and the fair treatment of participants all still apply. This means that we can learn from the work done in other areas of human subjects research. However, specific research contexts make a difference to how the more general ethical principles should be applied to them. Different medical conditions may require distinctive research designs, different patient populations may need special protections, and different locations may require researchers to respond to study populations who are very poor and lack access to health care or to significant variations in regulatory systems. The ethical analysis of international mental health research therefore needs to be tailored to its particularities.

Each case study in this collection focuses on the particular ethical issues that are relevant to the research it analyzes. Nevertheless, some issues arise in multiple cases. For example, questions about informed consent arise in the context of research with stroke patients, with students, and with other vulnerable groups. To help the reader compare the treatment of an ethical issue across the different case studies, the ethical analyses use the same nine headings to delineate the issues they consider. These are social value, study design, study population, informed consent, risks and benefits, confidentiality, post-trial obligations, legal versus ethical obligations, and oversight.

Here, I focus on five of these ethical issues as they arise in the context of international mental health research: (1) study design, (2) study population, (3) risks and benefits, (4) informed consent, and (5) post-trial obligations. I close by mentioning some of the most important guidelines that pertain to mental health research.

Study Design

The scientific design of a research study determines what sort of data it can generate. For example, the decision about what to give participants in each arm of a controlled trial determines what interventions the trial compares and what questions about relative safety and efficacy it can answer. What data a study generates makes a difference to the ethics of the study because research that puts human beings at risk is ethically justified in terms of the social value of the knowledge it produces. It is widely believed that human subject research without any social value is unethical and that the greater the research risks to participants, the greater the social value of the research must be to compensate ( Council for International Organizations of Medical Sciences [CIOMS], 2002 ; World Medical Association, 2008 ). However, changing the scientific design of a study frequently changes what happens to research participants, too. For example, giving a control group in a treatment trial an existing effective treatment rather than placebo makes it more likely that their condition will improve but may expose them to adverse effects they would not otherwise experience. Therefore, questions of scientific design can be ethically very complex because different possible designs are compared both in terms of the useful knowledge they may generate and their potential impact on participants.

One of the more controversial questions of scientific design concerns the standard of care that is offered to participants in controlled trials. Some commentators argue that research that tests therapeutic interventions is only permissible if there is equipoise concerning the relative merits of the treatments being compared, that is, there are not good reasons to think that participants in any arm of the trial are receiving inferior treatment ( Joffe and Truog, 2008 ). If there is not equipoise, the argument goes, then physician-researchers will be breaching their duty to give their patients the best possible care ( Freedman, 1987 ).

The Bucharest Early Intervention Project (BEIP) described in the case study by Charles Zeanah was a randomized controlled trial comparing foster care with institutional care in Bucharest, Romania. When designing the BEIP, the researchers wrestled with the issue of whether there was genuine equipoise regarding the relative merits of institutional and foster care. One interpretation of equipoise is that it exists when the professional community has not reached consensus about the better treatment ( Freedman, 1987 ). Childcare professionals in the United States were confident that foster care was superior, but there was no such confidence in Romania, where institutional care was the norm. Which, then, was the relevant professional community?

The equipoise requirement is justified by reference to the role morality of physicians: for a physician to give her patient treatment that she knows to be inferior would violate principles of therapeutic beneficence and nonmaleficence. As a result, the equipoise requirement has been criticized for conflating the ethics of the physician-patient relationship with the ethics of the researcher-participant relationship ( Miller and Brody, 2003 ). According to Miller and Brody (2003) , provided that other ethical requirements are met, including an honest null hypothesis, it is not unethical to assign participants to receive treatment regimens known to be inferior to the existing standard of care.

A subset of trial designs that violate equipoise are placebo-controlled trials of experimental treatments for conditions for which proven effective treatments already exist. Here, there is not equipoise because some participants will be assigned to placebo treatment, and ex hypothesi there already exists treatment that is superior to placebo. Even if we accept Miller and Brody's (2003) argument and reject the equipoise requirement, there remain concerns about these placebo-controlled trials. Providing participants with less effective treatment than they could get outside of the trial constitutes a research risk because trial participation makes them worse off. Moreover, on the face of it, a placebo-controlled trial of a novel treatment of a condition will not answer the most important scientific question about the treatment that clinicians are interested in: is this new treatment better than the old one? Consequently, in situations where there already exists a standard treatment of a condition, it has generally been considered unethical to use a placebo control when testing a new treatment, rather than using the standard treatment as an active-control ( World Medical Association, 2008 ).

Some psychiatric research provides scientific reasons to question a blanket prohibition on placebo-controlled trials when an effective intervention exists. For example, it is not unusual for antidepressive drugs to fail to show superiority to placebo in any given trial. This means that active-control trials may seem to show that an experimental drug is equivalent in effectiveness to the current standard treatment, when the explanation for their equivalence may, in fact, be that neither was better than placebo. Increasing the power of an active-control trial sufficiently to rule out this possibility may require an impractically large number of subjects and will, in any case, put a greater number of subjects at risk ( Carpenter et al., 2003 ; Miller, 2000 ). A 2005 trial of risperidone for acute mania conducted in India ( Khanna et al., 2005 ) was criticized for unnecessarily exposing subjects to risk ( Basil et al., 2006 ; Murtagh and Murphy, 2006 ; Srinivasan et al., 2006 ). The investigators' response to criticisms adopted exactly the line of argument just described:

A placebo group was included because patients with mania generally show a high and variable placebo response, making it difficult to identify their responses to an active medication. Placebo-controlled trials are valuable in that they expose the fewest patients to potentially ineffective treatments. In addition, inclusion of a placebo arm allows a valid evaluation of adverse events attributable to treatment v. those independent of treatment. ( Khanna et al., 2006 )

Concerns about the standard of care given to research participants are exacerbated in trials in developing countries, like India, where research participants may not have access to treatment independent of the study. In such cases, potential participants may have no real choice but to join a placebo-controlled trial, for example, because that is the only way they have a chance to receive treatment. In the Indian risperidone trial, the issue of exploitation is particularly stark because it seemed to some that participants were getting less than the international best standard of care, in order that a pharmaceutical company could gather data that was unlikely to benefit many Indian patients.

This is just one way in which trial design may present ethically troubling risks to participants. Other potentially difficult designs include washout studies, in which participants discontinue use of their medication, and challenge studies, in which psychiatric symptoms are experimentally induced ( Miller and Rosenstein, 1997 ). In both cases, the welfare of participants may seem to be endangered ( Zipursky, 1999 ). A variant on the standard placebo-controlled trial design is the withdrawal design, in which everyone starts the trial on medication, the people who respond to the medication are then selected for randomization, and then half of those people are randomized to placebo. This design was used by a Japanese research team to assess the effectiveness of sertraline for depression, as described by Shimon Tashiro and colleagues in this collection. The researchers regarded this design as more likely to benefit the participants because for legal reasons, sertraline was being tested in Japan despite its proven effectiveness in non-Japanese populations. Tashiro and colleagues analyze how the risks and benefits of a withdrawal design compare with those of standard placebo-controlled trials and consider whether the special regulatory context of Japan makes a difference.

Study Population

The choice of study population implicates considerations of justice. The Belmont Report, which lays out the ethical foundations for the United States system for ethical review of human subject research, says:

Individual justice in the selection of subjects would require that researchers … should not offer potentially beneficial research only to some patients who are in their favor or select only “undesirable” persons for risky research. Social justice requires that distinction be drawn between classes of subjects that ought, and ought not, to participate in any particular kind of research, based on the ability of members of that class to bear burdens and on the appropriateness of placing further burdens on already burdened persons. ( National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1978 )

Two distinct considerations are highlighted here. The first (“individual justice”) requires that the researchers treat people equally. Morally irrelevant differences between people should not be the basis for deciding whom to enroll in research. For example, it would normally be unjust to exclude women from a phase 3 trial of a novel treatment of early-stage Alzheimer disease, given that they are an affected group. Some differences are not morally irrelevant, however. In particular, there may be scientific reasons for choosing one possible research population over another, and there may be risk-related reasons for excluding certain groups. For example, a functional magnetic resonance imaging study in healthy volunteers to examine the acute effects of an antianxiety medication might reasonably exclude left-handed people because their brain structure is different from that of right-handed people, and a study of mood that required participants to forego medication could justifiably exclude people with severe depression or suicidal ideation.

The second consideration requires that we consider how the research is likely to impact “social justice.” Social justice refers to the way in which social institutions distribute goods, like property, education, and health care. This may apply to justice within a state ( Rawls, 1971 ) or to global justice ( Beitz, 1973 ). In general, research will negatively affect social justice when it increases inequality, for example, by making people who are already badly off even worse off. The quotation from the Belmont Report above suggests one way in which research might violate a requirement of social justice: people who are already badly off might be asked to participate in research and so be made worse off. For example, a study examining changes in the brain caused by alcohol abuse that primarily enrolled homeless alcoholics from a shelter near the study clinic might only put at further risk this group who are already very badly off. An alternative way in which research can promote justice or injustice is through its results. Research that leads to the development of expensive new attention deficit hyperactivity disorder medication is likely to do little, if anything, to make the world more just. Research on how to improve the cognitive development of orphaned children in poor environments (like the BEIP) is much more likely to improve social justice.

This last point suggests a further concern about fairness—exploitation—that frequently arises in the context of international collaborative research in developing countries. Exploitation occurs, roughly, when one party takes “unfair advantage” of the vulnerability of another. This means that the first party benefits from the interaction and does so to an unfair extent ( Wertheimer, 1996 ). These conditions may be met in international collaborative research when the burdens of research fall disproportionately on people and institutions in developing countries, but the benefits of research, such as access to new treatments, accrue to people in richer countries. A number of case studies in this collection raise this concern in one way or another. For example, Virginia Rodriguez analyzes a proposed study of the genetic basis of antisocial personality disorder run by US researchers but carried out at sites in several Latin American countries. One of the central objections raised by one of the local national research ethics committees with regard to this study was that there appeared to be few, if any, benefits for patients and researchers in the host country.

Risks and Benefits

Almost all research poses some risk of harm to participants. Participants in mental health research may be particularly susceptible to risk in several ways. First, and most obviously, they may be physically or psychologically harmed as a result of trial participation. For example, an intervention study of an experimental antipsychotic may result in some serious adverse effects for participants who take the drug. Less obvious but still very important are the potential effects of stopping medication. As mentioned above, some trials of psychoactive medications require that patients stop taking the medications that they were on before the trial ( e.g ., the Japanese withdrawal trial). Stopping their medication can lead to relapse, to dangerous behavior (like attempted suicide), and could mean that their previous treatment regimen is less successful when they attempt to return to it. Participants who were successfully treated during a trial may have similar effects if they do not have access to treatment outside of the trial. This is much more likely to happen in research conducted with poor populations, such as the Indian mania patients.

The harms resulting directly from research-related interventions are not the only risk to participants in mental health research. Participation can also increase the risks of psychosocial harms, such as being identified by one's family or community as having a particular condition. Such breaches of confidentiality need not involve gross negligence on the part of researchers. The mere fact that someone regularly attends a clinic or sees a psychiatrist could be sufficient to suggest that they have a mental illness. In other research, the design makes confidentiality hard to maintain. For example, the genetic research described by Rodriguez involved soliciting the enrollment of the family members of people with antisocial personality disorder.

The harm from a breach of confidentiality is exacerbated when the condition studied or the study population is stigmatized. Both of these were true in the case Sana Loue describes in this collection. She studied the co-occurrence of severe mental illnesses and human immunodeficiency virus risk in African-American men who have sex with men. Not only was there shame attached to the conditions under study, such that they were euphemistically described in the advertisements for the research, but also many of the participants were men who had heterosexual public identities.

Informed Consent

Many people with mental disorders retain the capacity (ability) and competence (legal status) to give informed consent. Conversely, potential participants without mental problems may lack or lose capacity (and competence). Nevertheless, problems with the ability to consent remain particularly pressing with regard to mental health research. This is partly a consequence of psychological conditions that reduce or remove the ability to give informed consent. To study these conditions, it may be necessary to use participants who have them, which means that alternative participants who can consent are, in principle, not available. This occurred in the study of South African stroke patients described by Anne Pope in this collection. The researcher she describes wanted to compare the effectiveness of exercises designed to help patients whose ability to communicate was compromised by their stroke. Given their communication difficulties and the underlying condition, there would inevitably be questions about their capacity. Whether it is permissible to enroll people who cannot give informed consent into a study depends on several factors, including the availability of alternative study populations, the levels of risk involved, and the possible benefits to participants in comparison with alternative health care they could receive.

In research that expects to enroll people with questionable capacity to consent, it is wise to institute procedures for assessing the capacity of prospective participants. There are two general strategies for making these assessments. The first is to conduct tests that measure the general cognitive abilities of the person being assessed, as an IQ test does. If she has the ability to perform these sorts of mental operations sufficiently well, it is assumed that she also has the ability to make autonomous decisions about research participation. A Mini-Mental State Examination might be used to make this sort of assessment ( Kim and Caine, 2002 ). The second capacity assessment strategy focuses on a prospective participant's understanding and reasoning with regard to the specific research project they are deciding about. If she understands that project and what it implies for her and is capable of articulating her reasoning about it, then it is clear that she is capable of consenting to participation, independent of her more general capacities. This sort of assessment requires questions that are tailored to each specific research project and cannot be properly carried out unless the assessor is familiar with that research.

Where someone lacks the capacity to give consent, sometimes a proxy decision maker can agree to trial participation on her behalf. In general, proxy consent is not equivalent to individual consent: unless the proxy was expressly designated to make research decisions by the patient while capacitated, the proxy lacks the power to exercise the patient's rights. As a result, the enrollment of people who lack capacity is only acceptable when the research poses a low net risk to participants or holds out the prospect of benefiting them. When someone has not designated a proxy decision maker for research, it is common to allow the person who has the power to make decisions about her medical care also to make decisions about research participation. However, because medical care is directed at the benefit of the patient, but research generally is not aimed at the benefit of participants, the basis for this assumption is unclear. Its legal basis may be weak, too. For example, in her discussion of research on South African stroke patients, Pope notes the confusion surrounding the legality of surrogate decision makers, given that the South African constitution forbids proxy decision making for adults (unless they have court-appointed curators), but local and international guidance documents seem to assume it.

Although it is natural to think of the capacity to give consent as an all-or-nothing phenomenon, it may be better conceptualized as domain-specific. Someone may be able to make decisions about some areas of her life, but not others. This fits with assumptions that many people make in everyday life. For example, a 10-year-old child may be deemed capable of deciding what clothes she will wear but may not be capable of deciding whether to visit the dentist. The capacity to consent may admit of degrees in another way, too. Someone may have diminished capacity to consent but still be able to make decisions about their lives if given the appropriate assistance. For example, a patient with mild dementia might not be capable of deciding on his own whether he should move in with a caregiver, but his memory lapses during decision making could be compensated for by having his son present to remind him of details relevant to the decision. The concept of supported decision making has been much discussed in the literature on disability; however, its application to consent to research has received little attention ( Herr, 2003 ; United Nations, 2007 ).

The ability to give valid informed consent is the aspect of autonomy that is most frequently discussed in the context of mental health research, but it is not the only important aspect. Several of the case studies in this collection also raise issues of voluntariness and coercion. For example, Douglas Wassenaar and Nicole Mamotte describe a study in which professors enrolled their students, which raises the question of the vulnerability of student subjects to pressure. Here, there is both the possibility of explicit coercion and the possibility that students will feel pressure even from well-meaning researchers. For various reasons, including dependence on caregivers or healthcare professionals and the stigma of their conditions, people with mental illnesses can be particularly vulnerable to coercion.

Post-Trial Obligations

The obligations of health researchers extend past the end of their study. Participants'data remain in the hands of researchers after their active involvement in a study is over, and patients with chronic conditions who enroll in clinical trials may leave them still in need of treatment.

Ongoing confidentiality is particularly important when studying stigmatized populations (such as men who have sex with men as discussed by Sana Loue) or people with stigmatizing conditions (such as bipolar disorder). In research on mental illnesses, as with many medical conditions, it is now commonplace for researchers to collect biological specimens and phenotypic data from participants to use in future research (such as genome-wide association studies). Additional challenges with regard to confidentiality are raised by the collection of data and biological specimens for future research because confidentiality must then be guaranteed in a long period of time and frequently with different research groups making use of the samples.

Biobanking also generates some distinctive ethical problems of its own. One concerns how consent to the future use of biological specimens should be obtained. Can participants simply give away their samples for use in whatever future research may be proposed, or do they need to have some idea of what this research might involve in order to give valid consent? A second problem, which arises particularly in transnational research, concerns who should control the ongoing use of the biobank. Many researchers think that biological samples should not leave the country in which they were collected, and developing country researchers worry that they will not be allowed to do research on the biobanks that end up in developed countries. This was another key concern with the proposed study in Latin America.

In international collaborative research, further questions arise as a result of the disparities between developing country participants and researchers and developed country sponsors and researchers. For example, when clinical trials test novel therapies, should successful therapies be made available after the trial? If they should, who is responsible for ensuring their provision, to whom should they be provided, and in what does providing them consist? In the case of chronic mental illnesses like depression or bipolar disorder, patient-participants may need maintenance treatment for the rest of their lives and may be at risk if treatment is stopped. This suggests that the question of what happens to them after the trial must at least be considered by those who sponsor and conduct the trial and the regulatory bodies that oversee it. Exactly on whom obligations fall remains a matter of debate ( Millum, 2011 ).

Ethics Guidelines

A number of important policy documents are relevant to the ethics of research into mental disorders. The WMA's Declaration of Helsinki and the CIOMS' Ethical Guidelines for Biomedical Research both consider research on individuals whose capacity and/or competence to consent is impaired. They agree on three conditions: a) research on these people is justified only if it cannot be carried out on individuals who can give adequate informed consent, b) consent to such research should be obtained from a proxy representative, and c) the goal of such research should be the promotion of the health of the population that the research participants represent ( Council for International Organizations of Medical Sciences, 2002 ; World Medical Association, 2008 ). In addition, with regard to individuals who are incapable of giving consent, Guideline 9 of CIOMS states that interventions that do not “hold out the prospect of direct benefit for the individual subject” should generally involve no more risk than their “routine medical or psychological examination.”

In 1998, the US National Bioethics Advisory Commission (NBAC) published a report entitled Research Involving Persons with Mental Disorders That May Affect Decision-making Capacity ( National Bioethics Advisory Commission, 1998 ). As the title suggests, this report concentrates on issues related to the capacity or competence of research participants to give informed consent. Its recommendations are largely consistent with those made in the Declaration of Helsinki and CIOMS, although it is able to devote much more space to detailed policy questions (at least in the United States context). Two domains of more specific guidance are of particular interest. First, the NBAC report considers the conditions under which individuals who lack the capacity to consent may be enrolled in research posing different levels of risk and supplying different levels of expected benefits to participants. Second, it provides some analysis of who should be recognized as an appropriate proxy decision maker (or “legally authorized representative”) for participation in clinical trials.

Finally, the World Psychiatric Association's Madrid Declaration gives guidelines on the ethics of psychiatric practice. This declaration may have implications for what is permissible in psychiatric research, insofar as the duties of psychiatrists as personal physicians are also duties of psychiatrists as medical researchers. It also briefly considers the ethics of psychiatric research, although it notes only the special vulnerability of psychiatric patients as a concern distinctive of mental health research ( World Psychiatric Association, 2002 ).

The opinions expressed are the author's own. They do not reflect any position or policy of the National Institutes of Health, U.S. Public Health Service, or Department of Health and Human Services.

Disclosure : The author declares no conflict of interest.

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Counseling Ethics Code: 10 Common Ethical Issues & Studies

Despite their potentially serious consequences, ethical issues are common, and without preparation and reflection, many might be violated unwittingly and with good intentions.

In this article, you’ll learn how to identify and approach a variety of frequently encountered counseling ethical issues, and how a counseling ethics code can be your moral compass.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises explore fundamental aspects of positive psychology, including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains:

Counseling & psychotherapy ethics code explained, 7 interesting case studies, 3 common ethical issues & how to resolve them, ethical considerations for group counseling, a take-home message.

Most of us live by a certain set of values that guide our behavior and mark the difference between right and wrong. These values almost certainly influence how you approach your work as a counselor .

Following these values might feel natural and even intuitive, and it might feel as though they don’t warrant closer examination. However, when practicing counseling or psychotherapy, working without a defined counseling code of ethics is a bit like sailing a ship without using a compass. You might trust your intuitive sense of direction, but more often than not, you’ll end up miles off course.

Fortunately, there are a variety of professional organizations that have published frameworks to help counselors navigate the challenging and disorienting landscape of ethics.

Members of these organizations are often recommended or required to adhere to a framework, so if you belong to one of them and you’re not familiar with their respective code of ethics, this should be your first port of call. However, these ethical frameworks are also often available online for anyone to read, and so you don’t need to join an organization to adhere to its principles.

Each organization takes a slightly different approach to their code of ethics, so you may find it useful to view several to find one that resonates best with your practice. As an example, the British Association of Counselling and Psychotherapy (2018) has a framework that emphasizes aspiring to a variety of different values and personal moral qualities.

Those values include protecting clients, improving the wellbeing and relationships of others, appreciating the diversity of perspectives, and honoring personal integrity. Personal moral qualities include courage, empathy , humility, and respect.

These values and qualities are not meant to be strict criteria, and there is no wholly objective way to interpret them. For example, two counselors might display the same legitimate values and qualities while arriving at different conclusions to an ethical problem. Instead, they reflect a general approach to how a counselor should think about ethics.

Nevertheless, this approach to ethics may be overly prescriptive for you, in which case a looser and more general framework may be better suited to the nature of your practice. Most professional organizations recognize this, and there is a set of foundational principles that feature widely across different frameworks and refine the collection of different values and qualities described above into simpler terms.

These principles are autonomy , beneficence, non-maleficence, fidelity, justice, veracity, and self-respect (American Counseling Association, 2014; British Association for Counselling and Psychotherapy, 2018). They are largely consistent across frameworks aside from some minor variations.

• Autonomy is the respect for a client’s free will.
• Beneficence and non-maleficence are the commitment to improve a client’s wellbeing and avoid harming them, respectively.
• Fidelity is honoring professional commitments.
• Veracity is a commitment to the truth.
• Justice is a professional commitment to fair and egalitarian treatment of clients.
• Self-respect is fostering a sense that the counselor is also entitled to self-care and respect.

Putting these principles into practice doesn’t require a detailed framework. Instead, as the British Association for Counselling and Psychotherapy (2018) recommends, you can simply ask yourself, “ Is this decision supported by these principles without contradiction? ” If so, the decision is ethically sound. If not, there may be a potential ethical issue that warrants closer examination.

Regardless of whether you navigate using values, qualities, or principles, it’s important to be prepared for how they might be challenged in practice. As explained above, these are not intended to be strict criteria, and it’s good to foster a healthy amount of flexibility and intuition when applying your ethical framework to real-life situations.

You might also interpret challenges to other principles. There is no correct or incorrect interpretation to any of these cases (Cottone & Tarvydas, 2016; Zur, 2008).

For each, consider where you think the problem lies and how you would respond.

A counselor has been seeing their client for several months to work through substance use issues. A good rapport has been formed, but the client has not complied with meeting goals set during therapy and has not reduced their substance use.

The counselor feels they may benefit from referring the client to a trusted colleague who specializes in helping individuals with substance use issues who are struggling to engage with therapy. The counselor contacts the colleague and arranges an appointment within their client’s schedule.

When the client is informed, the client is upset and does not wish to be seen by the colleague. The counselor replies that rescheduling is not possible, and they should consider the appointment a necessary part of therapy.

Beneficence

A counselor working as part of a university service is assigned a client expressing issues with their body image. The counselor lacks any knowledge in working with these issues, but feels as though they may help the client, given the extent of their experience with other issues.

On reflection, the counselor decides to contact a colleague outside the university service who specializes in body image issues and asks for supervision and advice.

Non-maleficence

A counselor developing a new exposure-based form of anxiety therapy is working with a client with severe post-traumatic stress. There is promising evidence suggesting the therapy is effective for reducing mild anxiety, but it is unknown whether the therapy is effective in more extreme cases.

As a result, the counselor recognizes that this client in particular would provide a particularly valuable case study for developing the therapy. The counselor recommends this therapy to the client.

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A client with a history of depression and suicidal ideation has been engaging successfully with therapy for the last year. However, recently they have experienced an unfortunate coincidence of extremely challenging life events because of their unstable living arrangement.

The counselor has noticed problematic behaviors and thought patterns emerging, and is seriously concerned about the client’s mental health given the history.

In order to have the client moved from their challenging living environment, they decide to recommend that the client be hospitalized for suicidal ideation, despite there being no actual sign of suicidal ideation and their client previously expressing the desire to avoid hospitalization.

A school counselor sees two students who are experiencing stress regarding their final exams. The first is a high-achieving and popular student who is likable, whereas the second is a student with a history of poor attendance and engagement with their education.

The counselor agrees that counseling is appropriate for the first student, but recommends the second student does not attend counseling, instead addressing the “transient” exam stress by directing their energy into “working harder.”

A counselor is assigned a teenage client after both the client and their family consent to therapy for issues with low mood. After the first session together, it is apparent that the client has been withholding information about their mental health from their family and is showing symptoms typical of clinical depression.

The counselor knows that their client is a high-performing student about to enter a prestigious school and that the client’s family has high hopes for the future. The counselor reassures the family that there is no cause for serious concern in order to protect them from facing the negative implications of the client’s condition.

Self-interest

A counselor is working with a client who is a professional massage therapist. The client offers a free massage therapy session to the counselor as a gesture of gratitude. The client explains that this is a completely platonic and professional gesture.

The counselor has issues with close contact and also feels as though the client’s gesture may not be entirely platonic. The counselor respectfully declines the offer and suggests they continue their relationship as usual. However, the client discontinues therapy abruptly in response.

Ethics in counseling

Ethical issues do not occur randomly in a vacuum, but in particular situations where various factors make them more likely. As a result, although ethical issues can be challenging to navigate, they are not necessarily difficult to anticipate.

Learning to recognize and foresee common ethical issues may help you remain vigilant and not be taken unaware when encountering them.

Informed consent

Issues of consent are common in therapeutic contexts. The right to informed consent – to know all the pertinent information about a decision before it is made – is a foundational element of the relationship between a counselor and their client  that allows the client to engage in their therapy with a sense of autonomy and trust.

In many ways, consent is not difficult at all. Ultimately, your client either does or does not consent. But informed consent can be deceptively difficult.

As a brief exercise, consider what “informed” means to you. What is the threshold for being informed? Is there a threshold? Is it more important to be informed about some aspects of a choice than others? These questions do not necessarily have a clearcut answer, but nevertheless it is important to consider them carefully. They may determine whether or not your client has given sufficient consent (West, 2002).

A related but distinct challenge to informed consent is that it is inherently subjective. For example, your client may have as much knowledge about a decision as you do and feel as though they fully understand what a decision entails. However, while you have both experience and knowledge of the decision, they only have knowledge.

That is to say, to some extent, it is not possible for your client to be informed about something they have not actually experienced, as their anticipated experience based on their knowledge may be wholly different from their actual experience.

The best resolution to these issues is to avoid treating informed consent like a checkbox that needs to be satisfied, where the client is required to ingest information and then give their consent.

Instead, encourage your client to appreciate the importance of their consent, reflect on their decision, and consider the limitations of their experience. In doing so, while they may not be able to become fully informed in an objective sense, they will achieve the nearest approximation.

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Termination of therapy

Another time of friction when ethical issues can surface is at the conclusion of therapy , when the counselor and client go their separate ways. When this termination is premature or happens without a successful resolution of the client’s goals, it is understandable why this time is difficult.

This can be a challenging transition even when therapy is concluded after a successful result. Like any relationship, the one between a counselor and client can become strained when the time comes for it to end.

Your client may feel uncertain about their ability to continue independently or may feel rejected when reminded of the ultimately professional and transactional nature of the relationship (Etherington & Bridges, 2011).

A basic preemptive action that can be taken to reduce the friction between you and your client during this time is ‘pre-termination counseling,’ in which the topic of termination is explicitly addressed and discussed.

This can be anything from a brief conversation during one of the concluding appointments, to a more formal exploration of termination as a concept. Regardless, this can give your client the opportunity to acclimatize and highlight any challenges related to termination that may be important to explore before the conclusion of therapy.

These challenges may involve features of your client’s background such as their attachment history, which may predispose them toward feelings of abandonment, or their experience of anxiety, which may influence their perceived ability to cope independently after therapy.

If you already have knowledge of these features of your client’s background, it may be worth considering these potential challenges well in advance of the termination of therapy.

Online counseling

Remote forms of therapy are becoming increasingly common. This has many obvious benefits for clients and counselors alike; counseling is more accessible than ever, and counselors can offer their services to a broad and diverse audience. However, online counseling is also fraught with commonly encountered ethical issues (Finn & Barak, 2010).

As remote practice frequently takes place outside the structured contexts more typical of traditional counseling, ethical issues commonly encountered in online counseling are rooted in this relative informality.

Online counseling lacks the type of dedicated ethical frameworks described above, which means e-counselors may have no choice but to operate using their own ethical compass or apply ethical frameworks used in traditional counseling that may be less appropriate for remote practice.

Research suggests that some online counselors may not consider the unique challenges of working online (Finn & Barak, 2010). For example, online counselors may feel as though they do not have the same responsibility for mandatory reporting, as their relationship with their clients may not be as directly involved as in traditional counseling.

For online counselors who are aware of their duty to report safeguarding concerns, the inherent anonymity of online clients may present a barrier. Anonymity certainly has the benefit of improved discretion, but it also means a counselor may be unable to identify their client if they feel they are threatened or otherwise endangered.

Online counselors may also be unclear regarding the limits of their jurisdiction, as qualifications or professional memberships attained in one region may not be applicable in others. It can often seem like borders do not exist online, and while to some extent this is true, it is important to respect that jurisdictions exist for a reason, and it may be unethical to take on a client who you are not licensed to work with.

If you work as an e-counselor, the best way to resolve or preemptively prepare for these issues is to acknowledge they exist and engage with them. A good place to start may be to develop a personal framework for your practice that has a plan for issues of anonymity and confidentiality, and includes an indication of how you will report safeguarding concerns.

In a group setting, clients may no longer feel estranged from society or alone in their challenges, and instead view themselves as part of a community of people with shared experiences.

Clients may benefit from insights generated by other group members, and for some individuals, group counseling may literally amplify the benefits of a one-to-one approach.

However, group settings can also bring unique ethical issues. Just as some groups can bring out the best in us, and a therapeutic context can foster shared insights, other groups can become toxic and create a space in which counter-therapeutic behaviors are enabled by the implicit or explicit encouragement of other group members.

Similarly, just as some group leaders can inspire others and foster a productive community, it is also all too easy for group leaders to become victims of their status.

This is true for any relationship in which there is an inherent imbalance of power, such as traditional one-to-one practice, but in a group context, the counselor is naturally invested with a greater magnitude of influence and responsibility. This can lead to the judgment of the counselor becoming warped and increase the risk of overstepping ethical boundaries (Mashinter, 2020).

As a group counselor, first and foremost, you should foster a diligent practice of self-reflection to ensure you are mindful of the actions you take and remain alert to any blind spots in your judgment.

If possible, it may also be useful to examine ethical issues related to your authority by referring to another authority, in the form of supervision with one of your colleagues.

Finally, to prevent counter-therapeutic dynamics from developing within your group of clients, it may be useful to develop a clear code of conduct that emphasizes a commitment to group beneficence through mutual respect (Marson & McKinney, 2019).

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Take a structured approach to preparing for and dealing with ethical issues, whether this is referring to a framework published by a professional organization or simply navigating by a set of core values.

Prepare for the most common types of ethical issues, while also keeping an open mind to the often complex nature of ethics in practice, as well as the specific ethical issues that may be unique to your practice. Case studies can be a useful tool for doing this.

If in doubt, refer to these five steps from Dhai and McQuiod-Mason (2010):

• Formulate the problem.
• Gather information.
• Consult authoritative sources.
• Consider the alternatives.
• Make an ethical assessment.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

• American Counseling Association. (2014). Ethical & professional standards . Retrieved July 22, 2021, from https://www.counseling.org/knowledge-center/ethics
• British Association for Counselling and Psychotherapy. (2018). BACP ethical framework for the counselling professions . Retrieved from https://www.bacp.co.uk/events-and-resources/ethics-and-standards/ethical-framework-for-the-counselling-professions/
• Cottone, R., & Tarvydas, V. (2016). Ethics and decision making in counseling and psychotherapy . Springer.
• Dhai, A., & McQuoid-Mason, D. J. (2010). Bioethics, human rights and health law: Principles and practice . Juta and Company.
• Etherington, K., & Bridges, N. (2011). Narrative case study research: On endings and six session reviews. Counseling and Psychotherapy Research , 11 (1), 11–22. https://doi.org/10.1080/14733145.2011.546072
• Finn, J., & Barak, A. (2010). A descriptive study of e-counselor attitudes, ethics, and practice. Counseling and Psychotherapy Research , 10 (4), 268–277. https://doi.org/10.1080/14733140903380847
• Marson, S. M., & McKinney, R. E. (2019). The Routledge handbook of social work ethics and values . Routledge.
• Mashinter, P. (2020). Is group therapy effective? BU Journal of Graduate Studies in Education , 12 (2), 33–36.
• West, W. (2002). Some ethical dilemmas in counseling and counseling research. British Journal of Guidance & Counselling , 30 (3), 261–268. https://doi.org/10.1080/0306988021000002308
• Zur, O. (2008). Bartering in psychotherapy & counseling: Complexities, case studies and guidelines. New Therapist , 58 , 18–26.

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What our readers think.

I appreciated your insight on the autonomy of the client, and this article was a great help for me in my master’s program and things to consider as I choose the right path for practice.

I enjoyed the lessons

I was recently at a social gathering where a former chemical dependency group counselor also attended. I tried to be polite, however I felt stalked. I was speaking with another person at the event, and he was within earshot of the conversation and hijacked my intent and the conversation. I had to literally seek an escape route. Before the event was over, he knocked my food from my plate and then ran to take the seat intended for me. This person knew that I am a retired professional and had access to my mental and physical health files. To say I was triggered is an understatement. What else could I have done in the moment to protect my psyche from the collateral damage that his inappropriate behaviors caused me? Is there any recourse? Do I now have to avoid the venue for fear he may show up there again and harass me further? Thank you in advance for your prompt attention.

I’m truly sorry to hear about your distressing experience. No one should ever feel cornered or unsafe, especially in social settings. In the moment, prioritizing your safety and well-being is paramount. If you ever find yourself in a similar situation, consider:

– Seeking Support : Approach a trusted friend or event organizer to stay with you, making it less likely for the individual to approach. – Setting Boundaries : Politely yet firmly assert your boundaries if you feel safe to do so. Let the person know their behavior is unwelcome. – Seeking Professional Advice : Consider discussing the situation with a legal professional or counselor to understand potential recourse.

Remember, you have every right to attend venues without fear. If you’re concerned about future encounters, perhaps inform the venue’s management about your experience.

Warm regards, Julia | Community Manager

Thanks for the reminder that group counseling is also a whole different thing compared to a more typical counseling session. I’d like to look for professional counseling services soon because I might need help in processing my grief. After my dog died a month ago, it’s still difficult for me to get on with my life and get on with life normally.

https://www.barbarasabanlcsw.net/therapy-with-me

Thanks the topic is well explained have learnt alot from it

Very informative article. I particularly enjoyed the case studies on the ethical principles

Thanks a lot

Ngini Nairobi, Kenya

very useful article .thank u very much. from… Sri Lanka

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Psychology Case Study Examples: A Deep Dive into Real-life Scenarios

Peeling back the layers of the human mind is no easy task, but psychology case studies can help us do just that. Through these detailed analyses, we’re able to gain a deeper understanding of human behavior, emotions, and cognitive processes. I’ve always found it fascinating how a single person’s experience can shed light on broader psychological principles.

Over the years, psychologists have conducted numerous case studies—each with their own unique insights and implications. These investigations range from Phineas Gage’s accidental lobotomy to Genie Wiley’s tragic tale of isolation. Such examples not only enlighten us about specific disorders or occurrences but also continue to shape our overall understanding of psychology .

As we delve into some noteworthy examples , I assure you’ll appreciate how varied and intricate the field of psychology truly is. Whether you’re a budding psychologist or simply an eager learner, brace yourself for an intriguing exploration into the intricacies of the human psyche.

Understanding Psychology Case Studies

Diving headfirst into the world of psychology, it’s easy to come upon a valuable tool used by psychologists and researchers alike – case studies. I’m here to shed some light on these fascinating tools.

Psychology case studies, for those unfamiliar with them, are in-depth investigations carried out to gain a profound understanding of the subject – whether it’s an individual, group or phenomenon. They’re powerful because they provide detailed insights that other research methods might miss.

Let me share a few examples to clarify this concept further:

• One notable example is Freud’s study on Little Hans. This case study explored a 5-year-old boy’s fear of horses and related it back to Freud’s theories about psychosexual stages.
• Another classic example is Genie Wiley (a pseudonym), a feral child who was subjected to severe social isolation during her early years. Her heartbreaking story provided invaluable insights into language acquisition and critical periods in development.

You see, what sets psychology case studies apart is their focus on the ‘why’ and ‘how’. While surveys or experiments might tell us ‘what’, they often don’t dig deep enough into the inner workings behind human behavior.

It’s important though not to take these psychology case studies at face value. As enlightening as they can be, we must remember that they usually focus on one specific instance or individual. Thus, generalizing findings from single-case studies should be done cautiously.

To illustrate my point using numbers: let’s say we have 1 million people suffering from condition X worldwide; if only 20 unique cases have been studied so far (which would be quite typical for rare conditions), then our understanding is based on just 0.002% of the total cases! That’s why multiple sources and types of research are vital when trying to understand complex psychological phenomena fully.

In the grand scheme of things, psychology case studies are just one piece of the puzzle – albeit an essential one. They provide rich, detailed data that can form the foundation for further research and understanding. As we delve deeper into this fascinating field, it’s crucial to appreciate all the tools at our disposal – from surveys and experiments to these insightful case studies.

Importance of Case Studies in Psychology

I’ve always been fascinated by the human mind, and if you’re here, I bet you are too. Let’s dive right into why case studies play such a pivotal role in psychology.

One of the key reasons they matter so much is because they provide detailed insights into specific psychological phenomena. Unlike other research methods that might use large samples but only offer surface-level findings, case studies allow us to study complex behaviors, disorders, and even treatments at an intimate level. They often serve as a catalyst for new theories or help refine existing ones.

To illustrate this point, let’s look at one of psychology’s most famous case studies – Phineas Gage. He was a railroad construction foreman who survived a severe brain injury when an iron rod shot through his skull during an explosion in 1848. The dramatic personality changes he experienced after his accident led to significant advancements in our understanding of the brain’s role in personality and behavior.

Moreover, it’s worth noting that some rare conditions can only be studied through individual cases due to their uncommon nature. For instance, consider Genie Wiley – a girl discovered at age 13 having spent most of her life locked away from society by her parents. Her tragic story gave psychologists valuable insights into language acquisition and critical periods for learning.

Finally yet importantly, case studies also have practical applications for clinicians and therapists. Studying real-life examples can inform treatment plans and provide guidance on how theoretical concepts might apply to actual client situations.

• Detailed insights: Case studies offer comprehensive views on specific psychological phenomena.
• Catalyst for new theories: Real-life scenarios help shape our understanding of psychology .
• Study rare conditions: Unique cases can offer invaluable lessons about uncommon disorders.
• Practical applications: Clinicians benefit from studying real-world examples.

In short (but without wrapping up), it’s clear that case studies hold immense value within psychology – they illuminate what textbooks often can’t, offering a more nuanced understanding of human behavior.

Different Types of Psychology Case Studies

Diving headfirst into the world of psychology, I can’t help but be fascinated by the myriad types of case studies that revolve around this subject. Let’s take a closer look at some of them.

Firstly, we’ve got what’s known as ‘Explanatory Case Studies’. These are often used when a researcher wants to clarify complex phenomena or concepts. For example, a psychologist might use an explanatory case study to explore the reasons behind aggressive behavior in children.

Second on our list are ‘Exploratory Case Studies’, typically utilized when new and unexplored areas of research come up. They’re like pioneers; they pave the way for future studies. In psychological terms, exploratory case studies could be conducted to investigate emerging mental health conditions or under-researched therapeutic approaches.

Next up are ‘Descriptive Case Studies’. As the name suggests, these focus on depicting comprehensive and detailed profiles about a particular individual, group, or event within its natural context. A well-known example would be Sigmund Freud’s analysis of “Anna O”, which provided unique insights into hysteria.

Then there are ‘Intrinsic Case Studies’, which delve deep into one specific case because it is intrinsically interesting or unique in some way. It’s sorta like shining a spotlight onto an exceptional phenomenon. An instance would be studying savants—individuals with extraordinary abilities despite significant mental disabilities.

Lastly, we have ‘Instrumental Case Studies’. These aren’t focused on understanding a particular case per se but use it as an instrument to understand something else altogether—a bit like using one puzzle piece to make sense of the whole picture!

So there you have it! From explanatory to instrumental, each type serves its own unique purpose and adds another intriguing layer to our understanding of human behavior and cognition.

Exploring Real-Life Psychology Case Study Examples

Let’s roll up our sleeves and delve into some real-life psychology case study examples. By digging deep, we can glean valuable insights from these studies that have significantly contributed to our understanding of human behavior and mental processes.

First off, let me share the fascinating case of Phineas Gage. This gentleman was a 19th-century railroad construction foreman who survived an accident where a large iron rod was accidentally driven through his skull, damaging his frontal lobes. Astonishingly, he could walk and talk immediately after the accident but underwent dramatic personality changes, becoming impulsive and irresponsible. This case is often referenced in discussions about brain injury and personality change.

Next on my list is Genie Wiley’s heart-wrenching story. She was a victim of severe abuse and neglect resulting in her being socially isolated until she was 13 years old. Due to this horrific experience, Genie couldn’t acquire language skills typically as other children would do during their developmental stages. Her tragic story offers invaluable insight into the critical periods for language development in children.

Then there’s ‘Little Hans’, a classic Freudian case that delves into child psychology. At just five years old, Little Hans developed an irrational fear of horses -or so it seemed- which Sigmund Freud interpreted as symbolic anxiety stemming from suppressed sexual desires towards his mother—quite an interpretation! The study gave us Freud’s Oedipus Complex theory.

Lastly, I’d like to mention Patient H.M., an individual who became amnesiac following surgery to control seizures by removing parts of his hippocampus bilaterally. His inability to form new memories post-operation shed light on how different areas of our brains contribute to memory formation.

Each one of these real-life psychology case studies gives us a unique window into understanding complex human behaviors better – whether it’s dissecting the role our brain plays in shaping personality or unraveling the mysteries of fear, language acquisition, and memory.

How to Analyze a Psychology Case Study

Diving headfirst into a psychology case study, I understand it can seem like an intimidating task. But don’t worry, I’m here to guide you through the process.

First off, it’s essential to go through the case study thoroughly. Read it multiple times if needed. Each reading will likely reveal new information or perspectives you may have missed initially. Look out for any patterns or inconsistencies in the subject’s behavior and make note of them.

Next on your agenda should be understanding the theoretical frameworks that might be applicable in this scenario. Is there a cognitive-behavioral approach at play? Or does psychoanalysis provide better insights? Comparing these theories with observed behavior and symptoms can help shed light on underlying psychological issues.

Now, let’s talk data interpretation. If your case study includes raw data like surveys or diagnostic tests results, you’ll need to analyze them carefully. Here are some steps that could help:

• Identify what each piece of data represents
• Look for correlations between different pieces of data
• Compute statistics (mean, median, mode) if necessary
• Use graphs or charts for visual representation

Keep in mind; interpreting raw data requires both statistical knowledge and intuition about human behavior.

Finally, drafting conclusions is key in analyzing a psychology case study. Based on your observations, evaluations of theoretical approaches and interpretations of any given data – what do you conclude about the subject’s mental health status? Remember not to jump to conclusions hastily but instead base them solidly on evidence from your analysis.

In all this journey of analysis remember one thing: every person is unique and so are their experiences! So while theories and previous studies guide us, they never define an individual completely.

Applying Lessons from Psychology Case Studies

Let’s dive into how we can apply the lessons learned from psychology case studies. If you’ve ever studied psychology, you’ll know that case studies offer rich insights. They shed light on human behavior, mental health issues, and therapeutic techniques. But it’s not just about understanding theory. It’s also about implementing these valuable lessons in real-world situations.

One of the most famous psychological case studies is Phineas Gage’s story. This 19th-century railroad worker survived a severe brain injury which dramatically altered his personality. From this study, we gained crucial insight into how different brain areas are responsible for various aspects of our personality and behavior.

• Lesson: Recognizing that damage to specific brain areas can result in personality changes, enabling us to better understand certain mental conditions.

Sigmund Freud’s work with a patient known as ‘Anna O.’ is another landmark psychology case study. Anna displayed what was then called hysteria – symptoms included hallucinations and disturbances in speech and physical coordination – which Freud linked back to repressed memories of traumatic events.

• Lesson: The importance of exploring an individual’s history for understanding their current psychological problems – a principle at the heart of psychoanalysis.

Then there’s Genie Wiley’s case – a girl who suffered extreme neglect resulting in impaired social and linguistic development. Researchers used her tragic circumstances as an opportunity to explore theories around language acquisition and socialization.

• Lesson: Reinforcing the critical role early childhood experiences play in shaping cognitive development.

Lastly, let’s consider the Stanford Prison Experiment led by Philip Zimbardo examining how people conform to societal roles even when they lead to immoral actions.

• Lesson: Highlighting that situational forces can drastically impact human behavior beyond personal characteristics or morality.

These examples demonstrate that psychology case studies aren’t just academic exercises isolated from daily life. Instead, they provide profound lessons that help us make sense of complex human behaviors, mental health issues, and therapeutic strategies. By understanding these studies, we’re better equipped to apply their lessons in our own lives – whether it’s navigating personal relationships, working with diverse teams at work or even self-improvement.

Challenges and Critiques of Psychological Case Studies

Delving into the world of psychological case studies, it’s not all rosy. Sure, they offer an in-depth understanding of individual behavior and mental processes. Yet, they’re not without their share of challenges and criticisms.

One common critique is the lack of generalizability. Each case study is unique to its subject. We can’t always apply what we learn from one person to everyone else. I’ve come across instances where results varied dramatically between similar subjects, highlighting the inherent unpredictability in human behavior.

Another challenge lies within ethical boundaries. Often, sensitive information surfaces during these studies that could potentially harm the subject if disclosed improperly. To put it plainly, maintaining confidentiality while delivering a comprehensive account isn’t always easy.

Distortion due to subjective interpretations also poses substantial difficulties for psychologists conducting case studies. The researcher’s own bias may color their observations and conclusions – leading to skewed outcomes or misleading findings.

Moreover, there’s an ongoing debate about the scientific validity of case studies because they rely heavily on qualitative data rather than quantitative analysis. Some argue this makes them less reliable or objective when compared with other research methods such as experiments or surveys.

To summarize:

• Lack of generalizability
• Ethical dilemmas concerning privacy
• Potential distortion through subjective interpretation
• Questions about scientific validity

While these critiques present significant challenges, they do not diminish the value that psychological case studies bring to our understanding of human behavior and mental health struggles.

Conclusion: The Impact of Case Studies in Understanding Human Behavior

Case studies play a pivotal role in shedding light on human behavior. Throughout this article, I’ve discussed numerous examples that illustrate just how powerful these studies can be. Yet it’s the impact they have on our understanding of human psychology where their true value lies.

Take for instance the iconic study of Phineas Gage. It was through his tragic accident and subsequent personality change that we began to grasp the profound influence our frontal lobes have on our behavior. Without such a case study, we might still be in the dark about this crucial aspect of our neurology.

Let’s also consider Genie, the feral child who showed us the critical importance of social interaction during early development. Her heartbreaking story underscores just how vital appropriate nurturing is for healthy mental and emotional growth.

Here are some key takeaways from these case studies:

• Our brain structure significantly influences our behavior.
• Social interaction during formative years is vital for normal psychological development.
• Studying individual cases can reveal universal truths about human nature.

What stands out though, is not merely what these case studies teach us individually but collectively. They remind us that each person constitutes a unique combination of various factors—biological, psychological, and environmental—that shape their behavior.

One cannot overstate the significance of case studies in psychology—they are more than mere stories or isolated incidents; they’re windows into the complexities and nuances of human nature itself.

In wrapping up, I’d say that while statistics give us patterns and trends to understand groups, it’s these detailed narratives offered by case studies that help us comprehend individuals’ unique experiences within those groups—making them an invaluable part of psychological research.

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What Is a Case Study?

Weighing the pros and cons of this method of research

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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Common Ethical Issues: Case Studies and Test Your Knowledge

Case studies.

What follows are three case studies taken from Bernard and Goodyear (1999). Try analyzing the cases from the perspective of a trainee and a supervisor. How does the ethical decision-making model presented in this module apply to the case? You might also want to talk with your supervisor, classmates, professors, or other practitioners about these cases. After the three cases are presented there are some questions that might guide your discussion.

Vanessa has been a marriage and family therapist at an agency for six months. Gary, one of the other three therapists in the agency and the only other single therapist, is her clinical supervisor. It will take Vanessa 2 years under supervision to accrue the experience she needs to be eligible to sit for the state licensing examination for her LMFT. One evening Gary calls Vanessa to inquire whether she would like to go to a day-long workshop with him. The speaker for the workshop specializes in a kind of therapy in which Vanessa has expressed interest. Vanessa accepts and the workshop turns out to be an excellent professional experience. On the way home, Vanessa and Gary stop for dinner. Vanessa picks up the tab to thank Gary for including her. The following day Vanessa is sharing some of the experiences of the workshop with Camille, another therapist at the agency. When Camille asks, “Isn’t Gary your supervisor?” Vanessa feels defensive and misunderstood. Later that day, Vanessa decides to go to her agency director and ask his opinion of the situation. He tells her not to be concerned about it and that Camille “worries about everything.” During her next supervision session, Vanessa chooses not to mention either conversation to Gary (pp. 191-192).

Margaret is a school counselor who has been assigned a trainee from the local university for the academic year. As she observes Noah work with elementary school children, she is increasingly impressed with his skills. She asks him to work with Peter, a nine-year-old, who has not adjusted well to his parents’ recent divorce. Again, she is impressed with Noah’s skill, his warmth and understanding, and ultimately, with the success he has in working with Peter. Margaret is a single parent who is concerned about her nine-year-old son. She decides to ask Noah to see him. Noah is complimented by her confidence in him. Margaret’s son attends a different school, but she arranges to have Noah see him after school hours (p. 192).

Ruth has been assigned to a local mental health hospital for her internship to work with patients who are preparing to be discharged. It is her first day at the site and she is meeting with her site supervisor. He gives her a form to fill out, which asks for information regarding her student malpractice insurance. When Ruth tells her supervisor that she does not carry such insurance, he advises her that it is their policy not to accept any student who does not have insurance. The supervisor also expresses some surprise because this has always been the hospital’s policy and Ruth is not the first student to be assigned to them from her training program (p. 186).

Questions for Case Studies

• What are the main issues in the case?
• What ethical issues are of concern in the case?
• Are there particular breaches of ethical principles? What are they?
• What can the supervisor do, if anything, to resolve the ethical problem(s) presented in the case?
• What can the trainee do, if anything, to resolve the ethical problem(s) presented in the case?
• Is there other information that might have been helpful in the resolution of this case?
• What could have been done to prevent the ethical problem from occurring in the first place?

Test Your Knowledge

What follows are 15 multiple choice items designed to test the knowledge that you have gained as a result of completing this module. Answers are provided at the end. Good Luck!

• epistemology
• eschatology
• Kantian Deontologism
• Consequentialism
• Virtue ethics
• Natural Law
• Respecting autonomy
• Doing no harm (Nonmaleficience)
• Benefiting others (Beneficence)
• Being just (Justice)
• Being faithful (Fidelity)
• They provide protection to consumers and further the professional stance of organizations.
• They provide a vehicle for professional identity.
• They provide a framework to resolve all ethical issues that might face a profession.
• They provide some means of defence for those who conscientiously practice within the ethical guidelines laid down by a particular profession.
• They provide evidence that a particular profession has a body of knowledge and skills that it can proclaim.
• Ethical guidelines
• Ethics scholarship
• supervisor and respected colleagues
• practicum class
• internship class
• Covers the relationship between supervisor and trainee. Trainees are made aware of their responsibilities and those of the supervisor during the clinical supervision process.
• The extent to which interactions between supervisor and trainee can be disclosed to others.
• Your clinical supervisor is also the instructor for one of your classes.
• Addresses the extent to which fair and consistent application of the criteria that governs your training program has been followed.
• Addresses the rights that you have as a participant in a training program.
• file police charges.
• call your professional organization.
• talk to the appropriate person in either your academic department or in the agency in which you are working to determine the proper procedure for filing a grievance.
• report your supervisor to the state licensing board.
• do nothing. It was probably a mistake.

1: d; 2: c; 3: a; 4: d; 5: a; 6: e; 7: c; 8: a; 9: a; 10: d; 11: c; 12: a; 13: e; 14: b; 15: c;

Yogi, P. \(2015, February 11\). Ethical issues in psychology. Psych Yogi. Retrieved from http://psychyogi.org/ethical-issues-in-psychology.

CITE AS: Yogi, P. \(2015, February 11\). Ethical issues in psychology. Psych Yogi. http://psychyogi.org/ethical-issues-in-psychology.

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Embodied Ethical Decision-Making: A Clinical Case Study of Respect for Culturally Based Meaning Making in Mental Healthcare

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• Published: 15 January 2021
• Volume 43 , pages 36–63, ( 2021 )

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How does embodied ethical decision-making influence treatment in a clinical setting when cultural differences conflict? Ethical decision-making is usually a disembodied and rationalized procedure based on ethical codes (American Counseling Association, 2014; American Dance Therapy Association, 2015; American Mental Health Counseling Association, 2015) and a collective understanding of right and wrong. However, these codes and collective styles of meaning making were shaped mostly by White theorists and clinicians. These mono-cultural lenses lead to ineffective mental health treatment for persons of color. Hervey’s (2007) EEDM steps encourage therapists to return to their bodies when navigating ethical dilemmas as it is an impetus for bridging cultural differences in healthcare. Hervey’s (2007) nonverbal approach to Welfel’s (2001) ethical decision steps was explored in a unique case that involved the ethical decision-making process of an African-American dance/movement therapy intern, while providing treatment in a westernized hospital setting to a spiritual Mexican–American patient diagnosed with PTSD and generalized anxiety disorder. This patient had formed a relationship with a spirit attached to his body that he could see, feel, and talk to, but refused to share this experience with his White identifying psychiatric nurse due to different cultural beliefs. Information gathered throughout the clinical case study by way of chronological loose and semi-structured journaling, uncovered an ethical dilemma of respect for culturally based meanings in treatment and how we identify pathology in hospital settings. The application of the EEDM steps in this article is focused on race/ethnicity and spiritual associations during mental health treatment at an outpatient hospital setting. Readers are encouraged to explore ways in which this article can influence them to apply EEDM in other forms of cultural considerations (i.e. age) and mental health facilities. The discussion section of this thesis includes a proposed model for progressing towards active multicultural diversity in mental healthcare settings by way of the three M’s from the relational-cultural theory: movement towards mutuality, mutual empathy, and mutual empowerment (Hartling & Miller, 2004).

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Embodied ethical decision-making (EEDM) can effectively influence treatment in a clinical setting when cultural differences conflict. Professional ethics are the standards of care and rules that govern the expectations for professionals, protect patients from harm, and guide ethical decision-making when faced with an ethical dilemma (Welfel, 2016 ). The two determinants of ethical decision-making are biological make-up and cultural norms (Ayala, 2010 ). Biological make-up includes our capacity to 1. Anticipate consequences of actions taken; 2. Make valuable judgments; and 3. Possess the ability to choose between courses of action (Ayala, 2010 ). Cultural norms are learned standards based on our shared experiences with family, friends, school systems, and other social environments (Sieck, 2019 ). Typically cultural norms of dominant cultures and are used to assist therapists with decision-making when faced with ethical dilemmas (Laws & Chilton, 2013 ).

Ethical decision-making is usually a disembodied and rationalized procedure based on ethical codes and a collective understanding of right and wrong. Trahan and Lemberger ( 2014 ) recognized that professional ethics codes are incomplete when considering underrepresented populations. Many studies have provided examples that point to insufficient measures taken in academic settings to address cultural competency, therefore producing counselors, psychologists, doctors, and nurses who are inadequately culturally sensitive and ignore cultural complexities (Alqahtani & Altamimi, 2015 ; Carmichael, 2012 ; Harris, 2016 ; Hebenstreit, 2017 ; Laws & Chilton, 2013 ; McEldowney & Connor, 2011 ; Dominguez, 2017; Wadley, 2016 ). The underlying somatic and intuitive constructs of our cultural norms, morals, and values are what guide our ethical decisions (Robson, Cook, Hunt & Alred, 2000 ). Hervey ( 2007 ) positioned that we can enhance the ethical decision making process by shifting from a rule-based approach to an embodied approach to address dilemmas in a more effective manner.

The purpose of this clinical case study was to explore how Hervey’s ( 2007 ) EEDM steps influenced ethical decision-making when cultural differences conflicted during treatment for a spiritual Mexican–American patient. My intersectional identities as an African-American, non-heterosexual woman have inspired my ambition towards creating change within healthcare systems. Healthcare systems have a long history of creating unsafe environments for people with diverse cultural identities; consequently the construct of cultural safety was established in the 1980′s in an effort to protect people of color from these harmful practices (McEldowney & Connor, 2011 ).

Embodied Ethical Decision-Making

As movers and body-based practitioners, it is difficult to ignore the intelligence held within the body. To explore knowledge surfacing from the body during an ethical dilemma grants vital data and, “using the body as a teacher puts the mover in charge of the process” (Goldman, 2004 , p. 131). It further allows us to use our body for inter-affectivity and empathetic understanding (Schmidsberger & Loffler-Stastka, 2018 ), thereby experiencing and sensing the perspectives of other individuals. Hervey outlined Welfel’s ( 2001 ) nine ethical decision-making steps and paired them with corresponding embodiment suggestions collected from roughly 80 dance/movement therapists and student participants (Table 1 ). These participants attended Hervey’s EEDM workshops, and from there, she analyzed the records of their movement responses and rationales to hypothesized ethical dilemmas (Hervey, 2007 ). I included these movement suggestions from the participants for each step in this article to provide readers with movement stimulating recommendations that may be helpful while engaging in the ethical steps as they were for me. At the time of Hervey’s ( 2007 ) article, Welfel ( 2001 ) identified nine ethical decision-making steps to thoroughly guide counselors in the process of making ethical decisions. In 2012, Welfel added an extra step that includes clarifying socio-cultural contexts of the dilemma. However, since this article is embedded with cultural context, I encourage readers to consider socio-cultural contexts for their patient, the situation, and themselves throughout the entire ethical decision-making process, and how one’s cultural lens can further deepen the movement suggestions presented by Hervey ( 2007 ).

Clinical Case

The case where the ethical dilemma arose involved a Mexican–American male patient, Juan. (Juan is a pseudonym used to protect this patient’s privacy.) Juan hesitantly disclosed having a spirit attached to his right shoulder that he could regularly see, feel, and talk to. Juan was being treated in an urban outpatient hospital facility for generalized anxiety disorder and post-traumatic stress disorder (PTSD), which involved individual therapy and medication management. Neighboring communities that the hospital served were made up of majority Latino and African American identifying populations. As reported by the Chicago Community Trust ( 2018 ), social and economic resources are historically and unjustly distributed in this area, and have resulted in health inequities that nearly three times the well-being concerns of the U.S. on average.

Juan mentioned in the beginning of our work together that he did not trust hospital systems, specifically, employees who identified as White. Therefore, the patient did not disclose important information regarding his mental health to the hospital and me, as his therapist. I reflected on my own mistrust of the medical system and assured Juan that his apprehension was valid and accepted in our therapeutic space. We met once a week for two months to assist Juan with developing coping skills to manage his anxiety and to support his recovery from traumatic experiences. Our sessions included movement experientials that drew from Laban Movement Analysis (LMA) techniques, improvisational movement, and mindfulness-based activities, and were supplemented with verbal processing. Many of our sessions involved evocative verbal exploration into Juan’s interpretation of his life experiences; this helped to strengthen our therapeutic relationship and build trust. During our seventh individual session, one of his deepest secrets was revealed. He stared me in the eyes and stated, “I have a spirit attached to my right shoulder. I can see him and feel him. He’s talking to you. Can you hear him?” I was thunderstruck and became curious about his unexpected disclosure. The spirit had attached to Juan two months prior after he prayed to his God for companionship and guidance. What started out as a positive human-spirit friendship turned into daily negative comments from the spirit, which led the patient to share his experience with me, but not without hesitation.

Juan communicated that he would not return to treatment if the divulgence of his private information had to be revealed as he had his own codes that he lived by. Identified as street codes, or rules regulating interpersonal public behavior (Anderson, 1994 ), these rules evolved from street culture as an adaptation to the lack of faith and trust in America’s oppressive systems. Street codes recognize that toughness is a virtue and that vulnerability equaled death; thus, privacy is a necessary survival skill amongst cultures that are dependent upon street living (Anderson, 1994 ). Additionally, Juan closely identified with being spiritually gifted since childhood. He talked about seeing people’s auras (even mine) and sightings of spiritual entities throughout his upbringing and adulthood. This was the first time Juan had confided in anyone, aside from his mother, about seeing spirits.

Culture Interfaces in Ethical Decision Making

Spirituality, religion, and culture have been omitted from psychology for many decades. Current mental health models are built upon, and view patients through, a mono-cultural lens (Dominguez, 2017) and this miscommunication results in increased and worsened health disparities for populations who identify as non-White. Ethical decisions become harmful when they disempower the cultural identity of a patient and insensitively discount individual and cultural views of treatment (McEldowney & Connor, 2011 ). Although my dance/movement therapy program often brought awareness to culture, I still did not feel prepared or adequately trained to know what to do with Juan’s disclosure.

While the support and involvement of practitioners who identify as persons of color are insufficient, there are new efforts being made to reduce these deficits in mental health programs (Dominguez, 2017; Walker, Burman & Gowrisunkur, 2002 ). For example, Frame and Williams ( 2005 ) introduced an ethical decision-making model from a multicultural perspective that helps therapists view differently the Eurocentric, one-dimensional, and ruled-based way of approaching ethics. The counseling profession has begun to support the idea of spiritual needs in counseling for patients and has shown an increase in therapy effectiveness, both spiritually and psychologically (Giordano & Cashwell, 2014 ).

Theoretical Orientation

Informed by a humanistic/existential paradigm and a relational-cultural theory (RCT) and positive psychology clinical approach, my spirituality, intersectional identities, and familial experiences motivated me to fully engage in this clinical case study and to advocate for increased multicultural competency amongst healthcare practitioners. From a relational-cultural perspective, our goal when Juan and I worked together was to build our relationship, so as to increase the patient’s sense of safety and trust within the treatment facility and me. My positive psychology approach served to foster the patient’s happiness and well-being in addressing his adverse life experiences. Both approaches led to a strong therapeutic relationship between Juan and me, and helped to increase his ability to open up and share with me his circumstance with the spirit.

Exploration of Ethical Decision-Making with Juan

It was clear that further culturally based ethical decisions needed to be made in order to provide ethical, safe and cultural focused care to Juan. This article identifies and evaluates the EEDM process by working through the case using the embodied ethical steps as outlined by Hervey ( 2007 ). Along with the movement recommendations from Hervey ( 2007 ), I also explored my own movement experiences as I embodied each step in response to my ethical dilemma during the process of writing this article.

Step One: Become Familiar

Given how violently ethical conflicts can be experienced in the body, (Hervey, 2007 ), clinicians are drawn away from their embodied experience and shift towards more cognitive approaches to solve ethical dilemmas. Instead of allowing this mind/body disconnect to happen, dance/movement therapists are able to embrace the body using EEDM steps. Hervey ( 2007 ) reminds readers that true ethics started as a body-based experience of wrong and right, and in order to find appropriate solutions for ethical dilemmas, one must return to the body for guidance. Embodiment permits us to move past the rational thinking brain (prefrontal cortex) and enter the body. This allows us to develop ethical sensitivity and recognize that there is an ethical dilemma in existence (Hervey, 2007 ). Step one involves attending to our body’s experience (Csrodas, 1993) by being present and engaged with its perceptual experience. This takes place in the form of movement.

Analytic and somatic movements are two avenues to consider when analyzing bodily movements (Moore, 2014 ). Moore ( 2014 ) introduces analytics as the observation of body movement from an external perspective and somatics as the first-person perspective of internal movement. Csordas ( 1993 ) adds that the somatic dimension of movement not only includes attending to one’s internal bodily experiences but also involves attending to the bodies of others, called the somatic modes of attention. Humans are gifted with the ability to interpersonally connect in a way that allows us to feel what others feel when we exercise our use of mirror neurons. Analytic and somatic movement shifts from one’s self and their environment provide evidence that deepens the collection of information and tell us when we have an ethical dilemma on our hands. Again, in this first step of EEDM, it is suggested to postpone any type of action, only to recognize the existence of an ethical dilemma in order to prevent premature and inappropriate action (Hervey, 2007 ). Instead, Hervey ( 2007 ) positions that “vertical containment” of just attending to the body signals and exploring movement in the horizontal plane is ideal for the initial development of an ethical dilemma.

Embodiment of Step One

In the initial stage of the ethical dilemma presented in this article, my movements became accelerated in the sagittal plane, specifically in my upper limbs, torso, and core. There was a sense of urgency I felt to confide in someone about Juan’s release of private information regarding the spirit attached to his shoulder. I was fascinated by my in-session encounter and wrote in my journals about feelings of excitement and tingling surges running through my body. I also recorded my impression of shaky sensations in my arms, knots in my throat and core, and decreasing pressure in my lower body. Tortora ( 2006 ) explains that weight assumes the physical intention of executing an action; the decreasing pressure I experienced in my legs indicated how careful I was to move forward in the dilemma. The vibratory action in my arms implied feelings of anxiousness, and the knots in my throat and core signified some sort of blockage. In my journal I reported feeling a sense of imprisonment; my body felt the restraint of navigating such a cultural dilemma in a hospital setting embedded with Eurocentric forms of healthcare. Though I was excited to learn more about Juan’s experience with the spirit, my movement observations for my core, arms, and legs suggested and confirmed a hesitancy to approach and navigate the disclosure about the spirit. I was motivated and empowered to advocate for him, but I also felt sad and angered by my thoughts of foreseeable outcomes that would be adverse to our therapeutic relationship. Given the cultural context of the dilemma and its tendency to be overlooked in westernized hospital settings, my thoughts held weight. I avoided making any decisions to address Juan’s case, except to obtain support in supervision.

Step Two: Define the Dilemma

After identifying that an ethical dilemma exists, we are encouraged to define the dilemma and identify potential problem solving opportunities. For this case, the ethical dilemma was respect for culturally based meanings in treatment and how mental health clinicians identify pathology. Juan believed his seeing the spirit was a gift given to him by God; he refused to accept any diagnosis that labeled it otherwise. What Juan described as a spiritual experience is usually understood as a form of psychosis in hospital systems that rely on symptom identification and diagnosis for the treatment of symptoms. Despite encouragement from me, he opposed the idea of talking to his psychiatric nurse about his spiritual experience. I felt stalled between my own spiritual and cultural awareness, Juan’s spirituality, his safety, and having to uphold the policies and procedures of the hospital where I was interning. I understood Juan’s story as a spiritual person, as a clinician, and as a Black woman from the inner city of Chicago; but I wondered if I resonated with his story all too well because we shared the people of color in the American healthcare system narrative. I wanted to make sure he felt heard and included in his treatment. On the other hand, I wanted to avoid compromising his safety in an effort to advocate for him and for increasing cultural awareness at my site. This case with Juan was a culturally embedded ethical dilemma that required my full participation with the embodied ethical steps.

Embodiment of Step Two

My body and my mind felt uneasy about making a decision; there was a fight between my cultural background and my emergence as a clinician. The idea of both weighed heavy on my shoulders and drained my energy. My upper torso gradually sank downward along the vertical dimension and my entire body wanted to enclose itself and curl like a ball. I encountered feelings of isolation as one of few Black clinicians at my internship site as well as in the academic program at my college. I felt lonely in my ethical dilemma. There are very few articles that talk about a Black clinician’s experience of loneliness during a culturally situated ethical dilemma. Smith ( 2012 ), communicated in her thesis about a similar struggle she felt during an ethical dilemma when battling between holding on to her cultural identity as an African American woman versus choosing an identity as a clinician and abiding by ethical codes. I thought with frustration: Why does there have to be a choice? Why cannot my cultural background and my developing identity as a clinician co-exist? Hervey ( 2007 ) acknowledged the need to cope with one’s bodily felt experiences when managing complex cases. She concluded that dance/movement therapist found value in moving out the dilemma with full embodiment to support determining the next direction to take. In my attempt to release my body from the enclosed ball and fully embody the dilemma, I encountered hesitation and emotional discomfort. I felt my anger and frustration expand with my movement in the form of increased pressure and restricted affect. My body was reluctant to engage in an emotionally overwhelming, cultural dilemma, but there was a sense of freedom in knowing that I was not giving up.

Step two further required the embodiment of my patient as well as my supervisors and the treatment team to provide an empathic approach to decision-making and deciding the best course of action. In her workshops, Hervey ( 2007 ) noted that in this step participants commonly collaborated with one another using creative movement to unlock alternatives to ethical dilemmas. I recall deliberating about the advice of my supervisors, unsure if they realized the substance of my patient’s fear and request for confidentiality given that they did not identify as people of color. For them, it appeared simple: make sure he’s not homicidal or suicidal and inform the nurse practitioner. Juan denied suicidal (SI) and homicidal ideation (HI). But again, one of my supervisors informed me that regardless of his denial of SI and HI, it was imperative that I report his spiritual experience to his nurse due to the fact that she prescribed him medication and that operating as a team in our department was a requirement.

Embodying Juan, my supervisors, and others who played part in the dilemma, such as the psychiatric nurse, helped to increase my understanding of their positioning in the case. My movement consisted of taking on each person’s postures and gestures, and verbalizing notable statements from our encounters. My kinesthetic empathy allowed me to view the case from their perspective. I felt each person’s concern for safety: safety for the patient, the hospital, the college, and each person involved in the dilemma, including myself. To consider safety for everyone and everything taking part in the ethical dilemma, it required diverse methods of examination, risk management, and knowledge. My movement responded with openness to the varying perspectives of stakeholders.

Identifying the Options

Lastly in step two, Hervey found it helpful to encourage participants to imagine the most ludicrous option and move it (Hervey, 2007 , p. 103). In this way, options disregarded due to fear and being premeditated as unethical decisions become spontaneous possibilities to solving one’s ethical dilemma (Hervey, 2007 ). Identifying options will help counselors focus their energy during complex ethical dilemmas. In Table 2 , I present options considered for Juan’s case. Ultimately, I wanted to avoid causing harm to him and his beliefs by providing space for autonomy and cultural advocacy. Conversely, I was thoughtful about improperly treating a patient who may in fact benefit from receiving a diagnosis in alignment with his symptoms.

Step Three and Four: Search, Evaluate, and Determine

Hervey ( 2007 ) joins steps three and four of Welfel’s ( 2001 ) ethical decision-making model into one complete phase to evaluate options and to determine the best solution. It requires dance/movement therapists to utilize professional literature, ethical codes and regulations, and agency policies to provide structure for later deliberating processes (Hervey, 2007 ). Referencing codes, regulations and policies, as implied by Constable, Kreider, Smith & Taylor (2011), helps novice therapists navigate the uncertainties associated with ethical decision-making. Even for experienced counselors, this step remains a priority for continued growth and development and enhanced ethical judgment (Oramas, 2017 ). Ethical standards are designed to protect professionals and patients; yet, these standards usually result in more reactive than proactive ethical decision-making (Trahan & Lemberger, 2014 ). So in addition, seeking guidance from ethics scholarship enables counselors to vicariously learn by trial and error from practiced professionals. Aside from providing clarity, focus, and structure, this step also increases confidence through skill building and acquisition of ethical knowledge, and further limits risky decision-making. Once all relevant information has been obtained regarding options identified in step two, dance/movement therapists are to move out those possibilities. It is essential to utilize this step as an explorative measure with movement to create more available options than to rely on rules to quickly resolve the dilemma (Hervey, 2007 ).

Codes and Scholarship

The ethical dilemma of respect for culturally based meanings in treatment and how mental health clinicians identify pathology is related to the American Dance Therapy Association’s (ADTA, 2015) ethical standard of display of integrity within the therapeutic relationship. It states, “Dance/movement therapists encourage the patient’s voice in treatment and respect the patient’s right to make decisions based on personal values” (ADTA, 2015 , p. 3). The ADTA ( 2015 ) Code of Ethics additionally encourages dance/movement therapists to continuously reexamine their own biases and worldviews to avoid imposing them onto patients, and to consider the impact of oppressive systems on individual patient experiences. According to these ethical codes, Juan had every right to name his spiritual experience as he saw most fitting with his beliefs. Providing space for Juan to do that directly aligned with my obligations as an intern dance/movement therapist. However, the hospital did not ascribe to these standards. Though Juan experienced a sense of safety in my office space, we were a part of a larger operating system that he relied on for treatment.

The American Counseling Association’s (ACA, 2014 ) ethical code Avoiding Harm and Imposing Values states that counselors work to avoid harm and minimize potential harm to patients. I perceived there could be potential harm in revealing Juan’s undisclosed information to the treatment team. Counselors are trusted with the safety of each patient as they enter our therapeutic spaces, and as humans who have accepted the responsibilities of a counselor as a life calling, we feel competent enough to complete this task. Avoiding harm requires more than providing evidence-based interventions, private and clean spaces for therapy, judgment-free zones, and upholding ethical standards. It requires constant self-awareness and reflection, and honoring cultural differences.

The ADTA ( 2015 ) Codes of Ethics are informed by and parallel the ACA ( 2014 ) Code of Ethics. It is acknowledged that the ACA Code of Ethics was constructed and shaped by an individualistic, Western society (Birrell & Bruns, 2016 ) and remains firmly established in a modern society that accordingly places emphasis on rules, independence, and power-over rather than relational engagement and power-with patients in treatment. Ergo, complex situations in treatment settings become central when persons in power are compelled to make ethical decisions regarding the well-being of a patient, even when cultural beliefs conflict (Laws & Chilton, 2013 ). The patient in this case had a different cultural meaning of issues regarding his psyche than that of the hospital setting where he received treatment.

The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA) is a manual of classified mental disorders that serves as a guide for interventions and treatment recommendations. In the DSM-5 (APA, 2013 ), a practical diagnosis for Juan’s case would fall under schizophrenia spectrum and psychotic disorders given his presentation of what the mental health field considers visual, auditory, and somatic hallucinations. Overtime, the DSM-5 has integrated cultural factors into disorders in the form of V-codes, described as supplementary conditions influencing a disorder. V-code 62.89, “Religious or Spiritual Problem”, accounts for loss or questioning of religion or spirituality (APA, 2013 , p. 725), however, this code does not encompass religious or spiritual factors as it pertains to this case. The option of diagnosing Juan carried the risk of deterring him from seeking therapy and decreasing his overall well-being. A diagnosis would suggest that his cultural interpretation of his spiritual experience was either false or meaningless. Timimi ( 2014 ) and Allmon ( 2013 ) are clear that these types of interpretations of culturally based beliefs disempower the patient and could increase negative symptoms.

The second professional value listed in the ACA’s ( 2014 ) code of ethics honors and supports, “the worth, dignity, potential, and uniqueness of people within their social and cultural contexts” (p. 3). Since values are the cornerstone of which ethical decisions are carried out, counselors are to refrain from submitting a diagnosis if they know that it will cause harm to the patient in some way (ACA, 2014 ). It is rational to consider how the stigmatization of an oppressive label from the western culture will cause individual, cultural, and societal adverse consequences for some patients (Ratts & Hutchins, 2009 ).

Social consequences for the patient must be taken into consideration when making ethical decisions (Zheng, Gray, Zhu & Jiang, 2014). Usually in the decision-making process, the counselor identifies the ethical dilemma, takes the necessary steps to problem-solve outside of the therapy room, and decides on a resolution to the dilemma absent the patient’s voice (Birrell & Bruns, 2016 ). Yet, the ACA’s ( 2014 ) code of ethics states that counselors work collaboratively with patients to promote growth and development during an ethical decision-making process. Shared decision-making (SDM) is a model that was first developed in the 1980′s to improve the experience of patients in treatment settings by encouraging a collaborative process between the patient and health professional (Bradley & Green, 2018 ). This comes with controversy regarding the risks of granting access to a patient, which allows them to collaborate with doctors regarding their treatment, given their level of competency of medical knowledge may be limited (Christine & Kaldjian, 2013 ; Herlitz, Munthe, Torner & Forsander, 2016). The same is true to consider when patients are invited to autonomously collaborate in counseling settings.

Embodiment of Steps Three and Four

As I embodied the Effort weight, for this ethical dilemma, I found strong feelings surfacing about my cultural identity and the desire to advocate for marginalized groups. There was increasing pressure in my upper body and I associated this with the idea of fighting oppressive systems at my site, as well as healthcare systems in general. I let that increasing pressure sink downward into my lower body and invited decreasing pressure to my upper body. The anger and frustration of having to engage with such a system did not disappear, however, awareness of my embodied experience encouraged me to take a gentler approach to ethical decision-making.

I had a lot mixed feelings that were reflected in my movement while searching the ethics codes and gathering information. I felt confused and surrounded by information as I turned in circles reaching and pulling. The information seemed full of loose ends and, to a great extent, required interpretation. There was increased tension in my shoulders, and I eventually distanced myself from the imaginary visual of the ethics codes and scholarship. I entered into a remote state of increased bound flow and directing as I gazed at the information from a far. I began to move in my preferred style of popping and locking while visualizing the information regarding the clinical case. I was able to bring in my culture when understanding and interpreting the codes. Although complete clarity of the codes was not realized, I experienced increased confidence and intention for working through the dilemma with this new knowledge.

Step Five: Ethical Principles

Step five requires reference to the five ethical principles identified by Kitchener ( 1984 ). They are: autonomy, nonmaleficence, beneficence, justice, and fidelity, along with the added principle: veracity. Ethics involves cultural norms, personal morals, and values during the decision-making process, and these will serve counselors in the self-exploration process of relating to the guiding principles (Evans et al., 2012 ). Ethical principles were conceptualized to provide a foundation of morals to help interpret ethical codes and adjust routine responses to unconventional ethical dilemmas (Chmielewski, 2004 ).

Each ethical principle has been layed out with common movement qualities that were found by dance/movement therapists when they moved out the principles separately (Table 1 ; Hervey, 2007 ). A key part of step five is to be attentive to any embodied responses that are experienced while moving each principle. Principles have the potential to draw out essential details to help us strengthen our understanding of the dilemma and where the conflict is coming from, externally, and internally within ourselves in the form of values (Miller & Davis, 2016 ).

Another key factor is to acknowledge that these principles were created as a guide to culture-specific standards of behavior, and that ethical principles will be prioritized differently within varying cultures (Gauthier, Pettifor, & Ferrero, 2010 ). The new age invites new rules of behaviors, and these rules are changing rapidly (Hoose, 1986 ). It is important to be aware of the cultural body’s response to each principle and how it shapes our experience with them.

Autonomy describes mutual respect in a relationship, where both individuals honor one another’s ability to make autonomous decisions (Kitchener, 1984 ). During complex ethical dilemmas, counselors may feel an urgency to act on impulses, yet feel the tension of respecting the autonomy of the patients, others involved, and that of themselves (Hervey, 2007 ). Indeed, the act of yielding and pushing through movement, which can be realized in dance/movement therapy, informs our boundaries and asserts greater independence (Schwartz, 2018 ).

There was constant pushing in my movement to create boundaries while embodying autonomy. I used my arms to separate and push back on the healthcare system to provide space for Juan and myself. It felt like I was taking on the role of advocate: working to gain autonomy for two people of color in a Eurocentric hospital setting. While moving I wondered how much autonomy could I actually encourage Juan to have given his presentation of symptoms and possible limitations of mental health information. Juan had previously omitted important details regarding his symptoms because he did not feel safe. I cautioned myself against allowing too much space as I thought about what other information might be unknown about him. As I moved and created space for myself, I realized I needed separation from both Juan and my internship site to be free in my own autonomy. In a cultural sense, autonomy for me meant expressing and standing strong with my own beliefs. I had responsibilities as an intern clinician to uphold the policies at the hospital, policies that I understood to be Eurocentric cultural norms and did not fully agree with. However, as a novice clinician, how much autonomy could I possess given my own limitation concerning the knowledge of policies and procedures regarding the clinical case? I engaged in a back and forth movement, suggesting the tug between inviting space for autonomy and enclosing space where autonomy may have been less beneficial to resolving the dilemma.

Nonmaleficence

Nonmaleficence means not causing harm to patients, including intentional actions to harm or carrying out risky actions that have the potential to harm them (Kitchener, 1984 ). This ethical principle corresponded with careful, cautious, and tentative movement responses (Hervey, 2007 ).

I attuned to my visceral experience of decreasing pressure and binding flow, as suggested by Hervey ( 2007 ), as I moved carefully. There were multiple pieces to consider to avoid harm. I wanted to culturally empower Juan and I wanted to keep him safe; however, safety could have looked like many things from the different perspectives of everyone involved in the dilemma. Safety could look like Juan feeling empowered and gaining trust in the healthcare system because he felt heard and believed by his treatment team. Safety could look like diagnosing Juan and giving him medication from the nurse’s perspective. Safety could look like informing Juan’s treatment team and engaging in ongoing investigation of his symptoms from my supervisors’ perspective. Safety could also look like keeping the information to myself and linking Juan to spiritual healers in nearby communities. I engaged in movements that looked like dipping and dodging as I moved, carefully considering all of these pieces that surfaced. I further examined my own safety in relationship to nonmaleficence. A decision to inform Juan’s treatment team would potentially cause harm to my cultural identity; I would feel like I betrayed my values and my community by going against street codes and abiding by rules of a mistrusted healthcare system. On the other hand, a decision to not inform the treatment team would leave me feeling disconnected as a team member at the hospital and also feeling like I am not doing my job correctly as a clinician; both would cause harm to my professional identity.

Beneficence

Beneficence is the act of reducing human suffering by supporting the welfare of others and enhancing their sense of empowerment (Jennings et al, 2005 ). This was a principle that I found myself sitting on during the time of my ethical dilemma. There is a two-sided impression of what doing good actually looks like; it could be the literal act of taking action to do good, or it could involve being good in a time of complexity and chaos (Hervey, 2007 ). Naturally I wanted to advocate for Juan by taking action, and I deemed it necessary for a culturally embedded case. Robson et al., ( 2000 ) argues that beneficence carries the obligation for counselors to seek substantial knowledge and perform in the best interest of the patient’s welfare. On the other hand, I felt that beneficence was just being good for my patient by offering a therapeutic space where his cultural interpretation of his experience was true, regardless whether the site was willing to change its process of labeling pathology. My upper torso instantly advanced forward in the sagittal plane without hesitation, my head shook side to side suggesting the word no, my limbs supported me with increased weight. My body gladly considered no other option but to actively engage in this clinical case by advocating for Juan and other underserved people who could benefit from a change in the healthcare system.

Justice, as an ethical principle, means fairness, treating others as equals, and promoting equality counseling. This ethical principle was most challenging for me to embody. In my body I felt stuck with increased bound flow at thoughts of how inequalities in healthcare systems continue to persist. In my exploration of balancing movements for justice, my body maintained its bound flow in every part except my arms. My bound flow was accompanied by rage and sadness. I attempted to take on the posture of the scales of justice with my hands held outward to the side; they felt empty and light. I brought my hands in front of me, side-by-side, and gazed at the emptiness for a moment. The ethical codes themselves require revamping to address the inequalities that exist within them (Kitchener, 1984 ; Robson, et al., 2000 ; Trahan & Lemberger, 2013). ‘It started to become clear that Juan’s case was a step forward in advocating for others like him who want and deserve fair and culturally sensitive treatment. This clinical case study was a component of seeking justice in itself.

Fidelity is an act of faithfulness; it is about remaining loyal and keeping promises to patients (Kitchener, 1986). This was another challenging principle to embody. The moment a counseling relationship is established, there is an obligation on the part of the therapist to honor commitments and promises, and to fulfill the responsibility of trust and accountability (Wade, 2015 ). While some dance/movement therapists affiliated fidelity with commitment, honesty, and integrity, others associated it with retaining secrets. I considered how this principle could relate to one of my options: doing nothing and disregarding my patient’s spiritual experience in an effort to protect Juan from harm. During my embodied experience, I felt the sensation of being pulled in different directions with an uncomfortable tingling sensation in my stomach. I was confounded, caught in the middle of both my developed and emerging identities. On one end, I felt a pull from my patient to be with him in our marginalized identities. On another end, I felt pulling from my internship site and the counseling field to be an ethical therapist. Lastly, I saw an image of me pulling myself to just be me and to separate from both. I resorted back to autonomy and engaged in boundary setting movements, realizing that being faithful and honest to myself was my first responsibility.

Healthy disconnections are a key factor in the RCT framework. I refused the idea of becoming enmeshed with either the hospital or my patient during process of navigating the dilemma. I desired a healthy balance of connecting and disconnecting, which meant standing in my own identity while engaging with the clinical case. I reflected back to autonomy while moving this dilemma; fidelity helped me see where multiple truths encountered and overlapped one another. The nurse practitioner’s truth may be helping others in an informed way by assigning diagnostic labels in order to effectively treat multiple patients and prescribe medication. The nurse’s truth overlapped Juan’s truth of seeing his mental concerns as something spiritual, but not having many resources to turn to for support. I understood fidelity as a principle to encourage all involved in the case to be true to themselves and not place rules and labels above being human.

Veracity was added to the most recent addition of the ACA’s ( 2014 ) Code of Ethics and is defined as dealing truthfully with individuals during professional interactions. In my embodiment of veracity, I discovered a vertical stance that turned into spiraling movements of my spine with free flow and lightness. I felt authentic and vulnerable in my movement, and I also felt the willingness to share myself and connect with others involved in the ethical dilemma. True veracity requires authenticity to be effective; vulnerability is a bonus. It goes back to fidelity and being aware of placing rules above respect for human differences. The dilemma in this clinical case rose from a lack of acknowledgement of cultural differences and viewing ethical dilemmas through intellectualized codes instead of the truth within the human body.

Step Six: Consult and Share

When does spirituality become pathology? How do we ethically honor a patient’s cultural meaning of spirituality in a westernized medical system? These were the questions that had surfaced for me in supervision. Interestingly, I had three White identifying supervisors, and I was one of very few Black clinicians in training at my academic setting and the only Black supervisee at my site. There is an established power differential that comes with a supervisee-supervisor relationship which was compounded by Black-White dyads that constituted each of my supervisory relationships. Clinicians of color in training commonly experience their voices being silenced in clinical and academic settings, especially when topics of culture and race need to be addressed (Estrada, 2005 ; Hardy, 2015 ; Hernández, 2003 ; Jernigan, Green, Helms, & Perez-Gualdron, 2016 ). This is likely a consequence of practiced cultural conditioning in Western societies as well as a lack of cultural awareness and training that has persisted throughout the counseling field, thus continuing the cycle of supervisors overlooking cultural issues (Estrada, 2005 ; Vereen, Hill, & McNeal, 2008 ; Jernigan, et al., 2016 ; Ivers, Rogers, Borders, & Turner, 2017). As a result of being a therapist in training, a therapist of color, and dealing with an ethical dilemma involving a cultural conflict, I was very hesitant to confide in my supervisors due to our cultural differences.

I struggled with feelings of discomfort when it came time to discuss the dilemma with my supervisors. Supervision felt like an unsafe setting to express my anger and frustrations of being a Black woman working to resolve an ethical situation deeply embedded with cultural conflict. My experience was not normalized. When I brought up the cultural factors of the case, the room seemed to either become silently heavy or the conversation deflected to an idea outside of culture. That only led to more frustration. I wanted to avoid the angry Black woman stereotype that accompanied my skin tone and aesthetic appearance and affected the way others perceived me interpersonally. I knew it would only hurt my professional career if my expressions were perceived outside of professional behavior, whatever professional behavior is according to Eurocentric standards. Consequently, I eventually suppressed my feelings and operated from a place of numbness whenever I had to discuss the clinical case further. I thought it was pointless to continue to take my body through a wave of unheard, misunderstood emotions. Suppressing my feelings and emotions was not the best coping strategy, but it was healthier and less exhausting than continuing to feel shut down or deflected. I objectively shared all the facts about the case with Juan. I did not share my subjective experiences, at least not nearly to the extent of how they lived in my body during supervision.

Embodiment of Step Six

Hervey ( 2007 ) recommends that dance/movement therapists share their ethical dilemma with trusted colleagues or supervisors through authentic movement, verbal communication, or by designing their own way of sharing. Step six aims to increase the mover’s confidence for consultation.

While engaging in this step during my journey of writing this article, I experienced step six to be helpful with extracting the dilemma from my body and putting into movement. I shared the dilemma alone first, and then I shared my movement with a peer. By first moving the dilemma alone, I was able to see what I wanted to share and how I wanted to share it, absent the influence of another body in the room. When I offered my movement to my confidant, I was again nervous, worried about their criticism of my choice of movement, as they were unfamiliar with embodiment practices. The art of moving past internal and external criticism of who I am as a dance/movement therapist allowed me to connect deeper to how the dilemma lived in my body. I could extract it and put it into an art form in which I have always experienced healing. It allowed me to gain control over what was suppressed inside of my Black body.

Step Seven and Eight: Deliberate, Decide, and Rehearse

Steps seven and eight of Welfel’s ( 2001 ) ethical model prompt therapists to deliberate and decide the best plan of action, and Hervey ( 2007 ) puts emphasis on taking responsibility of the final decision. Ethical thinking is a complicated process and we must consider the impact of our decisions on individuals and the institution we serve (Chmielewski, 2004 ). Without careful acknowledgement of the responsibility we hold in these types of situations, counselors run the risk of creating unsafe environments for current and future patients, and further risk producing adverse consequences for institutions. (Chmielewski, 2004 ). This step precedes any action to promote clarifying our intentions while solidifying our final decision.

Decision Made for the Case with Juan

I decided to inform Juan’s nurse practitioner of his spiritual experiences. Ultimately, it felt like I was without much choice as I had already informed my internship site supervisor before I was aware this clinical case was an ethical dilemma, and one that would affect me deeply from a cultural perspective. I abided by the rules of the hospital and complied with directions given to me regarding the next steps to take. Before disclosing Juan’s information, I talked with him in one of our sessions about my obligation as an interning clinician to inform his nurse. Again, I provided the option for him to tell his nurse, alone or accompanied by me; however he refused both. Juan stated he understood and respected my responsibilities, but he would not return to therapy. I informed him of the sadness that his decision brought me and expressed that I also understood his responsibility to protect himself. In the end, Juan ended up coming back to therapy. The relationship we built in our therapeutic space of allowing our cultural identities to exist freely without judgment surmounted the undesired ethical decision that was executed, and led to Juan’s return.

Honestly, if I could go back and engage in this ethical decision-making process and change something, I would not. The process has taught me so much about who I am as a clinician and an advocate of cultural needs in healthcare systems. I also believe that Juan benefitted greatly from our therapeutic relationship that involved increased sensitivity to and active inclusion of cultural differences. Though he felt our trust was broken, we were able to rebuild it in our proceeding sessions by repairing the rupture that had taken place. Repairing our rupture contributed to strengthening our therapeutic alliance even further. From an RCT perspective, the therapeutic relationship was the healing factor to the decision made in this culturally situated ethical dilemma.

Embodiment of Steps Seven and Eight

In order to clarify intentions and solidify a plan, dance/movement therapists are directed to move alone, journal, or do both while deliberating (Hervey, 2007 ). This is a resourceful point in the ethical decision-making process to connect all of the important pieces of the case and evaluate the risks involved for one’s self, the patient, and treatment team. The deliberation process can create feelings of reconnection and groundedness as we reach for clarity. Once deliberation has been finalized and intention clarified, the next measure is to commit to a plan of action (Hervey, 2007 ). It is recommended to rehearse acting out the final decision through movement or imagination to increase one’s confidence before implementing the plan (Hervey, 2007 ). After the decision has been carried out, counselors are to head into the final step of the EEDM process for reflection. In an effort to support a reconnection to my own intentions, it was helpful for me to ask myself questions as a way to facilitate my movement. For instance: What motivated me to engage in this ethical decision-making process? Why and how will this benefit my patient? How will my decision support future patients and therapists who encounter a similar ethical dilemma? It was interesting to notice my arms reaching outward in all directions of the dimensional scale, and then carving their way back to my core, as if they were bringing me something back. I experienced a sense of clarity, and moreover, I experienced a sense of knowing who I am in this dilemma, and on a spiritual plane, what purpose this dilemma has brought to my career as a dance/movement therapist.

Step Nine: Reflect and Evaluate

Though Hervey ( 2007 ) excluded this final step from her workshops, it is important to engage in this reflective step to evaluate how effective the entire EEDM process has been, and doing so in an embodied fashion (Hervey, 2007 ). While understanding what parts of the process were effective, it is also possible to learn what steps can be done differently for future dilemmas (Hervey, 2007 ; Constable et al., 2011 ). Cottone ( 2001 ) agrees that the reflection process is not one of the mind, but an appraisal process of actions and a continued process of seeking alternative perspectives. Cottone ( 2001 ) encourages clinicians to go beyond the perspectives of supervisors, peers, and respected colleagues, and consider the cultural context in which the decision was implemented and how it affects the community at large.

For one, extending an open conversation to the patient in an effort to understand how the final decision affected them can increase feelings of safety and empathy for both the patient and counselor, especially if the ethical decision was contrary to the stated desire of that patient. Furthermore, I also suggest reaching out to community members and persons who identify within that associated culture. Shah (2011), described inviting pushback, where a group of people express resistance or redirection, as a way to show care and feelings of importance to the perspectives of underserved communities that may otherwise go unnoticed. Shah (2011) also brings attention to the fact that mistakes are inevitable during ethical decision-making, and it is essential that counselors prepare themselves for this kind of feedback. If not, the fear of criticism will keep counselors oblivious to the needs of patients, community members, and different cultures, therefore creating greater barriers that could potentially aid in the progression of mental healthcare for those in need.

Embodiment of Step Nine

In my movement reflection, I discovered that I was able to remove the heaviness of my culture from my back and place it in my hands in front of me. I now saw it as a tangible construct, something I could work with and move through. My body felt mobile with free flow as I integrated movements from the previous steps as a way to reflect on my experiences. There was a sense of gained knowledge and tools to assist me with navigating future complex ethical dilemmas in a culturally informed and embodied way.

By engaging in this in-depth exploration with the EEDM steps, I learned how meaningful this case was to me and possibly to underserved populations who engage in healthcare services. As opposed to intellectually escaping my bodily felt responses to the dilemma, these steps encouraged me to listen to and engage with them. Without doing so, I would not have reached the conclusions I have presented in this article. My connection to this clinical case was a deep visceral experience that had been silenced by an oppressive healthcare system and me, but illuminated through an embodied process. Current healthcare practices disempower and affect the long-term health of people of color because they are expected to comply with mono-cultural views of mental health and treatment. I made a decision to share Juan’s spiritual experiences with his nurse against his will. My therapeutic approach of displaying respect and giving prominence to Juan’s culturally based meaning-making of his spiritual experience was what encouraged Juan to return to treatment. Still, it is essential to examine potential harmful outcomes and how they can be prevented or diminished until healthcare systems modify their operations.

Throughout the ethical dilemma, I was the intermediary between my patient, the psychiatric nurse, and my site supervisor. ACA’s ( 2014 ) Code of Ethics assert a collaborative process between counselors and patients, yet, in most ethical dilemmas, the counselor makes decisions in isolation (Birrell & Bruns, 2016 ). Most clinical guidelines similarly recommend involving patients in decisions regarding assessment and treatment thus supporting collaborative and informed goals (Elwyn et al., 2006 ). This type of patient-centered care has been increasingly adopted as interdisciplinary teams realize how valuable shared decision-making (SDM) is for patient success and well-being (Adisso et al., 2018 ; Chewning et al., 2012 ; Elwyn, Edwards, Kinnersley, 1999; Elwyn, Edwards, Kinnersley, Grol, 2000; Légaré et al., 2011 ). Persons directly involved in an ethical dilemma have great potential to effectively influence the decision-making process, and no one voice should be given exclusive privilege over another (Birrell & Bruns, 2016 ). From an RCT perspective, interconnection during ethical decision-making processes can invite real change in a positive direction for not only the patient, but for the counselor and institution as well.

RCT acknowledges that growth-fostering relationships, relationships that include increased understanding and empathy for one another’s thoughts and feelings, display respect for the multitude of sociocultural aspects that each individual brings to the experience (Duffey & Somody, 2011 ). As humans, we are wired to move through and toward connection with others, and it is the connection and relational experience that contributes to healthy functioning and flourishing (McCauley, 2013 ).

What I desired most during my ethical decision-making process was to have all the people involved in the dilemma to be in one room listening to each other with openness, curiosity, and empathy. I was the intermediary of all communication amongst my supervisors, Juan, and the nurse. It was exhausting relaying information, and a lot of the time I was repeating the same information to a different person. So much of my time and energy was expelled in this back and forth communication, only to implement the decision alone. As the intermediary, I additionally witnessed statements from my encounters with each of them that made me feel uncomfortable or suggested a lack of empathy for one another. I wished they were able to learn of one another’s circumstances to create more understanding and empathy within the case. I understood that our workloads prevented a collaborative decision-making meeting that would have included my site supervisor, the nurse, Juan, and myself in one room discussing the details of the case and all the possible solutions to working with Juan’s spiritual experience. I further understood that such a meeting would have been quite frightening for Juan who wanted to keep his experience a secret. I wondered how that might have been different if Juan discovered the hospital altered their policies to accept and consider his meaning making of his spiritual experience? A joint meeting could have saved me much time, energy, and stress over a dilemma that affected others and me deeply.

Based on my experiences with this ethical dilemma, I developed a model for active multicultural diversity (AMD), a term credited to Carmichael ( 2012 ), as a guide for ethical decision-making aimed at increasing effective outcomes for patients by taking culture from a concept that exists in one’s awareness to a concept acted upon (Fig.  1 ). It incorporates the EEDM steps with SDM and the three M’s of RCT: movement to mutuality, mutual empathy, and mutual empowerment. With the embodied ethical decision making steps at the center of decision-making, I encourage the patient, therapist, and treatment team to equally collaborate when making ethical decisions. In this way, the burden of resolving the ethical dilemma is not placed in the hands of one person, but instead, all are responsible for reaching a conclusion, therefore increasing the vitality of each person through involvement and interconnectedness.

Active multicultural diversity in ethical decision-making

Movement Towards Mutuality

Hartling and Miller (2004) describe non-mutual relationships as dominate/subordinate or power-over relationships, which the more powerful or dominant participant in the relationship receives greater benefit. Instead, movement towards mutuality calls for all participants of the relationship to engage in, and take emotional and cognitive action towards change (Hartling & Miller, 2004). This movement towards mutuality benefits people by preventing humiliation while supporting growth, healing, and human rights. All participants in the ethical dilemma must be willing to change where possible and appropriate in order to see each other as equal individuals while collaborating to resolve the ethical dilemma.

Mutual Empathy

Mutual empathy is the ability to be impactful and to be impacted in the relationship through seeing and feeling within the experience (Duffey & Somody, 2011 ). It is through acceptance and validation that an authentic relationship can be built and become a priority (Duffey & Somody, 2011 ; Hartling & Miller, 2004). This is an essential piece to navigating complex ethical dilemmas.

Mutual Empowerment

Empowerment is the feeling of having control and understanding over one’s life (World Health Organization, 2010 ). The World Health Organization ( 2010 ) realizes that institutions have a responsibility of operating in ways that empower the people and communities they serve to encourage vitality, health and well-being. Empowerment in relationships must be mutual so that all parties feel competent, heard, seen and respected as they collectively shape and develop the experience (Hartling & Miller 2004). Decision-making is best done when those engaging in the collaborative process do so feeling confident and empowered.

I envision healthcare facilities employing a designated ethical dilemma consultant, to mediate the collaboration process. Clinicians, nurses, doctors, and even patients could send the consultant a notification that a potential ethical dilemma arose. From there, the consultant would initiate communication for all involved in the dilemma to decide on a date and time to meet and work through the AMD model to resolve the case. The consultation session could be structured according to the persons participating in the meeting. A session may involve a lot of movement or minimal movement with mostly postures and gestures. A simplified version might employ mindfulness techniques to identify body-felt sensations to each embodied step. The three M’s should be illustrated at the beginning of each consultation to help clarify the intent and goal of engaging in the EEDM process. The three M’s, movement to mutuality, mutual empathy, and mutual empowerment, effectively work to create an open and safe atmosphere that encourages full participation in the EEDM steps.

Active Multicultural Diversity for Juan’s Case

In order for AMD to work in this clinical case with Juan, increased funding for mental health programs leading to less overworked professionals is a definite necessity. Professionals at the hospital were consistently double booked with patients for the majority of the workday. The oppressive system in which the hospital was situated, affected patients and employees alike. The hospital consistently treated people of color with limited support service options. It is feasible that if the hospital had sufficient funding for mental health services, increasing staff and office space, the AMD model could have been implemented in this clinical case. Further, to participate in a collaborative process, the patient, nurse, and clinical supervisor would have to be willing to engage with one another with an increased open mind and non-judgmental attitude. This would help cultivate a collaborative process insofar as Juan would have been able to communicate his desires to resolving the dilemma in a way that would also increase his trust for the hospital setting through our relational experience.

Limitations and Possibilities

Active multicultural diversity in ethical decision-making does not come without its challenges and limitations when considering the integral components of how westernized healthcare systems have been operating for decades. For one, SDM requires more time for collective consultations between healthcare professionals and patients (Elwyn et al., 1999 ). Most healthcare professionals are occupied with required treatment planning, writing notes, other consultations, case management, and other daily tasks. Counselors may also experience the obligation to educate patients on mental health to increase competency levels for ethical decision-making, which also requires more time (Elwyn et al., 1999 ). In light of this, patient decision aids, new technologies designed to prepare patients and to increase their knowledge of information related to treatment, are used to assist in making informed choices when collaborating with healthcare providers (Elwyn et al., 2006 ; Adisso et al., 2018 ). In an effort to increase active multicultural diversity in healthcare settings, patient decision aids should be made accessible to all communities, all populations, and in all forms of healthcare. Another limitation of active multicultural diversity is the perceived threat to power in professional-patient relationships (Elwyn et al., 1999 ). This is associated with a lack of cultural competence, caring knowledge, mono-cultural embedded lenses, and power-over preferences from health professionals and institutions. Moreover, just like cultural competency training is deficient in mental health programs, SDM is also deficient in programs and skill building workshops, and is further absent in modeling from older, more experienced clinicians (Elwyn et al., 1999 ). It is possible that with an ethical decision-making consultant on site, regular trainings could be provided to keep professionals and patients informed on ethical decision-making and cultural competency.

Finally, embodiment is a skill that dance/movement therapists and other body-based practitioners are accustomed to, and it could be a challenging to engage non-body-based practitioners and patients in movement during an ethical decision-making process without significant willingness or training. This could reshape healthcare systems requiring leadership figures to provide more resources, education/training, and time to healthcare professionals so they are prepared and available to engage patients and team members in active multicultural diversity for ethical decision-making.

I can embrace the AMD model moving forward by including my patients in the EEDM process as a part of our therapy sessions, if a dilemma happens to emerge during our work together. We could collaborate to identify options to resolve the dilemma. I would then present those options in consultations with the treatment team to include and discuss their viewpoints. Another possibility is having someone from the treatment team join one of the therapy sessions with my patient and have them witness our movement, as identified in step six of sharing the dilemma. After, we might engage in a discussion to decide on an action to take, invite the team member to join the movement, or both. In this manner, there is an inclusion of multiple voices to collectively resolve a dilemma in an embodied way. Inviting a treatment team member into a session also indicates movement towards mutuality as each person shows initiative by taking time out of their day to dedicate to the safety and care of the patient. Mutual empathy happens in the process of moving and witnessing movement; illuminating how the movement affected each person in the room can deepen the process. Mutual empowerment is experienced in the feelings of inclusion, displaying respect and interest in one another’s opinion.

The purpose of this clinical case study was to illustrate how the EEDM steps influenced ethical decision-making when cultural differences conflicted. I found that by engaging in the embodied ethical steps, I was able to deepen the decision-making process by accessing the lived experience of the dilemma in my body. I carried the heaviness of a silenced cultural identity until it was able to speak through movement. The ethical dilemma in this case was respect for culturally based meanings in treatment and how we name pathology. Culture is inadequately considered in healthcare operations, treatment models, and educational programs. We must actively consider how this deficiency affects patient health over time and disempowers underserved populations from engaging in treatment. The EEDM steps provide an effective way for working with diverse populations as we can connect to our bodies to explore new possibilities for complex situations. In this clinical case with Juan, though the decision to inform his nurse practitioner of his spiritual experience was against his will, our relationship encouraged his continued engagement with treatment services. To consider culturally based meanings in treatment, the relational experience is essential in order to receive support from different perspectives. Sharing the embodied decision-making process can be most effective for culturally situated ethical dilemmas. As suggested in the AMD model presented here, engaging in the EEDM steps through a RCT lens benefits silenced and underserved patients, and healthcare professionals with an increased sense of mutuality through a meaningful process.

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Roberts, M. Embodied Ethical Decision-Making: A Clinical Case Study of Respect for Culturally Based Meaning Making in Mental Healthcare. Am J Dance Ther 43 , 36–63 (2021). https://doi.org/10.1007/s10465-020-09338-3

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Case Study Research Method in Psychology

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Case studies are in-depth investigations of a person, group, event, or community. Typically, data is gathered from various sources using several methods (e.g., observations & interviews).

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events that are currently occurring in his or her everyday life.

The case study is not a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

 Famous Case Studies

• Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
• Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
• Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
• Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
• Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

• Studying the effectiveness of psychotherapy approaches with an individual patient
• Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
• Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

• Studying psychological development from birth through adolescence
• Cases of learning disabilities, autism spectrum disorders, ADHD
• Effects of trauma, abuse, deprivation on development

Types of Case Studies

• Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
• Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
• Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
• Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
• Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
• Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

• Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.
• Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
• Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

• News/Media – News coverage of events related to the case study.
• Academic articles – Journal articles, dissertations etc. that discuss the case.
• Government reports – Official data and records related to the case context.
• Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

• Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
• Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
• School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

1. Introduction

• Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
• Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

• Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
• Include client demographics like age and gender, information about social relationships, and mental health history.
• Describe all physical, emotional, and/or sensory symptoms reported by the client.
• Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
• Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
• Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

• Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
• Present the results of the intervention,including any quantitative or qualitative data collected.
• For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

• Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
• Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
• Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
• Offer clinical implications, and suggest future research directions.

5. Additional Items

• Thank specific assistants for writing support only. No patient acknowledgments.
• References should directly support any key claims or quotes included.
• Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
• Provides detailed (rich qualitative) information.
• Provides insight for further research.
• Permitting investigation of otherwise impractical (or unethical) situations.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

• Lacking scientific rigor and providing little basis for generalization of results to the wider population.
• Researchers’ own subjective feelings may influence the case study (researcher bias).
• Difficult to replicate.
• Time-consuming and expensive.
• The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data , a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for Anna O , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

Breuer, J., & Freud, S. (1895).  Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Harlow J. M. (1848). Passage of an iron rod through the head.  Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868).  Recovery from the Passage of an Iron Bar through the Head .  Publications of the Massachusetts Medical Society. 2  (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972).  Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

Further Information

• Case Study Approach
• Case Study Method
• Enhancing the Quality of Case Studies in Health Services Research
• “We do things together” A case study of “couplehood” in dementia
• Using mixed methods for evaluating an integrative approach to cancer care: a case study

Ethical Principles of Psychologists and Code of Conduct

Effective date June 1, 2003 with amendments effective June 1, 2010 and January 1, 2017. Copyright © 2017 American Psychological Association. All rights reserved.

The American Psychological Association's (APA) Ethical Principles of Psychologists and Code of Conduct (hereinafter referred to as the Ethics Code) consists of an Introduction, a Preamble , five General Principles  (A-E) and specific Ethical Standards . The Introduction discusses the intent, organization, procedural considerations, and scope of application of the Ethics Code. The Preamble and General Principles are aspirational goals to guide psychologists toward the highest ideals of psychology. Although the Preamble and General Principles are not themselves enforceable rules, they should be considered by psychologists in arriving at an ethical course of action. The Ethical Standards set forth enforceable rules for conduct as psychologists. Most of the Ethical Standards are written broadly, in order to apply to psychologists in varied roles, although the application of an Ethical Standard may vary depending on the context. The Ethical Standards are not exhaustive. The fact that a given conduct is not specifically addressed by an Ethical Standard does not mean that it is necessarily either ethical or unethical.

This Ethics Code applies only to psychologists' activities that are part of their scientific, educational, or professional roles as psychologists. Areas covered include but are not limited to the clinical, counseling, and school practice of psychology; research; teaching; supervision of trainees; public service; policy development; social intervention; development of assessment instruments; conducting assessments; educational counseling; organizational consulting; forensic activities; program design and evaluation; and administration. This Ethics Code applies to these activities across a variety of contexts, such as in person, postal, telephone, Internet, and other electronic transmissions. These activities shall be distinguished from the purely private conduct of psychologists, which is not within the purview of the Ethics Code.

Membership in the APA commits members and student affiliates to comply with the standards of the APA Ethics Code and to the rules and procedures used to enforce them. Lack of awareness or misunderstanding of an Ethical Standard is not itself a defense to a charge of unethical conduct.

The procedures for filing, investigating, and resolving complaints of unethical conduct are described in the current Rules and Procedures of the APA Ethics Committee . APA may impose sanctions on its members for violations of the standards of the Ethics Code, including termination of APA membership, and may notify other bodies and individuals of its actions. Actions that violate the standards of the Ethics Code may also lead to the imposition of sanctions on psychologists or students whether or not they are APA members by bodies other than APA, including state psychological associations, other professional groups, psychology boards, other state or federal agencies, and payors for health services. In addition, APA may take action against a member after his or her conviction of a felony, expulsion or suspension from an affiliated state psychological association, or suspension or loss of licensure. When the sanction to be imposed by APA is less than expulsion, the 2001 Rules and Procedures do not guarantee an opportunity for an in-person hearing, but generally provide that complaints will be resolved only on the basis of a submitted record.

The Ethics Code is intended to provide guidance for psychologists and standards of professional conduct that can be applied by the APA and by other bodies that choose to adopt them. The Ethics Code is not intended to be a basis of civil liability. Whether a psychologist has violated the Ethics Code standards does not by itself determine whether the psychologist is legally liable in a court action, whether a contract is enforceable, or whether other legal consequences occur.

The modifiers used in some of the standards of this Ethics Code (e.g., reasonably, appropriate, potentially) are included in the standards when they would (1) allow professional judgment on the part of psychologists, (2) eliminate injustice or inequality that would occur without the modifier, (3) ensure applicability across the broad range of activities conducted by psychologists, or (4) guard against a set of rigid rules that might be quickly outdated. As used in this Ethics Code, the term reasonable means the prevailing professional judgment of psychologists engaged in similar activities in similar circumstances, given the knowledge the psychologist had or should have had at the time.

In the process of making decisions regarding their professional behavior, psychologists must consider this Ethics Code in addition to applicable laws and psychology board regulations. In applying the Ethics Code to their professional work, psychologists may consider other materials and guidelines that have been adopted or endorsed by scientific and professional psychological organizations and the dictates of their own conscience, as well as consult with others within the field. If this Ethics Code establishes a higher standard of conduct than is required by law, psychologists must meet the higher ethical standard. If psychologists' ethical responsibilities conflict with law, regulations, or other governing legal authority, psychologists make known their commitment to this Ethics Code and take steps to resolve the conflict in a responsible manner in keeping with basic principles of human rights.

Psychologists are committed to increasing scientific and professional knowledge of behavior and people's understanding of themselves and others and to the use of such knowledge to improve the condition of individuals, organizations, and society. Psychologists respect and protect civil and human rights and the central importance of freedom of inquiry and expression in research, teaching, and publication. They strive to help the public in developing informed judgments and choices concerning human behavior. In doing so, they perform many roles, such as researcher, educator, diagnostician, therapist, supervisor, consultant, administrator, social interventionist, and expert witness. This Ethics Code provides a common set of principles and standards upon which psychologists build their professional and scientific work.

This Ethics Code is intended to provide specific standards to cover most situations encountered by psychologists. It has as its goals the welfare and protection of the individuals and groups with whom psychologists work and the education of members, students, and the public regarding ethical standards of the discipline.

The development of a dynamic set of ethical standards for psychologists' work-related conduct requires a personal commitment and lifelong effort to act ethically; to encourage ethical behavior by students, supervisees, employees, and colleagues; and to consult with others concerning ethical problems.

This section consists of General Principles. General Principles, as opposed to Ethical Standards, are aspirational in nature. Their intent is to guide and inspire psychologists toward the very highest ethical ideals of the profession. General Principles, in contrast to Ethical Standards, do not represent obligations and should not form the basis for imposing sanctions. Relying upon General Principles for either of these reasons distorts both their meaning and purpose.

Principle A: Beneficence and Nonmaleficence Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons, and the welfare of animal subjects of research. When conflicts occur among psychologists' obligations or concerns, they attempt to resolve these conflicts in a responsible fashion that avoids or minimizes harm. Because psychologists' scientific and professional judgments and actions may affect the lives of others, they are alert to and guard against personal, financial, social, organizational, or political factors that might lead to misuse of their influence. Psychologists strive to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work.

Principle B: Fidelity and Responsibility Psychologists establish relationships of trust with those with whom they work. They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct, clarify their professional roles and obligations, accept appropriate responsibility for their behavior, and seek to manage conflicts of interest that could lead to exploitation or harm. Psychologists consult with, refer to, or cooperate with other professionals and institutions to the extent needed to serve the best interests of those with whom they work. They are concerned about the ethical compliance of their colleagues' scientific and professional conduct. Psychologists strive to contribute a portion of their professional time for little or no compensation or personal advantage.

Principle C: Integrity Psychologists seek to promote accuracy, honesty, and truthfulness in the science, teaching, and practice of psychology. In these activities psychologists do not steal, cheat or engage in fraud, subterfuge, or intentional misrepresentation of fact. Psychologists strive to keep their promises and to avoid unwise or unclear commitments. In situations in which deception may be ethically justifiable to maximize benefits and minimize harm, psychologists have a serious obligation to consider the need for, the possible consequences of, and their responsibility to correct any resulting mistrust or other harmful effects that arise from the use of such techniques.

Principle D: Justice Psychologists recognize that fairness and justice entitle all persons to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures, and services being conducted by psychologists. Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to or condone unjust practices.

Principle E: Respect for People's Rights and Dignity 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.

1.01 Misuse of Psychologists' Work If psychologists learn of misuse or misrepresentation of their work, they take reasonable steps to correct or minimize the misuse or misrepresentation.

1.02 Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority If psychologists’ ethical responsibilities conflict with law, regulations, or other governing legal authority, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights.

1.03 Conflicts Between Ethics and Organizational Demands   If the demands of an organization with which psychologists are affiliated or for whom they are working are in conflict with this Ethics Code, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights.

1.04 Informal Resolution of Ethical Violations When psychologists believe that there may have been an ethical violation by another psychologist, they attempt to resolve the issue by bringing it to the attention of that individual, if an informal resolution appears appropriate and the intervention does not violate any confidentiality rights that may be involved. (See also Standards 1.02, Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority , and 1.03, Conflicts Between Ethics and Organizational Demands .)

1.05 Reporting Ethical Violations If an apparent ethical violation has substantially harmed or is likely to substantially harm a person or organization and is not appropriate for informal resolution under Standard 1.04, Informal Resolution of Ethical Violations , or is not resolved properly in that fashion, psychologists take further action appropriate to the situation. Such action might include referral to state or national committees on professional ethics, to state licensing boards, or to the appropriate institutional authorities. This standard does not apply when an intervention would violate confidentiality rights or when psychologists have been retained to review the work of another psychologist whose professional conduct is in question. (See also Standard 1.02, Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority .)

1.06 Cooperating with Ethics Committees Psychologists cooperate in ethics investigations, proceedings, and resulting requirements of the APA or any affiliated state psychological association to which they belong. In doing so, they address any confidentiality issues. Failure to cooperate is itself an ethics violation. However, making a request for deferment of adjudication of an ethics complaint pending the outcome of litigation does not alone constitute noncooperation.

1.07 Improper Complaints Psychologists do not file or encourage the filing of ethics complaints that are made with reckless disregard for or willful ignorance of facts that would disprove the allegation.

1.08 Unfair Discrimination Against Complainants and Respondents Psychologists do not deny persons employment, advancement, admissions to academic or other programs, tenure, or promotion, based solely upon their having made or their being the subject of an ethics complaint. This does not preclude taking action based upon the outcome of such proceedings or considering other appropriate information.

2.01 Boundaries of Competence (a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

(b) 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 .

(c) Psychologists planning to provide services, teach, or conduct research involving populations, areas, techniques, or technologies new to them undertake relevant education, training, supervised experience, consultation, or study.

(d) When psychologists are asked to provide services to individuals for whom appropriate mental health services are not available and for which psychologists have not obtained the competence necessary, psychologists with closely related prior training or experience may provide such services in order to ensure that services are not denied if they make a reasonable effort to obtain the competence required by using relevant research, training, consultation, or study.

(e) In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm.

(f) When assuming forensic roles, psychologists are or become reasonably familiar with the judicial or administrative rules governing their roles.

2.02 Providing Services in Emergencies In emergencies, when psychologists provide services to individuals for whom other mental health services are not available and for which psychologists have not obtained the necessary training, psychologists may provide such services in order to ensure that services are not denied. The services are discontinued as soon as the emergency has ended or appropriate services are available.

2.03 Maintaining Competence Psychologists undertake ongoing efforts to develop and maintain their competence.

2.04 Bases for Scientific and Professional Judgments Psychologists' work is based upon established scientific and professional knowledge of the discipline. (See also Standards 2.01e, Boundaries of Competence , and 10.01b, Informed Consent to Therapy .)

2.05 Delegation of Work to Others Psychologists who delegate work to employees, supervisees, or research or teaching assistants or who use the services of others, such as interpreters, take reasonable steps to (1) avoid delegating such work to persons who have a multiple relationship with those being served that would likely lead to exploitation or loss of objectivity; (2) authorize only those responsibilities that such persons can be expected to perform competently on the basis of their education, training, or experience, either independently or with the level of supervision being provided; and (3) see that such persons perform these services competently. (See also Standards 2.02, Providing Services in Emergencies ; 3.05, Multiple Relationships ; 4.01, Maintaining Confidentiality ; 9.01, Bases for Assessments ; 9.02, Use of Assessments ; 9.03, Informed Consent in Assessments ; and 9.07, Assessment by Unqualified Persons .)

2.06 Personal Problems and Conflicts (a) Psychologists refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner.

(b) When psychologists become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work-related duties. (See also Standard 10.10, Terminating Therapy .)

3.01 Unfair Discrimination In their work-related activities, psychologists do not engage in unfair discrimination based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, socioeconomic status, or any basis proscribed by law.

3.02 Sexual Harassment Psychologists do not engage in sexual harassment. Sexual harassment is sexual solicitation, physical advances, or verbal or nonverbal conduct that is sexual in nature, that occurs in connection with the psychologist's activities or roles as a psychologist, and that either (1) is unwelcome, is offensive, or creates a hostile workplace or educational environment, and the psychologist knows or is told this or (2) is sufficiently severe or intense to be abusive to a reasonable person in the context. Sexual harassment can consist of a single intense or severe act or of multiple persistent or pervasive acts. (See also Standard 1.08, Unfair Discrimination Against Complainants and Respondents .)

3.03 Other Harassment Psychologists do not knowingly engage in behavior that is harassing or demeaning to persons with whom they interact in their work based on factors such as those persons' age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status.

3.04 Avoiding Harm (a) Psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm where it is foreseeable and unavoidable. 

(b) Psychologists do not participate in, facilitate, assist, or otherwise engage in torture, defined as any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person, or in any other cruel, inhuman, or degrading behavior that violates 3.04(a).

3.05 Multiple Relationships 

(a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.

A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.

Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.

(b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code.

(c) When psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur. (See also Standards 3.04, Avoiding Harm , and 3.07, Third-Party Requests for Services .)

3.06 Conflict of Interest Psychologists refrain from taking on a professional role when personal, scientific, professional, legal, financial, or other interests or relationships could reasonably be expected to (1) impair their objectivity, competence, or effectiveness in performing their functions as psychologists or (2) expose the person or organization with whom the professional relationship exists to harm or exploitation.

3.07 Third-Party Requests for Services When psychologists agree to provide services to a person or entity at the request of a third party, psychologists attempt to clarify at the outset of the service the nature of the relationship with all individuals or organizations involved. This clarification includes the role of the psychologist (e.g., therapist, consultant, diagnostician, or expert witness), an identification of who is the client, the probable uses of the services provided or the information obtained, and the fact that there may be limits to confidentiality. (See also Standards 3.05, Multiple relationships , and 4.02, Discussing the Limits of Confidentiality.)

3.08 Exploitative Relationships Psychologists do not exploit persons over whom they have supervisory, evaluative or other authority such as clients/patients, students, supervisees, research participants, and employees. (See also Standards 3.05, Multiple Relationships ; 6.04, Fees and Financial Arrangements ; 6.05, Barter with Clients/Patients ; 7.07, Sexual Relationships with Students and Supervisees ; 10.05, Sexual Intimacies with Current Therapy Clients/Patients ; 10.06, Sexual Intimacies with Relatives or Significant Others of Current Therapy Clients/Patients ; 10.07, Therapy with Former Sexual Partners ; and 10.08, Sexual Intimacies with Former Therapy Clients/Patients .)

3.09 Cooperation with Other Professionals When indicated and professionally appropriate, psychologists cooperate with other professionals in order to serve their clients/patients effectively and appropriately. (See also Standard 4.05, Disclosures .)

3.10 Informed Consent (a) When psychologists conduct research or provide assessment, therapy, counseling, or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person or persons except when conducting such activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Code. (See also Standards 8.02, Informed Consent to Research ; 9.03, Informed Consent in Assessments ; and 10.01, Informed Consent to Therapy .)

(b) For persons who are legally incapable of giving informed consent, psychologists nevertheless (1) provide an appropriate explanation, (2) seek the individual's assent, (3) consider such persons' preferences and best interests, and (4) obtain appropriate permission from a legally authorized person, if such substitute consent is permitted or required by law. When consent by a legally authorized person is not permitted or required by law, psychologists take reasonable steps to protect the individual's rights and welfare.

(c) When psychological services are court ordered or otherwise mandated, psychologists inform the individual of the nature of the anticipated services, including whether the services are court ordered or mandated and any limits of confidentiality, before proceeding.

(d) Psychologists appropriately document written or oral consent, permission, and assent. (See also Standards 8.02, Informed Consent to Research ; 9.03, Informed Consent in Assessments ; and 10.01, Informed Consent to Therapy .)

3.11 Psychological Services Delivered to or Through Organizations (a) Psychologists delivering services to or through organizations provide information beforehand to clients and when appropriate those directly affected by the services about (1) the nature and objectives of the services, (2) the intended recipients, (3) which of the individuals are clients, (4) the relationship the psychologist will have with each person and the organization, (5) the probable uses of services provided and information obtained, (6) who will have access to the information, and (7) limits of confidentiality. As soon as feasible, they provide information about the results and conclusions of such services to appropriate persons.

(b) If psychologists will be precluded by law or by organizational roles from providing such information to particular individuals or groups, they so inform those individuals or groups at the outset of the service.

3.12 Interruption of Psychological Services Unless otherwise covered by contract, psychologists make reasonable efforts to plan for facilitating services in the event that psychological services are interrupted by factors such as the psychologist's illness, death, unavailability, relocation, or retirement or by the client's/patient's relocation or financial limitations. (See also Standard 6.02c, Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work .)

4.01 Maintaining Confidentiality Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship. (See also Standard 2.05, Delegation of Work to Others .)

4.02 Discussing the Limits of Confidentiality (a) Psychologists discuss with persons (including, to the extent feasible, persons who are legally incapable of giving informed consent and their legal representatives) and organizations with whom they establish a scientific or professional relationship (1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities. (See also Standard 3.10, Informed Consent .)

(b) Unless it is not feasible or is contraindicated, the discussion of confidentiality occurs at the outset of the relationship and thereafter as new circumstances may warrant.

(c) Psychologists who offer services, products, or information via electronic transmission inform clients/patients of the risks to privacy and limits of confidentiality.

4.03 Recording Before recording the voices or images of individuals to whom they provide services, psychologists obtain permission from all such persons or their legal representatives. (See also Standards 8.03, Informed Consent for Recording Voices and Images in Research ; 8.05, Dispensing with Informed Consent for Research ; and 8.07, Deception in Research .)

4.04 Minimizing Intrusions on Privacy (a) Psychologists include in written and oral reports and consultations, only information germane to the purpose for which the communication is made.

(b) Psychologists discuss confidential information obtained in their work only for appropriate scientific or professional purposes and only with persons clearly concerned with such matters.

4.05 Disclosures (a) Psychologists may disclose confidential information with the appropriate consent of the organizational client, the individual client/patient, or another legally authorized person on behalf of the client/patient unless prohibited by law.

(b) Psychologists disclose confidential information without the consent of the individual only as mandated by law, or where permitted by law for a valid purpose such as to (1) provide needed professional services; (2) obtain appropriate professional consultations; (3) protect the client/patient, psychologist, or others from harm; or (4) obtain payment for services from a client/patient, in which instance disclosure is limited to the minimum that is necessary to achieve the purpose. (See also Standard 6.04e, Fees and Financial Arrangements .)

4.06 Consultations When consulting with colleagues, (1) psychologists do not disclose confidential information that reasonably could lead to the identification of a client/patient, research participant, or other person or organization with whom they have a confidential relationship unless they have obtained the prior consent of the person or organization or the disclosure cannot be avoided, and (2) they disclose information only to the extent necessary to achieve the purposes of the consultation. (See also Standard 4.01, Maintaining Confidentiality .)

4.07 Use of Confidential Information for Didactic or Other Purposes Psychologists do not disclose in their writings, lectures, or other public media, confidential, personally identifiable information concerning their clients/patients, students, research participants, organizational clients, or other recipients of their services that they obtained during the course of their work, unless (1) they take reasonable steps to disguise the person or organization, (2) the person or organization has consented in writing, or (3) there is legal authorization for doing so.

5.01 Avoidance of False or Deceptive Statements (a) Public statements include but are not limited to paid or unpaid advertising, product endorsements, grant applications, licensing applications, other credentialing applications, brochures, printed matter, directory listings, personal resumes or curricula vitae, or comments for use in media such as print or electronic transmission, statements in legal proceedings, lectures and public oral presentations, and published materials. Psychologists do not knowingly make public statements that are false, deceptive, or fraudulent concerning their research, practice, or other work activities or those of persons or organizations with which they are affiliated.

(b) Psychologists do not make false, deceptive, or fraudulent statements concerning (1) their training, experience, or competence; (2) their academic degrees; (3) their credentials; (4) their institutional or association affiliations; (5) their services; (6) the scientific or clinical basis for, or results or degree of success of, their services; (7) their fees; or (8) their publications or research findings.

(c) Psychologists claim degrees as credentials for their health services only if those degrees (1) were earned from a regionally accredited educational institution or (2) were the basis for psychology licensure by the state in which they practice.

5.02 Statements by Others (a) Psychologists who engage others to create or place public statements that promote their professional practice, products, or activities retain professional responsibility for such statements.

(b) Psychologists do not compensate employees of press, radio, television, or other communication media in return for publicity in a news item. (See also Standard 1.01, Misuse of Psychologists' Work .)

(c) A paid advertisement relating to psychologists' activities must be identified or clearly recognizable as such.

5.03 Descriptions of Workshops and Non-Degree-Granting Educational Programs To the degree to which they exercise control, psychologists responsible for announcements, catalogs, brochures, or advertisements describing workshops, seminars, or other non-degree-granting educational programs ensure that they accurately describe the audience for which the program is intended, the educational objectives, the presenters, and the fees involved.

5.04 Media Presentations When psychologists provide public advice or comment via print, Internet, or other electronic transmission, they take precautions to ensure that statements (1) are based on their professional knowledge, training, or experience in accord with appropriate psychological literature and practice; (2) are otherwise consistent with this Ethics Code; and (3) do not indicate that a professional relationship has been established with the recipient. (See also Standard 2.04, Bases for Scientific and Professional Judgments .)

5.05 Testimonials Psychologists do not solicit testimonials from current therapy clients/patients or other persons who because of their particular circumstances are vulnerable to undue influence.

5.06 In-Person Solicitation Psychologists do not engage, directly or through agents, in uninvited in-person solicitation of business from actual or potential therapy clients/patients or other persons who because of their particular circumstances are vulnerable to undue influence. However, this prohibition does not preclude (1) attempting to implement appropriate collateral contacts for the purpose of benefiting an already engaged therapy client/patient or (2) providing disaster or community outreach services.

6.01 Documentation of Professional and Scientific Work and Maintenance of Records Psychologists create, and to the extent the records are under their control, maintain, disseminate, store, retain, and dispose of records and data relating to their professional and scientific work in order to (1) facilitate provision of services later by them or by other professionals, (2) allow for replication of research design and analyses, (3) meet institutional requirements, (4) ensure accuracy of billing and payments, and (5) ensure compliance with law. (See also Standard 4.01, Maintaining Confidentiality .)

6.02 Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work (a) Psychologists maintain confidentiality in creating, storing, accessing, transferring, and disposing of records under their control, whether these are written, automated, or in any other medium. (See also Standards 4.01, Maintaining Confidentiality , and 6.01, Documentation of Professional and Scientific Work and Maintenance of Records .)

(b) If confidential information concerning recipients of psychological services is entered into databases or systems of records available to persons whose access has not been consented to by the recipient, psychologists use coding or other techniques to avoid the inclusion of personal identifiers.

(c) Psychologists make plans in advance to facilitate the appropriate transfer and to protect the confidentiality of records and data in the event of psychologists' withdrawal from positions or practice. (See also Standards 3.12, Interruption of Psychological Services , and 10.09, Interruption of Therapy .)

6.03 Withholding Records for Nonpayment Psychologists may not withhold records under their control that are requested and needed for a client's/patient's emergency treatment solely because payment has not been received.

6.04 Fees and Financial Arrangements (a) As early as is feasible in a professional or scientific relationship, psychologists and recipients of psychological services reach an agreement specifying compensation and billing arrangements.

(b) Psychologists' fee practices are consistent with law.

(c) Psychologists do not misrepresent their fees.

(d) If limitations to services can be anticipated because of limitations in financing, this is discussed with the recipient of services as early as is feasible. (See also Standards 10.09, Interruption of Therapy , and 10.10, Terminating Therapy .)

(e) If the recipient of services does not pay for services as agreed, and if psychologists intend to use collection agencies or legal measures to collect the fees, psychologists first inform the person that such measures will be taken and provide that person an opportunity to make prompt payment. (See also Standards 4.05, Disclosures ; 6.03, Withholding Records for Nonpayment ; and 10.01, Informed Consent to Therapy .)

6.05 Barter with Clients/Patients Barter is the acceptance of goods, services, or other nonmonetary remuneration from clients/patients in return for psychological services. Psychologists may barter only if (1) it is not clinically contraindicated, and (2) the resulting arrangement is not exploitative. (See also Standards 3.05, Multiple Relationships , and 6.04, Fees and Financial Arrangements .)

6.06 Accuracy in Reports to Payors and Funding Sources In their reports to payors for services or sources of research funding, psychologists take reasonable steps to ensure the accurate reporting of the nature of the service provided or research conducted, the fees, charges, or payments, and where applicable, the identity of the provider, the findings, and the diagnosis. (See also Standards 4.01, Maintaining Confidentiality ; 4.04, Minimizing Intrusions on Privacy ; and 4.05, Disclosures .)

6.07 Referrals and Fees When psychologists pay, receive payment from, or divide fees with another professional, other than in an employer-employee relationship, the payment to each is based on the services provided (clinical, consultative, administrative, or other) and is not based on the referral itself. (See also Standard 3.09, Cooperation with Other Professionals .)

7.01 Design of Education and Training Programs Psychologists responsible for education and training programs take reasonable steps to ensure that the programs are designed to provide the appropriate knowledge and proper experiences, and to meet the requirements for licensure, certification, or other goals for which claims are made by the program. (See also Standard 5.03, Descriptions of Workshops and Non-Degree-Granting Educational Programs .)

7.02 Descriptions of Education and Training Programs Psychologists responsible for education and training programs take reasonable steps to ensure that there is a current and accurate description of the program content (including participation in required course- or program-related counseling, psychotherapy, experiential groups, consulting projects, or community service), training goals and objectives, stipends and benefits, and requirements that must be met for satisfactory completion of the program. This information must be made readily available to all interested parties.

7.03 Accuracy in Teaching (a) Psychologists take reasonable steps to ensure that course syllabi are accurate regarding the subject matter to be covered, bases for evaluating progress, and the nature of course experiences. This standard does not preclude an instructor from modifying course content or requirements when the instructor considers it pedagogically necessary or desirable, so long as students are made aware of these modifications in a manner that enables them to fulfill course requirements. (See also Standard 5.01, Avoidance of False or Deceptive Statements .)

(b) When engaged in teaching or training, psychologists present psychological information accurately. (See also Standard 2.03, Maintaining Competence .)

7.04 Student Disclosure of Personal Information Psychologists do not require students or supervisees to disclose personal information in course- or program-related activities, either orally or in writing, regarding sexual history, history of abuse and neglect, psychological treatment, and relationships with parents, peers, and spouses or significant others except if (1) the program or training facility has clearly identified this requirement in its admissions and program materials or (2) the information is necessary to evaluate or obtain assistance for students whose personal problems could reasonably be judged to be preventing them from performing their training- or professionally related activities in a competent manner or posing a threat to the students or others.

7.05 Mandatory Individual or Group Therapy (a) When individual or group therapy is a program or course requirement, psychologists responsible for that program allow students in undergraduate and graduate programs the option of selecting such therapy from practitioners unaffiliated with the program. (See also Standard 7.02, Descriptions of Education and Training Programs .)

(b) Faculty who are or are likely to be responsible for evaluating students' academic performance do not themselves provide that therapy. (See also Standard 3.05, Multiple Relationships .)

7.06 Assessing Student and Supervisee Performance (a) In academic and supervisory relationships, psychologists establish a timely and specific process for providing feedback to students and supervisees. Information regarding the process is provided to the student at the beginning of supervision.

(b) Psychologists evaluate students and supervisees on the basis of their actual performance on relevant and established program requirements.

7.07 Sexual Relationships with Students and Supervisees Psychologists do not engage in sexual relationships with students or supervisees who are in their department, agency, or training center or over whom psychologists have or are likely to have evaluative authority. (See also Standard 3.05, Multiple Relationships .)

8.01 Institutional Approval When institutional approval is required, psychologists provide accurate information about their research proposals and obtain approval prior to conducting the research. They conduct the research in accordance with the approved research protocol.

8.02 Informed Consent to Research (a) When obtaining informed consent as required in Standard 3.10, Informed Consent, psychologists inform participants about (1) the purpose of the research, expected duration, and procedures; (2) their right to decline to participate and to withdraw from the research once participation has begun; (3) the foreseeable consequences of declining or withdrawing; (4) reasonably foreseeable factors that may be expected to influence their willingness to participate such as potential risks, discomfort, or adverse effects; (5) any prospective research benefits; (6) limits of confidentiality; (7) incentives for participation; and (8) whom to contact for questions about the research and research participants' rights. They provide opportunity for the prospective participants to ask questions and receive answers. (See also Standards 8.03, Informed Consent for Recording Voices and Images in Research ; 8.05, Dispensing with Informed Consent for Research ; and 8.07, Deception in Research .)

(b) Psychologists conducting intervention research involving the use of experimental treatments clarify to participants at the outset of the research (1) the experimental nature of the treatment; (2) the services that will or will not be available to the control group(s) if appropriate; (3) the means by which assignment to treatment and control groups will be made; (4) available treatment alternatives if an individual does not wish to participate in the research or wishes to withdraw once a study has begun; and (5) compensation for or monetary costs of participating including, if appropriate, whether reimbursement from the participant or a third-party payor will be sought. (See also Standard 8.02a, Informed Consent to Research .)

8.03 Informed Consent for Recording Voices and Images in Research Psychologists obtain informed consent from research participants prior to recording their voices or images for data collection unless (1) the research consists solely of naturalistic observations in public places, and it is not anticipated that the recording will be used in a manner that could cause personal identification or harm, or (2) the research design includes deception, and consent for the use of the recording is obtained during debriefing. (See also Standard 8.07, Deception in Research .)

8.04 Client/Patient, Student, and Subordinate Research Participants (a) When psychologists conduct research with clients/patients, students, or subordinates as participants, psychologists take steps to protect the prospective participants from adverse consequences of declining or withdrawing from participation.

(b) When research participation is a course requirement or an opportunity for extra credit, the prospective participant is given the choice of equitable alternative activities.

8.05 Dispensing with Informed Consent for Research Psychologists may dispense with informed consent only (1) where research would not reasonably be assumed to create distress or harm and involves (a) the study of normal educational practices, curricula, or classroom management methods conducted in educational settings; (b) only anonymous questionnaires, naturalistic observations, or archival research for which disclosure of responses would not place participants at risk of criminal or civil liability or damage their financial standing, employability, or reputation, and confidentiality is protected; or (c) the study of factors related to job or organization effectiveness conducted in organizational settings for which there is no risk to participants' employability, and confidentiality is protected or (2) where otherwise permitted by law or federal or institutional regulations.

8.06 Offering Inducements for Research Participation (a) Psychologists make reasonable efforts to avoid offering excessive or inappropriate financial or other inducements for research participation when such inducements are likely to coerce participation.

(b) When offering professional services as an inducement for research participation, psychologists clarify the nature of the services, as well as the risks, obligations, and limitations. (See also Standard 6.05, Barter with Clients/Patients .)

8.07 Deception in Research (a) Psychologists do not conduct a study involving deception unless they have determined that the use of deceptive techniques is justified by the study's significant prospective scientific, educational, or applied value and that effective nondeceptive alternative procedures are not feasible.

(b) Psychologists do not deceive prospective participants about research that is reasonably expected to cause physical pain or severe emotional distress.

(c) Psychologists explain any deception that is an integral feature of the design and conduct of an experiment to participants as early as is feasible, preferably at the conclusion of their participation, but no later than at the conclusion of the data collection, and permit participants to withdraw their data. (See also Standard 8.08, Debriefing .)

8.08 Debriefing (a) Psychologists provide a prompt opportunity for participants to obtain appropriate information about the nature, results, and conclusions of the research, and they take reasonable steps to correct any misconceptions that participants may have of which the psychologists are aware.

(b) If scientific or humane values justify delaying or withholding this information, psychologists take reasonable measures to reduce the risk of harm.

(c) When psychologists become aware that research procedures have harmed a participant, they take reasonable steps to minimize the harm.

8.09 Humane Care and Use of Animals in Research (a) Psychologists acquire, care for, use, and dispose of animals in compliance with current federal, state, and local laws and regulations, and with professional standards.

(b) Psychologists trained in research methods and experienced in the care of laboratory animals supervise all procedures involving animals and are responsible for ensuring appropriate consideration of their comfort, health, and humane treatment.

(c) Psychologists ensure that all individuals under their supervision who are using animals have received instruction in research methods and in the care, maintenance, and handling of the species being used, to the extent appropriate to their role. (See also Standard 2.05, Delegation of Work to Others .)

(d) Psychologists make reasonable efforts to minimize the discomfort, infection, illness, and pain of animal subjects.

(e) Psychologists use a procedure subjecting animals to pain, stress, or privation only when an alternative procedure is unavailable and the goal is justified by its prospective scientific, educational, or applied value.

(f) Psychologists perform surgical procedures under appropriate anesthesia and follow techniques to avoid infection and minimize pain during and after surgery.

(g) When it is appropriate that an animal's life be terminated, psychologists proceed rapidly, with an effort to minimize pain and in accordance with accepted procedures.

8.10 Reporting Research Results (a) Psychologists do not fabricate data. (See also Standard 5.01a, Avoidance of False or Deceptive Statements .)

(b) If psychologists discover significant errors in their published data, they take reasonable steps to correct such errors in a correction, retraction, erratum, or other appropriate publication means.

8.11 Plagiarism Psychologists do not present portions of another's work or data as their own, even if the other work or data source is cited occasionally.

8.12 Publication Credit (a) Psychologists take responsibility and credit, including authorship credit, only for work they have actually performed or to which they have substantially contributed. (See also Standard 8.12b, Publication Credit .)

(b) Principal authorship and other publication credits accurately reflect the relative scientific or professional contributions of the individuals involved, regardless of their relative status. Mere possession of an institutional position, such as department chair, does not justify authorship credit. Minor contributions to the research or to the writing for publications are acknowledged appropriately, such as in footnotes or in an introductory statement.

(c) Except under exceptional circumstances, a student is listed as principal author on any multiple-authored article that is substantially based on the student's doctoral dissertation. Faculty advisors discuss publication credit with students as early as feasible and throughout the research and publication process as appropriate. (See also Standard 8.12b, Publication Credit .)

8.13 Duplicate Publication of Data Psychologists do not publish, as original data, data that have been previously published. This does not preclude republishing data when they are accompanied by proper acknowledgment.

8.14 Sharing Research Data for Verification (a) After research results are published, psychologists do not withhold the data on which their conclusions are based from other competent professionals who seek to verify the substantive claims through reanalysis and who intend to use such data only for that purpose, provided that the confidentiality of the participants can be protected and unless legal rights concerning proprietary data preclude their release. This does not preclude psychologists from requiring that such individuals or groups be responsible for costs associated with the provision of such information.

(b) Psychologists who request data from other psychologists to verify the substantive claims through reanalysis may use shared data only for the declared purpose. Requesting psychologists obtain prior written agreement for all other uses of the data.

8.15 Reviewers Psychologists who review material submitted for presentation, publication, grant, or research proposal review respect the confidentiality of and the proprietary rights in such information of those who submitted it.

9.01 Bases for Assessments (a) Psychologists base the opinions contained in their recommendations, reports, and diagnostic or evaluative statements, including forensic testimony, on information and techniques sufficient to substantiate their findings. (See also Standard 2.04, Bases for Scientific and Professional Judgments .)

(b) Except as noted in 9.01c , psychologists provide opinions of the psychological characteristics of individuals only after they have conducted an examination of the individuals adequate to support their statements or conclusions. When, despite reasonable efforts, such an examination is not practical, psychologists document the efforts they made and the result of those efforts, clarify the probable impact of their limited information on the reliability and validity of their opinions, and appropriately limit the nature and extent of their conclusions or recommendations. (See also Standards 2.01, Boundaries of Competence , and 9.06, Interpreting Assessment Results .)

(c) When psychologists conduct a record review or provide consultation or supervision and an individual examination is not warranted or necessary for the opinion, psychologists explain this and the sources of information on which they based their conclusions and recommendations.

9.02 Use of Assessments (a) Psychologists administer, adapt, score, interpret, or use assessment techniques, interviews, tests, or instruments in a manner and for purposes that are appropriate in light of the research on or evidence of the usefulness and proper application of the techniques.

(b) Psychologists use assessment instruments whose validity and reliability have been established for use with members of the population tested. When such validity or reliability has not been established, psychologists describe the strengths and limitations of test results and interpretation.

(c) Psychologists use assessment methods that are appropriate to an individual's language preference and competence, unless the use of an alternative language is relevant to the assessment issues.

9.03 Informed Consent in Assessments (a) Psychologists obtain informed consent for assessments, evaluations, or diagnostic services, as described in Standard 3.10, Informed Consent, except when (1) testing is mandated by law or governmental regulations; (2) informed consent is implied because testing is conducted as a routine educational, institutional, or organizational activity (e.g., when participants voluntarily agree to assessment when applying for a job); or (3) one purpose of the testing is to evaluate decisional capacity. Informed consent includes an explanation of the nature and purpose of the assessment, fees, involvement of third parties, and limits of confidentiality and sufficient opportunity for the client/patient to ask questions and receive answers.

(b) Psychologists inform persons with questionable capacity to consent or for whom testing is mandated by law or governmental regulations about the nature and purpose of the proposed assessment services, using language that is reasonably understandable to the person being assessed.

(c) Psychologists using the services of an interpreter obtain informed consent from the client/patient to use that interpreter, ensure that confidentiality of test results and test security are maintained, and include in their recommendations, reports, and diagnostic or evaluative statements, including forensic testimony, discussion of any limitations on the data obtained. (See also Standards 2.05, Delegation of Work to Others ; 4.01, Maintaining Confidentiality ; 9.01, Bases for Assessments ; 9.06, Interpreting Assessment Results ; and 9.07, Assessment by Unqualified Persons .)

9.04 Release of Test Data (a) The term test data refers to raw and scaled scores, client/patient responses to test questions or stimuli, and psychologists' notes and recordings concerning client/patient statements and behavior during an examination. Those portions of test materials that include client/patient responses are included in the definition of test data . Pursuant to a client/patient release, psychologists provide test data to the client/patient or other persons identified in the release. Psychologists may refrain from releasing test data to protect a client/patient or others from substantial harm or misuse or misrepresentation of the data or the test, recognizing that in many instances release of confidential information under these circumstances is regulated by law. (See also Standard 9.11, Maintaining Test Security .)

(b) In the absence of a client/patient release, psychologists provide test data only as required by law or court order.

9.05 Test Construction Psychologists who develop tests and other assessment techniques use appropriate psychometric procedures and current scientific or professional knowledge for test design, standardization, validation, reduction or elimination of bias, and recommendations for use.

9.06 Interpreting Assessment Results When interpreting assessment results, including automated interpretations, psychologists take into account the purpose of the assessment as well as the various test factors, test-taking abilities, and other characteristics of the person being assessed, such as situational, personal, linguistic, and cultural differences, that might affect psychologists' judgments or reduce the accuracy of their interpretations. They indicate any significant limitations of their interpretations. (See also Standards 2.01b and c, Boundaries of Competence , and 3.01, Unfair Discrimination .)

9.07 Assessment by Unqualified Persons Psychologists do not promote the use of psychological assessment techniques by unqualified persons, except when such use is conducted for training purposes with appropriate supervision. (See also Standard 2.05, Delegation of Work to Others .)

9.08 Obsolete Tests and Outdated Test Results (a) Psychologists do not base their assessment or intervention decisions or recommendations on data or test results that are outdated for the current purpose.

(b) Psychologists do not base such decisions or recommendations on tests and measures that are obsolete and not useful for the current purpose.

9.09 Test Scoring and Interpretation Services (a) Psychologists who offer assessment or scoring services to other professionals accurately describe the purpose, norms, validity, reliability, and applications of the procedures and any special qualifications applicable to their use.

(b) Psychologists select scoring and interpretation services (including automated services) on the basis of evidence of the validity of the program and procedures as well as on other appropriate considerations. (See also Standard 2.01b and c, Boundaries of Competence .)

(c) Psychologists retain responsibility for the appropriate application, interpretation, and use of assessment instruments, whether they score and interpret such tests themselves or use automated or other services.

9.10 Explaining Assessment Results Regardless of whether the scoring and interpretation are done by psychologists, by employees or assistants, or by automated or other outside services, psychologists take reasonable steps to ensure that explanations of results are given to the individual or designated representative unless the nature of the relationship precludes provision of an explanation of results (such as in some organizational consulting, preemployment or security screenings, and forensic evaluations), and this fact has been clearly explained to the person being assessed in advance.

9.11 Maintaining Test Security The term test materials refers to manuals, instruments, protocols, and test questions or stimuli and does not include test data as defined in Standard 9.04, Release of Test Data . Psychologists make reasonable efforts to maintain the integrity and security of test materials and other assessment techniques consistent with law and contractual obligations, and in a manner that permits adherence to this Ethics Code.

10.01 Informed Consent to Therapy (a) When obtaining informed consent to therapy as required in Standard 3.10, Informed Consent , psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers. (See also Standards 4.02, Discussing the Limits of Confidentiality , and 6.04, Fees and Financial Arrangements .)

(b) When obtaining informed consent for treatment for which generally recognized techniques and procedures have not been established, psychologists inform their clients/patients of the developing nature of the treatment, the potential risks involved, alternative treatments that may be available, and the voluntary nature of their participation. (See also Standards 2.01e, Boundaries of Competence , and 3.10, Informed Consent .)

(c) When the therapist is a trainee and the legal responsibility for the treatment provided resides with the supervisor, the client/patient, as part of the informed consent procedure, is informed that the therapist is in training and is being supervised and is given the name of the supervisor.

10.02 Therapy Involving Couples or Families (a) When psychologists agree to provide services to several persons who have a relationship (such as spouses, significant others, or parents and children), they take reasonable steps to clarify at the outset (1) which of the individuals are clients/patients and (2) the relationship the psychologist will have with each person. This clarification includes the psychologist's role and the probable uses of the services provided or the information obtained. (See also Standard 4.02, Discussing the Limits of Confidentiality .)

(b) If it becomes apparent that psychologists may be called on to perform potentially conflicting roles (such as family therapist and then witness for one party in divorce proceedings), psychologists take reasonable steps to clarify and modify, or withdraw from, roles appropriately. (See also Standard 3.05c, Multiple Relationships .)

10.03 Group Therapy When psychologists provide services to several persons in a group setting, they describe at the outset the roles and responsibilities of all parties and the limits of confidentiality.

10.04 Providing Therapy to Those Served by Others In deciding whether to offer or provide services to those already receiving mental health services elsewhere, psychologists carefully consider the treatment issues and the potential client's/patient's welfare. Psychologists discuss these issues with the client/patient or another legally authorized person on behalf of the client/patient in order to minimize the risk of confusion and conflict, consult with the other service providers when appropriate, and proceed with caution and sensitivity to the therapeutic issues.

10.05 Sexual Intimacies with Current Therapy Clients/Patients Psychologists do not engage in sexual intimacies with current therapy clients/patients.

10.06 Sexual Intimacies with Relatives or Significant Others of Current Therapy Clients/Patients Psychologists do not engage in sexual intimacies with individuals they know to be close relatives, guardians, or significant others of current clients/patients. Psychologists do not terminate therapy to circumvent this standard.

10.07 Therapy with Former Sexual Partners Psychologists do not accept as therapy clients/patients persons with whom they have engaged in sexual intimacies.

10.08 Sexual Intimacies with Former Therapy Clients/Patients (a) Psychologists do not engage in sexual intimacies with former clients/patients for at least two years after cessation or termination of therapy.

(b) Psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances. Psychologists who engage in such activity after the two years following cessation or termination of therapy and of having no sexual contact with the former client/patient bear the burden of demonstrating that there has been no exploitation, in light of all relevant factors, including (1) the amount of time that has passed since therapy terminated; (2) the nature, duration, and intensity of the therapy; (3) the circumstances of termination; (4) the client's/patient's personal history; (5) the client's/patient's current mental status; (6) the likelihood of adverse impact on the client/patient; and (7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a posttermination sexual or romantic relationship with the client/patient. (See also Standard 3.05, Multiple Relationships .)

10.09 Interruption of Therapy When entering into employment or contractual relationships, psychologists make reasonable efforts to provide for orderly and appropriate resolution of responsibility for client/patient care in the event that the employment or contractual relationship ends, with paramount consideration given to the welfare of the client/patient. (See also Standard 3.12, Interruption of Psychological Services .)

10.10 Terminating Therapy (a) Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service.

(b) Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship.

(c) Except where precluded by the actions of clients/patients or third-party payors, prior to termination psychologists provide pretermination counseling and suggest alternative service providers as appropriate.

The American Psychological Association’s  Council of Representatives  adopted this version of the APA Ethics Code during its meeting on Aug. 21, 2002. The Code became effective on June 1, 2003. The Council of Representatives amended this version of the Ethics Code on Feb. 20, 2010, effective June 1, 2010, and on Aug. 3, 2016, effective Jan. 1, 2017.  Inquiries concerning the substance or interpretation of the APA Ethics Code should be addressed to the Director, Office of Ethics, American Psychological Association, 750 First St. NE, Washington, DC 20002-4242. The standards in this Ethics Code will be used to adjudicate complaints brought concerning alleged conduct occurring on or after the effective date. Complaints will be adjudicated on the basis of the version of the Ethics Code that was in effect at the time the conduct occurred.

The APA has previously published its Ethics Code as follows:

American Psychological Association. (1953). Ethical standards of psychologists . Washington, DC: Author.

American Psychological Association. (1959). Ethical standards of psychologists. American Psychologist , 14 , 279-282.

American Psychological Association. (1963). Ethical standards of psychologists. American Psychologist , 18 , 56-60.

American Psychological Association. (1968). Ethical standards of psychologists. American Psychologist , 23 , 357-361.

American Psychological Association. (1977, March). Ethical standards of psychologists. APA Monitor , 22-23.

American Psychological Association. (1979). Ethical standards of psychologists . Washington, DC: Author.

American Psychological Association. (1981). Ethical principles of psychologists. American Psychologist , 36 , 633-638.

American Psychological Association. (1990). Ethical principles of psychologists (Amended June 2, 1989). American Psychologist , 45 , 390-395.

American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. American Psychologist , 47 , 1597-1611.

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist , 57 , 1060-1073.

American Psychological Association. (2010). 2010 amendments to the 2002 “ Ethical Principles of Psychologists and Code of Conduct. ” American Psychologist , 65 , 493.

American Psychological Association. (2016). Revision of ethical standard 3.04 of the “ Ethical Principles of Psychologists and Code of Conduct ” (2002, as amended 2010). American Psychologist , 71 , 900.

Request copies of the APA's Ethical Principles of Psychologists and Code of Conduct from the APA Order Department, 750 First St. NE, Washington, DC 20002-4242, or phone (202) 336-5510.

2010 Amendments

Introduction and Applicability If psychologists’ ethical responsibilities conflict with law, regulations, or other governing legal authority, psychologists make known their commitment to this Ethics Code and take steps to resolve the conflict in a responsible manner . If the conflict is unresolvable via such means, psychologists may adhere to the requirements of the law, regulations, or other governing authority in keeping with basic principles of human rights.

1.02 Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority If psychologists’ ethical responsibilities conflict with law, regulations, or other governing legal authority, psychologists clarify the nature of the conflict , make known their commitment to the Ethics Code, and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code . If the conflict is unresolvable via such means, psychologists may adhere to the requirements of the law, regulations, or other governing legal authority. Under no circumstances may this standard be used to justify or defend violating human rights .

1.03 Conflicts Between Ethics and Organizational Demands If the demands of an organization with which psychologists are affiliated or for whom they are working are in conflict with this Ethics Code, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and to the extent feasible, resolve the conflict in a way that permits adherence to the Ethics Code. take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights .

2016 Amendment

3.04 Avoiding Harm (a) Psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm where it is foreseeable and unavoidable. 

Additional Resources

2018 APA Ethics Committee Rules and Procedures (PDF, 197KB)

Revision of Ethics Code Standard 3.04 (Avoiding Harm) 

APA Ethical Principles of Psychologists and Code of Conduct (2017) (PDF, 272KB)

2016 APA Ethics Committee Rules and Procedures

Revision of Ethical Standard 3.04 of the “Ethical Principles of Psychologists and Code of Conduct” (2002, as Amended 2010) (PDF, 26KB)

2010 Amendments to the 2002 "Ethical Principles of Psychologists and Code of Conduct" (PDF, 39KB)

Compare the 1992 and 2002 Ethics Codes

Contact APA Ethics Office

Psychology’s 10 Greatest Case Studies – Digested

These ten characters have all had a huge influence on psychology and their stories continue to intrigue each new generation of students.

27 November 2015

By Christian Jarrett

These ten characters have all had a huge influence on psychology and their stories continue to intrigue each new generation of students. What's particularly fascinating is that many of their stories continue to evolve – new evidence comes to light, or new technologies are brought to bear, changing how the cases are interpreted and understood. What many of these 10 also have in common is that they speak to some of the perennial debates in psychology, about personality and identity, nature and nurture, and the links between mind and body.

Phineas Gage

One day in 1848 in Central Vermont, Phineas Gage was tamping explosives into the ground to prepare the way for a new railway line when he had a terrible accident. The detonation went off prematurely, and his tamping iron shot into his face, through his brain, and out the top of his head. Remarkably Gage survived, although his friends and family reportedly felt he was changed so profoundly (becoming listless and aggressive) that "he was no longer Gage."

There the story used to rest – a classic example of frontal brain damage affecting personality. However, recent years have seen  a drastic reevaluation  of Gage's story in light of new evidence. It's now believed that he underwent significant rehabilitation and in fact began work as a horse carriage driver in Chile. A  simulation of his injuries  suggested much of his right frontal cortex was likely spared, and  photographic evidence  has been unearthed showing a post-accident dapper Gage. Not that you'll find this revised account in many psychology textbooks:  a recent analysis  showed that few of them have kept up to date with the new evidence.

See also Jim Horne's ' Blasts from the past ', looking back at similar accounts from the era.

Henry Gustav Molaison (known for years as H.M. in the literature to protect his privacy), who died in 2008, developed severe amnesia at age 27 after undergoing brain surgery as a form of treatment for the epilepsy he'd suffered since childhood. He was subsequently the focus of study by over 100 psychologists and neuroscientists and he's been mentioned in over 12,000 journal articles! Molaison's surgery involved the removal of large parts of the hippocampus on both sides of his brain and the result was that he was almost entirely unable to store any new information in long-term memory (there were some exceptions – for example, after 1963 he was aware that a US president had been assassinated in Dallas). The extremity of Molaison's deficits was a surprise to experts of the day because many of them believed that memory was distributed throughout the cerebral cortex.

Today, Molaison's legacy lives on: his brain was carefully sliced and preserved and turned into a 3D digital atlas and his life story is reportedly due to be turned into a feature film based on the book researcher Suzanne Corkin wrote about him:  Permanent Present Tense, The Man With No Memory and What He Taught The World .

See also 'Understanding amnesia - Is it time to forget H.M.?'

Victor Leborgne (nickname "Tan")

The fact that, in most people, language function is served predominantly by the left frontal cortex has today almost become common knowledge, at least among psych students. However, back in the early 19th century, the consensus view was that language function (like memory, see entry for H.M.) was distributed through the brain. An 19th century patient who helped change that was Victor Leborgne, a Frenchman who was nicknamed "Tan" because that was the only sound he could utter (besides the expletive phrase "sacre nom de Dieu").

In 1861, aged 51, Leborgne was referred to the renowned neurologist Paul Broca, but died soon after. Broca examined Leborgne's brain and noticed a lesion in his left frontal lobe – a segment of tissue now known as Broca's area. Given Leborgne's impaired speech but intact comprehension, Broca concluded that this area of the brain was responsible for speech production and he set about persuading his peers of this fact – now recognised as a key moment in psychology's history.

For decades little was known about Leborgne, besides his important contribution to science. However, in a paper published in 2013, Cezary Domanski at Maria Curie-Sklodowska University in Poland uncovered new biographical details, including the possibility that Leborgne muttered the word "Tan" because his birthplace of Moret, home to several tanneries.

See also ' Glimpsed at last ', and ' Using brain imaging to re-evaluate psychology's three most famous cases '.

Wild Boy of Aveyron

The "Wild boy of Aveyron" – named Victor by the physician Jean-Marc Itard – was found emerging from Aveyron forest in South West France in 1800, aged 11 or 12, where's it's thought he had been living in the wild for several years. For psychologists and philosophers, Victor became a kind of "natural experiment" into the question of nature and nurture. How would he be affected by the lack of human input early in his life?

Those who hoped Victor would support the notion of the "noble savage" uncorrupted by modern civilisation were largely disappointed: the boy was dirty and dishevelled, defecated where he stood and apparently motivated largely by hunger. Victor acquired celebrity status after he was transported to Paris and Itard began a mission to teach and socialise the "feral child". This programme met with mixed success: Victor never learned to speak fluently, but he dressed, learned civil toilet habits, could write a few letters and acquired some very basic language comprehension. Autism expert Uta Frith believes Victor may have been abandoned because he was autistic, but she acknowledges we will never know the truth of his background.

Victor's story inspired the 2004 novel  The Wild Boy  and was dramatised in the 1970 French film  The Wild Child .

Listen to an episode of 'The Mind Changers'.

Nicknamed 'Kim-puter' by his friends, Peek who died in 2010 aged 58, was the inspiration for Dustin Hoffman's autistic savant character in the multi-Oscar-winning film  Rain Man . Before that movie, which was released in 1988, few people had heard of autism, so Peek via the film can be credited with helping to raise the profile of the condition.

Arguably though, the film also helped spread the popular misconception that giftedness is a hallmark of autism (in one notable scene, Hoffman's character deduces in an instant the precise number of cocktail sticks – 246 – that a waitress drops on the floor). Peek himself was actually a non-autistic savant, born with brain abnormalities including a malformed cerebellum and an absent corpus callosum (the massive bundle of tissue that usually connects the two hemispheres). His savant skills were astonishing and included calendar calculation, as well as an encyclopaedic knowledge of history, literature, classical music, US zip codes and travel routes. It was estimated that he read more than 12,000 books in his life time, all of them committed to flawless memory. Although outgoing and sociable, Peek had coordination problems and struggled with abstract or conceptual thinking.

"Anna O." is the pseudonym for Bertha Pappenheim, a pioneering German Jewish feminist and social worker who died in 1936 aged 77. As Anna O. she is known as one of the first ever patients to undergo psychoanalysis and her case inspired much of Freud's thinking on mental illness. Pappenheim first came to the attention of another psychoanalyst, Joseph Breuer, in 1880 when he was called to her house in Vienna where she was lying in bed, almost entirely paralysed. Her other symptoms include hallucinations, personality changes and rambling speech, but doctors could find no physical cause.

For 18 months, Breuer visited her almost daily and talked to her about her thoughts and feelings, including her grief for her father, and the more she talked, the more her symptoms seemed to fade – this was apparently one of the first ever instances of psychoanalysis or "the talking cure", although the degree of Breuer's success has been disputed and some historians allege that Pappenheim did have an organic illness, such as epilepsy.

Although Freud never met Pappenheim, he wrote about her case, including the notion that she had a hysterical pregnancy, although this too is disputed. The latter part of Pappenheim's life in Germany post 1888 is as remarkable as her time as Anna O. She became a prolific writer and social pioneer, including authoring stories, plays, and translating seminal texts, and she founded social clubs for Jewish women, worked in orphanages and founded the German Federation of Jewish Women.

Kitty Genovese

Sadly, it is not really Kitty Genovese the person who has become one of psychology's classic case studies, but rather the terrible fate that befell her. In 1964 in New York, Genovese was returning home from her job as a bar maid when she was attacked and eventually murdered by Winston Mosely. What made this tragedy so influential to psychology was that it inspired research into what became known as the Bystander Phenomenon – the now well-established finding that our sense of individual responsibility is diluted by the presence of other people. According to folklore, 38 people watched Genovese's demise yet not one of them did anything to help, apparently a terrible real life instance of the Bystander Effect.

However, the story doesn't end there because historians have since established  the reality was much more complicated  – at least two people did try to summon help, and actually there was only one witness the second and fatal attack. While the main principle of the Bystander Effect has stood the test of time, modern psychology's understanding of the way it works has become a lot more nuanced. For example, there's evidence that in some situations people are more likely to act when they're part of a larger group, such as when they and the other group members all belong to the same social category (such as all being women) as the victim.

See also another angle , on false confessions.

Little Albert

"Little Albert" was the nickname that the pioneering behaviourist psychologist John Watson gave to an 11-month-old baby, in whom, with his colleague and future wife Rosalind Rayner, he deliberately attempted to instill certain fears through a process of conditioning. The research, which was of dubious scientific quality, was conducted in 1920 and has become notorious for being so unethical (such a procedure would never be given approval in modern university settings).

Interest in Little Albert has reignited in recent years as an academic quarrel has erupted over his true identity. A group led by Hall Beck at Appalachian University announced in 2011 that they thought Little Albert was actually Douglas Merritte, the son of a wet nurse at John Hopkins University where Watson and Rayner were based. According to this sad account, Little Albert was neurologically impaired, compounding the unethical nature of the Watson/Rayner research, and he died aged six of  hydrocephalus (fluid on the brain).

However, this account was challenged by a different group of scholars led by Russell Powell at MacEwan University in 2014. They established that Little Albert was more likely William A Barger (recorded in his medical file as Albert Barger), the son of a different wet nurse. Earlier this year, textbook writer Richard Griggs weighed up all the evidence and concluded that the Barger story is the more credible, which would mean that Little Albert in fact died 2007 aged 87.

Chris Sizemore

Chris Costner Sizemore is one of the most famous patients to be given the controversial diagnosis of multiple personality disorder, known today as dissociative identity disorder. Sizemore's alter egos apparently included Eve White, Eve Black, Jane and many others. By some accounts, Sizemore expressed these personalities as a coping mechanism in the face of traumas she experienced in childhood, including seeing her mother badly injured and a man sawn in half at a lumber mill.

In recent years, Sizemore has described how her alter egos have been combined into one united personality for many decades, but she still sees different aspects of her past as belonging to her different personalities. For example, she has stated that her husband was married to Eve White (not her), and that Eve White is the mother of her first daughter. Her story was turned into a movie in 1957 called  The Three Faces of Eve  (based on a book of the same name written by her psychiatrists). Joanne Woodward won the best actress Oscar for portraying Sizemore and her various personalities in this film. Sizemore published her autobiography in 1977 called  I'm Eve . In 2009, she appeared on the BBC's  Hard Talk  interview show.

David Reimer

One of the most famous patients in psychology, Reimer lost his penis in a botched circumcision operation when he was just 8 months old. His parents were subsequently advised by psychologist John Money to raise Reimer as a girl, "Brenda", and for him to undergo further surgery and hormone treatment to assist his gender reassignment. Money initially described the experiment (no one had tried anything like this before) as a huge success that appeared to support his belief in the important role of socialisation, rather than innate factors, in children's gender identity.

In fact, the reassignment was seriously problematic and Reimer's boyishness was never far beneath the surface. When he was aged 14, Reimer was told the truth about his past and set about reversing the gender reassignment process to become male again. He later campaigned against other children with genital injuries being gender reassigned in the way that he had been. His story was turned into the book  As Nature Made Him, The Boy Who Was Raised As A Girl  by John Colapinto, and he is the subject of two BBC Horizon documentaries. Tragically, Reimer took his own life in 2004, aged just 38.

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Ethical Issues of Psychological Investigation

Last updated 22 Mar 2021

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Ethics are a key part of psychological investigation, as researchers have the responsibility to ensure that their practice is morally correct ; ill practice could lead to banning from further practice as a psychologist.

There are a number of important issues that researchers should be mindful of when undertaking investigations, with regards to the selection and subsequent treatment of their participants:

• Confidentiality

Participants should remain anonymous so that data cannot be identified as theirs (e.g. their names should be withheld when data is reported).

• Informed consent

Participants must be briefed on objectives of the investigation and what will be required of them should they take part. In turn they must accept these conditions to proceed, and be put under no pressure to do so.

Generally, participants should not be misled during an investigation. However, sometimes participants need to be unaware of the true aims of an investigation - or even that they are participating in a study - to yield results that are considered valid (i.e. the data is a true reflection of what was supposed to be measured). This emphasises the need for participants to be debriefed at end of the study.

When a study ends, participants should be told the true motivations behind the investigation, and given the opportunity to clarify any misunderstandings with the researchers. It is also essential to ensure that the participants leave having not suffered long-lasting negative physical or mental effects, particularly where deception (see above) was utilised for the purposes of the experiment. Having checked that participants are in a positive state of health, they should also be notified of relevant services such as counseling to seek, if partaking in the study presents negative effects.

• Right to withdraw

As part of their briefing prior to giving consent to partake, participants must be informed that they can leave the study at any point if they wish, and are under no obligation to disclose a reason why if they do.

Protection of participants

It is the responsibility of the researcher to ensure that participants are not caused any long-term physical or mental damage. For instance, it may be that participants are temporarily caused distress, although research will be pre-approved by an ethics committee to ensure this is sufficiently minimized, and researchers are expected to take participants through a detailed debriefing (see debriefing).

Working with animals

If non-human animals are to be used in an investigation, researchers can only use species that are considered scientifically suitable according to ethical guidelines. Procedures that could cause physical or mental harm should be avoided where possible, and it is encouraged that investigations take place in their natural environment. Animals must be properly cared for if the study requires them to kept captive.

There are some instances where it is deemed that the costs do not override the benefits of conducting some research. However, it should be appreciated that these ethical guidelines should always be carefully considered when scrutinising whether a study is ethically acceptable to be carried out.

• Ethical Issues

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Quizzes & Activities

Ethical Guidelines in Psychology - Classroom Posters or Student Handout Set

Poster / Student Handout

Minority Influence - Consistency and Commitment

Psychology Issues and Debates - Two Landing Pages for your Revision

28th December 2017

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