EPPP Prep: Ethical, Legal, & Professional Issues

When a referral is appropriate:

• It is appropriate & often ethically mandated whenever a psychologist’s continued involvement would compromise the client’s care or violate professional standards.

Lack of Specialized Competence:

• Ethically, psychologists must practice within their areas of expertise.

• A referral is necessary if the client’s needs exceed the psychologist’s specialized training or experience.

Dual Relationships: 

• The psychologist has a pre-existing social, business, or family relationship with the client.

Shared Social Circles: 

• Discovering that the psychologist is treating two individuals with a close or potentially conflicting relationship (e.g., family members or romantic partners).

Lack of Therapeutic Progress: 

• If a client has plateaued or is not benefiting from the current therapy after a reasonable amount of time, continuing the same treatment may be unethical.

• A referral provides the client with a "fresh perspective" or a more effective therapeutic alliance.

Boundary or Safety Issues:

• A referral is appropriate when the therapeutic relationship becomes unhealthy or unsafe.

Inappropriate Behavior: 

• Persistent flirting, romantic gestures, or sexualized transference that impairs the therapist's ability to remain objective.

Safety Risks: 

• Physical violence or credible threats from the client toward the psychologist.

Therapist-Specific Factors:

Emotional Triggering: 

• The client’s issues mirror a current personal crisis for the therapist (e.g., divorce or bereavement), making it impossible to maintain professional distance.

Practical Changes: 

• The psychologist is retiring, relocating, or becoming unavailable for extended periods due to illness or leave.

Logistical Barriers: 

• Changes in the psychologist’s availability or the client’s insurance coverage.

When a psychologist receives a subpoena:

• Psychologist must balance legal obligations with the ethical duty to maintain client confidentiality. 

• While a subpoena requires a response, it is generally not a direct order to release records immediately without further verification. 

Verify the Subpoena’s Validity:

• Before taking action, determine if the document is a court order signed by a judge or a subpoena signed by an attorney.

Attorney-issued: 

• This is a formal request, not a mandate for immediate disclosure. You cannot release records without client consent or a judge's order.

Judge-issued: 

• This carries the force of law, but you may still request limitations or a protective order to shield sensitive data.

Technical check: 

• Confirm if the subpoena was properly served (e.g., in person) and if the court has jurisdiction over you.

Contact Your Malpractice Insurer and Legal Counsel 

• Immediately notify your malpractice insurance carrier.

• Most provide free legal consultations to help you navigate state-specific laws and determine if a motion to quash (void) the subpoena is necessary.

Communicate with the Client

• Contact the client (or their legal guardian) to discuss the implications of the request.

If the client consents: 

• Obtain a written, signed Release of Information (ROI) before providing any records.

If the client objects: 

• You must assert psychotherapist-patient privilege on their behalf.

• Inform the requesting party in writing that you cannot release information without client authorization or a court order.

Negotiate or Object 

• If the client refuses disclosure, you or your attorney may negotiate with the requester to: 

• Limit the scope of the request (e.g., providing a treatment summary instead of raw notes).

• Redact sensitive information unrelated to the case.

• Request an in-camera review, where a judge reviews records privately to decide what is relevant.

Court-appointed psychological evaluation 

• It is a formal, evidence-based assessment mandated by a judge to provide objective information about an individual's mental state for legal decision-making. 

• It is strictly intended to answer specific legal questions.

Common Types of Evaluations

Courts may order these assessments for a variety of criminal, civil, and family law matters: 

Competency to Stand Trial: 

• Determining if a defendant understands the charges and can assist in their own defense.

Child Custody & Parental Fitness: 

• Assessing a parent's mental health and their capacity to care for a child’s best interests.

Risk Assessments: 

• Evaluating the likelihood that an individual will reoffend or pose a danger to themselves or others.

Insanity Defense: 

• Reviewing the defendant's mental state at the time of the alleged offense.

Mitigation for Sentencing: 

• Identifying psychological factors that might influence a judge’s sentencing decisions.

Psychosexual Evaluations: 

• Specialized assessments often used in cases involving sexual offenses to determine treatment or supervision needs

Key Differences from Standard Therapy:

Confidentiality: 

• There is no therapist-patient privilege in these cases.

  • The results are not private and are compiled into a formal report submitted directly to the court.

The "Client": 

• In a court-appointed evaluation, the "client" is the court or the referring legal party, not the person being evaluated.

Role of the Psychologist: 

• The professional remains a neutral "friend of the court" rather than an advocate for the individual.

Capitation

• It is a reimbursement model where therapists or mental health organizations receive a fixed, pre-arranged payment per enrolled client for a specific period (typically monthly), regardless of how many sessions the client attends. 

• This shifts the financial focus from the quantity of sessions to the outcomes and overall wellness of the patient population. 

Characteristics for Psychology Practices:

Predictable Revenue: 

• Therapists receive a steady "Per-Member-Per-Month" (PMPM) income, providing financial stability even if patient demand fluctuates.

Shift in Clinical Focus: 

• The model incentivizes preventive care, early intervention, and brief, problem-focused therapies to prevent long-term, costly crises.

Provider Risk: 

• The psychologist assumes the financial risk; if a client requires extensive, high-cost care that exceeds the capitated payment, the provider absorbs the loss.

Administrative Simplicity:

• It reduces the need for complex, session-by-session insurance billing and coding since payments are based on the patient roster rather than individual claims.

Capitation vs Fee-for-Service (FFS):

• Payments basis: 

  • number of enrolled members (vs # of sessions/procedures)

• Clinical style:

  • favors brief, action-oriented therapy (vs favoring longer-term, frequent sessions, when needed)

• Financial risk:

  • borne by the provider (vs borne by the payer/insurer)

Structure of the APA Ethics Code (2002)

It has four major parts:

1. Preamble  →  Purpose of psychology

2. Introduction  → How to apply the code

3. General Principles  → Ethical ideals

4. Ethical Standards  → Enforceable rules

Mission → Framework → Values → Rules

Introduction and Preamble: 

• Discusses the intent, organization, and scope of the code.

• It emphasizes protecting individuals and groups while educating the public.

General Principles:

• Principle A:  Beneficence and Nonmaleficence: 

  • Striving to benefit those they work with and taking care to do no harm.

• Principle B: Fidelity and Responsibility: 

  • Establishing relationships of trust and accepting professional and scientific responsibility to society.

• Principle C: Integrity: 

  • Promoting accuracy, honesty, and truthfulness in science, teaching, and practice.

• Principle D: Justice: 

  • Ensuring all persons have access to and benefit from the contributions of psychology and equal quality in processes and services.

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

  • Respecting the dignity and worth of all people, including their rights to privacy, confidentiality, and self-determination. 

Enforceable Ethical Standards

• These provide specific, mandatory rules for conduct across various professional roles. 

1: Resolving Ethical Issues 

• Addresses how to handle the misuse of work, reporting ethical violations, and conflicts between ethics and law or organizational demands.

2: Competence

• Defines the boundaries of a psychologist's expertise and the requirement for ongoing education and self-care.

3: Human Relations 

• Covers preventing discrimination and harassment, managing multiple relationships, avoiding harm, and obtaining informed consent.

4: Privacy and Confidentiality 

• Outlines the primary obligation to protect confidential information and the specific conditions for disclosures.

5: Advertising and Public Statements

• Prohibits false or deceptive public statements and regulates testimonials and in-person solicitation.

6: Record Keeping and Fees

• Details the requirements for documenting work, securely maintaining records, and establishing clear financial arrangements.

7: Education and Training

• Sets standards for the design and accuracy of training programs, as well as the assessment of student performance.

8: Research and Publication

• Establishes rules for institutional approval, informed consent for research, deception in studies, and credit for publications.

 9: Assessment

• Focuses on the proper use and interpretation of assessment techniques, test construction, and the maintenance of test security.

10: Therapy 

• Covers informed consent for treatment, therapy involving couples or families, sexual intimacies with clients, and termination of care.

APA Ethics Code (2002) Preamble

• It explains the overall goals of the profession and the ethical responsibilities psychologists hold.

• It describes the spirit and mission of the profession, but it is not enforceable.

Psychologists aim to:

• Increase knowledge about behavior

• Improve the condition of individuals and society

• Respect and protect civil and human rights

• Use psychological knowledge for public good

APA Ethics Code (2002) Introduction

• It outlines the intent, organization, procedural considerations, & scope of application for the entire Ethics Code.

  • Explains how it is organized and applied.

• They are enforceable & can lead to disciplinary action.

• Ethical decision making

  • Psychologists should use the code along with laws, professional judgment, and consultation.

• When ethics and law conflict:

  • Psychologists should:

    • 1. Clarify the conflict

    • 2. Attempt to resolve it ethically

    • 3. Follow the law if the conflict cannot be resolved

 

• The code applies to:

  • Clinical work

  • Research

  • Teaching

  • Supervision

  • Public statements

• The APA-specific guidelines are NOT applicable to psychologists when they are engaged in the following functions: 

  • Teaching Psychology → activities related to the instruction of students in academic settings.

  • Scientific Research → design and conduct of scientific studies and experiments.

  • Scholarly Writing and Editing → preparation or review of scientific manuscripts and scholarly publications.

• Forensic practitioners follow the Specialty Guidelines for Forensic Psychology, which were created because the general standards were found to lack "sufficient detail" for the unique ethical tensions found in the legal system.

• They are the "moral compass" of the APA Ethics Code.

• These are aspirational values, not enforceable rules.

• They guide ethical thinking but cannot be the sole basis for discipline.

• While they aren't legally enforceable like the Standards, they provide the rationale for every rule in the book.

Principle A: Beneficence and Nonmaleficence

• Psychologists strive to benefit those they work with and avoid causing harm.

• They are vigilant about any influence—personal, financial, or social—that might lead to its misuse.

• Protect client welfare

• Minimize harm

• Manage conflicts of interest

• Monitor personal problems that could impair work

Principle B: Fidelity and Responsibility

• Psychologists establish trust and professional responsibility.

• They are concerned about their colleagues' ethical compliance and contribute some of their professional time for little or no compensation (pro bono).

• Maintain professional relationships

• Uphold ethical standards

• Consult with colleagues

• Contribute to society

Principle C: Integrity

• Psychologists promote accuracy, honesty, and truthfulness.

• They do not steal, cheat, or engage in fraud.

  • While deception is sometimes used in research, it is only a last resort & must be corrected ASAP.

• Avoid deception or fraud

• Be truthful in research and practice

• Correct misleading information

Principle D: Justice

• All people should benefit equally from psychological knowledge and services.

• Fairness and equality.

  • Every person should have access to high-quality psychological services, and psychologists must ensure their own biases (regarding age, gender, race, etc.) do not lead to unjust practices.

• Fairness

• Avoiding bias

• Providing competent services to all populations

• Recognizing cultural bias in testing instruments.

Principle E: Respect for People's Rights and Dignity

• Psychologists respect privacy, confidentiality, autonomy, and cultural differences.

• This principle recognizes that individuals have the right to make their own decisions and that their private information must be fiercely protected.

• Protect confidentiality

• Respect diversity

• Support client self-determination

  • Respect a client’s autonomy in life decisions (self-determination).

Examples for Principle A: Beneficence and Nonmaleficence

Incompetent Colleague

• Senior psychologist showing signs of early dementia

• Ethical solution:
  Psychologists have a duty to protect clients from harm by addressing impaired colleagues (APA Ethical Standard 2.06). The appropriate action is to consult with the colleague, encourage evaluation or reduced duties, and report to appropriate authorities if client welfare is at risk.

High-Risk Patient vs Hospitalization

• Client with chronic suicidal ideation who opposes hospitalization

• Ethical solution:
  Psychologists should respect autonomy but prioritize protection of life and prevention of harm when risk becomes imminent. If there is serious risk of suicide, involuntary hospitalization or safety interventions may be ethically justified despite the client’s preferences.

“Tough Love” Modality (Exposure Therapy)

• High-stress exposure for PTSD

• Ethical solution:
  Short-term distress is acceptable when evidence-based treatments are used with informed consent and clinical justification. The psychologist must ensure the client understands the treatment rationale, risks, and alternatives before proceeding.

Examples for Principle B: Fidelity and Responsibility 

Insurance Conflict

• Pressure to diagnose to obtain coverage

• Ethical solution:
  Psychologists must not falsify diagnoses or misrepresent services (APA Standard 6.04). The ethical approach is to provide accurate documentation and explore alternative billing options or advocacy for coverage.

Rural Dual Relationships

• Mechanic who fixes your car wants therapy

• Ethical solution:
  Multiple relationships are not automatically unethical but must be avoided if they risk impairment or exploitation. In rural areas with limited providers, therapy may proceed only if boundaries are managed carefully and no harm or role conflict is likely.

Expert Witness Pressure

• Lawyer asks you to soften findings

• Ethical solution:
  Psychologists serving as expert witnesses must provide objective, independent opinions based on data and professional standards. The request should be refused because altering findings would violate integrity and professional objectivity.

Examples of Principle C: Integrity 

The “Placebo” in Research

• Deception in study design

• Ethical solution:
  Deception may be used in research only when scientifically justified, minimal risk is involved, and no feasible alternatives exist. Participants must be fully debriefed afterward and allowed to withdraw their data if they choose.

Correcting the Record

• Incorrect statistic given in media interview

• Ethical solution:
  Psychologists have an ethical responsibility to ensure accurate public statements. The appropriate action is to issue a correction to maintain scientific integrity and prevent misinformation.

Billing for “Ghost” Sessions

• Client asks to bill a missed appointment as a session

• Ethical solution:
  Billing for services not provided constitutes insurance fraud and misrepresentation. The psychologist must refuse and follow established cancellation policies.

Example of Principle D: Justice 

Culturally Biased Test

• Court orders use of culturally inappropriate IQ test

• Ethical solution:
  Psychologists must use assessment tools appropriate for the individual’s language and cultural background (Standard 9.02). The evaluator should inform the court of the limitations and recommend more valid alternatives or interpret results cautiously.

Algorithm vs Clinical Judgment

• AI triage system biased by zip code

• Ethical solution:
  Psychologists are responsible for ensuring that technology does not produce discriminatory or unjust outcomes. The clinician should challenge the system, advocate for review, and ensure fair and equitable access to care.

Pro Bono Threshold

• Already at limit of free cases

• Ethical solution:
  Psychologists are encouraged to provide some pro bono services, but there is no requirement to accept unlimited cases. The ethical response is to refer the individual to other resources or low-cost services.

Example of Principle E: Respect for Rights and Dignity 

Adolescent’s Secret

• 15-year-old using drugs asks for confidentiality

• Ethical solution:
  Psychologists should protect a minor’s confidentiality when possible, but parents generally retain legal rights to information. The best approach is to encourage the adolescent to involve parents while disclosing only information necessary for safety if required.

“Unwise” Life Choice

• Client returning to abusive partner

• Ethical solution:
  Psychologists must respect client autonomy, even when choices seem harmful. The therapist should provide support, risk education, and safety planning without imposing personal values.

Data vs Privacy

• University requests anonymized clinic data

• Ethical solution:
  Client data may be used for research only with proper consent or when data are fully de-identified and privacy protections are ensured. Confidentiality must be protected according to ethical and legal standards.

High-Yield Ethical Themes 

Most ethical questions ultimately resolve to one of these principles:

• Protect client welfare (beneficence & nonmaleficence)

• Maintain honesty and integrity

• Respect autonomy and confidentiality

• Avoid exploitation or conflicts of interest

• Ensure fairness and cultural competence

• Follow laws and professional standards

Ethical Standards

• These are the actual enforceable rules.

Standard 1: Resolving Ethical Issues

• Addressing ethical violations

• Informal resolution (unless harm is severe)

• Reporting misconduct

• Cooperation with ethics investigations

Standard 2: Competence

• Practice within boundaries of competence

• Obtain training or supervision when needed

• Maintain continuing education

• Manage personal impairment

Standard 3: Human Relations

• Avoid harm

• Avoid harassment

• Avoid exploitation

• Conflicts of interest

• Multiple relationships

  • They should be avoided if there is a risk of harm or exploitation

Standard 4: Privacy and Confidentiality

• Protecting confidential information

• Disclosures with consent

• Protecting records

• Limits of confidentiality

  • Can be broken when mandated by law or necessary to prevent serious harm.

Standard 5: Advertising and Public Statements

• Truthful advertising

• Accurate representation of credentials

• Avoiding misleading statements

Standard 6: Record Keeping and Fees

• Accurate documentation

• Financial arrangements

• Insurance billing

• Avoiding fraudulent billing

Standard 7: Education and Training

• Accurate course descriptions

• Fair student evaluation

• Appropriate supervision

• Avoiding exploitation of students

• Supervisors ensure trainees provide competent services.

Standard 8: Research and Publication

• Informed consent

• Deception in research (requires justification and debriefing)

• Protection of participants

• Plagiarism

• Authorship credit

Standard 9: Assessment

• Proper test use (valid tests for the population being assessed)

• Culturally appropriate assessment

• Informed consent for testing

• Protecting test security

Standard 10: Therapy

• Informed consent for therapy

• Avoiding sexual relationships with clients

• Appropriate termination

• Group therapy rules

“Jumping to Reporting Too Quickly”

The Trap:

The vignette describes a colleague engaging in questionable behavior, and one answer choice is “report them to the licensing board.”

What the Exam Wants:

Psychologists usually start with informal resolution first when appropriate.

Correct Strategy:

The typical order is:

1. Consult ethical guidelines

2. Discuss the concern with the colleague

3. Seek consultation

4. Report if the issue continues or if clients are harmed

 

Correct Strategy:

Reporting is usually not the first step unless there is serious harm or illegal behavior.

 “Break Confidentiality Too Easily”

The Trap:

A therapist is told something concerning (drug use, risky behavior, etc.), and one option is immediately informing others.

What the Exam Wants:

Confidentiality is very strong unless there is:

• Imminent danger

• Abuse reporting laws

• Court order

Correct Strategy:

Maintain confidentiality unless there is clear risk of serious harm.

“Overprotecting Clients by Removing Autonomy”

The Trap:

A client makes a bad or risky decision, and the therapist wants to stop them.

What the Exam Wants:

Adults have the right to make poor decisions.

Correct Strategy:

Respect autonomy unless the client is:

• incompetent

• suicidal/homicidal

• legally mandated

“Misdiagnosis to Help the Client”

The Trap:

Insurance coverage requires a diagnosis, and the client almost meets criteria.

What the Exam Wants:

Psychologists cannot falsify diagnoses.

Correct Strategy:

• Use accurate diagnosis only

• Advocate for care through other means

“Confusing Legal vs Ethical Duties”

The Trap:

An option looks compassionate but violates the law.

Example: Ignoring a subpoena to protect confidentiality.

Correct Strategy:

Psychologists must generally follow the law while minimizing harm.

Correct approach often includes:

• seeking legal consultation

• requesting the court limit disclosure

“Ignoring Competence Limits”

The Trap:

A therapist takes on a case outside their training.

What the Exam Wants:

Psychologists must practice within their competence.

Correct Strategy:

Either:

• obtain supervision/training

• refer the client

“Dual Relationship Panic”

The Trap:

Any multiple relationship appears unethical.

What the Exam Wants:

Multiple relationships are not automatically unethical.

Correct Strategy:

Ask:

Does it cause:

• exploitation?

• impaired judgment?

• harm to the client?

If no, it may be acceptable.

(Rural settings are a classic example.)

“Research Deception Confusion”

The Trap:

A study uses deception and the question asks if it is unethical.

What the Exam Wants:

Deception can be ethical if certain criteria are met.

Correct Strategy:

Allowed when:

• scientifically justified

• minimal risk

• no alternative

• participants are debriefed

“Supervision Responsibility”

The Trap:

A trainee makes a mistake.

What the Exam Wants:

The supervisor is responsible for oversight.

Correct Strategy:

The supervisor must:

• monitor work

• provide training

• intervene when necessary

“Technology & Telehealth Oversight”

The Trap:

A therapist uses texting, telehealth, or digital tools.

What the Exam Wants:

Psychologists must ensure:

• confidentiality

• secure communication

• informed consent

• competence with technology

The EPPP Ethical Decision Hierarchy 

When unsure, the exam usually expects this order of actions:

1. Clarify the ethical issue

2. Consult ethical guidelines

3. Seek supervision or consultation

4. Consider laws

5. Evaluate potential harm

6. Take the least harmful action

The Golden Rule for Ethics Questions

When stuck, choose the answer that:

• protects the client

• maintains honesty

• preserves confidentiality

• respects autonomy

• follows professional standards

Outside of the Jurisdiction of the APA Ethics Code

• The APA Ethics Code is specific about its boundaries.

• It does NOT apply to a psychologist’s purely private conduct, nor does it have the power of criminal law.

Purely Private Activities

• The code only applies to activities that are part of the psychologist’s scientific, educational, or professional roles.

  • Personal matters (e.g., being rude to a neighbor, a messy divorce, or a speeding ticket) do NOT apply.

• The Exception: 

  • Personal conduct can become an ethical issue if it reflects on the psychologist’s fitness to practice (e.g., public substance abuse that impairs their clinical judgment).

Non-Psychological Professional Roles

• If a psychologist is acting in a completely different professional capacity, the code typically does not apply to those specific actions.

• Example: 

  • A licensed psychologist who also owns a real estate agency is bound by real estate board ethics, not the APA code, when selling a house (unless they use their "psychologist" status to manipulate a buyer).

Non-Members

• The APA Ethics Code is a condition of membership in the American Psychological Association.

• The APA cannot directly revoke a psychologist's license for non-membership.

• However, most State Licensing Boards adopt the APA code as part of state law.

  • In those cases, the standards effectively apply to all licensed psychologists in that state, regardless of APA membership.

Legal Guilt or Innocence

• The Ethics Code is a professional standard, not a criminal or civil code.

• Example: 

  • A psychologist might be found "Ethically Inviolable" by the APA but still be found "Liable" for malpractice in a civil court, or vice versa.

    • The code does not determine legal liability.

Other Organizations

• The code does not govern the internal policies of organizations that employ psychologists (such as hospitals or corporations), though it governs how psychologists must behave within those organizations.

Specificity vs. Interpretation

• The code is intentionally not a "cookbook." It does not provide a specific answer for every possible situation. 

• It provides a framework, but the final decision often requires "professional judgment."

Assent vs. Consent

• Even if a person cannot legally consent, ethical standards (specifically Standard 3.10) require the psychologist to seek their assent.

• Assent → is the individual’s voluntary agreement to participate, explained in a way they can understand.

  • It respects the person's autonomy and dignity, even if they don't have the legal "pen" to sign the form. 

• If a child or impaired adult vigorously refuses (dissents), the psychologist must weigh the necessity of the treatment against the potential trauma of forcing it.

Emergency situations where consent cannot be given

• In a crisis where life or safety is at risk and a legal representative cannot be reached:

• Implied Consent → Psychologists may provide necessary emergency services under the assumption that a reasonable person would want life-saving or stabilizing help.

• The psychologist must carefully document why consent was not possible and the efforts made to contact a guardian.

Conflict of Interest vs Multiple Relationship

Multiple Relationships (Standard 3.05)

• This occurs when a psychologist is in a professional role with a person and simultaneously or subsequently is in another role with that same person (or someone closely associated with them). 

• The Focus → The structure of the relationship.

• Examples:

  • Treating your child's teacher in therapy (Social).

  • Hiring a client to design your website (Business).

  • Entering a romantic relationship with a former client (Sexual/Personal).

• The Rule: 

  • A multiple relationship is only "unethical" if it is likely to impair the psychologist's objectivity, competence, or effectiveness, or if it risks exploitation or harm to the client. 

Conflict of Interest (Standard 3.06)

• This occurs when a psychologist has a personal, scientific, professional, legal, financial, or other interest that could reasonably be expected to impair their objectivity. 

• The Focus → The motivation or bias of the psychologist.

• Examples:

  • Recommending an expensive, unnecessary assessment because you own the testing company.

  • Testifying as an "objective" expert in a case where the outcome directly affects your own stock holdings

  • Treating a high-profile celebrity specifically to gain fame or media access.

Dispense with Informed Consent 

• This occurs primarily in research settings where the study is unlikely to cause harm, or in clinical and legal situations where it is mandated by law or an emergency. 

In Research (Standard 8.05)

• Consent may be skipped if the study involves no reasonable assumption of distress or harm, specifically in these scenarios: 

Educational/Organizational Studies

• Research on normal educational practices or workplace effectiveness that does not risk employability.

Anonymous Data: 

• Studies using anonymous questionnaires or naturalistic observations that pose no risk to reputation.

Regulatory Waiver: 

• Where permitted by law or institutional review boards (IRBs). 

In Clinical Practice and Assessments

Emergencies: 

• When a patient is incapacitated and immediate care is necessary.

Court Orders: 

• When a forensic evaluation is mandated by a legal authority.

Incapacitated Clients: 

• Consent is obtained from a legal surrogate when the client cannot provide it. 

Recording in Public

• As per Standard 8.03, recording is allowed without consent if it involves naturalistic, public observation that does not cause harm or personal identification.

When a psychologist provides services without a direct examination

• Psychologists are still bound by Standard 9.01 of the APA Ethics Code.

They must explain:

The Nature of the Role: 

• They must clarify that they are acting as a consultant or reviewer, not as the individual's personal therapist or primary evaluator.

The Sources of Information: 

• They must state that their opinions are based solely on the available records and other documentation provided, rather than on a personal interview.

The Limitations of the Findings: 

• They must explicitly explain how the lack of a direct examination might limit the reliability or validity of their conclusions. 

The Purpose of the Service: 

• They must define who the "client" is (e.g., the court, an employer, or an insurance carrier) and how the information will be used.

• This transparency ensures that the recipients of the report—like judges or claims adjusters—understand the scope and weight of the psychologist's testimony or findings.

Forensic psychology

• The "client" is typically a legal entity (a court, an attorney, or a government agency) rather than the individual being evaluated. 

• The primary goal is to provide objective, data-driven answers to specific legal questions.

Criminal Law Activities:

• Competency Evaluations: 

  • Assessing if a defendant understands the charges and can assist their attorney (Competency to Stand Trial).

• Criminal Responsibility: 

  • Evaluating a defendant's mental state at the time of the crime (Insanity Defense).

• Risk Assessment: 

  • Predicting the likelihood of future violence or reoffending (often used in parole or sentencing hearings).

• Mitigation Specialists: 

  • Finding psychological factors (like trauma or cognitive deficits) to argue for a reduced sentence.

Civil & Family Law Activities

• Child Custody Evaluations: 

  • Determining the "best interests of the child" in divorce or parental rights cases.

• Personal Injury: 

  • Assessing psychological damages (like PTSD) resulting from accidents, harassment, or malpractice.

• Guardianship: 

  • Evaluating if an elderly or disabled adult is competent to manage their own finances and medical decisions.

• Civil Commitment: 

  • Providing testimony on whether an individual meets the legal criteria for involuntary hospitalization.

Specialized Consultation

• Jury Selection: 

  • Using psychological profiles to help attorneys pick jurors who might be more receptive to their arguments.

• Trial Strategy: 

  • Advising lawyers on how to present evidence or cross-examine witnesses based on behavioral science.

• Police & Public Safety: 

  • Conducting "Fitness-for-Duty" evaluations or pre-employment screenings for law enforcement officers.

Expert Testimony

• The "Expert Witness": 

• Testifying in court to explain complex psychological concepts, validate assessment results, or provide an opinion on a specific legal "nexus" (the link between a mental condition and a legal standard).

• Before engaging in forensic activity, psychologists must ensure they possess a specific foundation of legal knowledge, specialized clinical competence, and a clear understanding of their ethical role. 

• Because the work directly impacts legal rights and liberties, the standard for preparation is higher than in general clinical practice, including: 

  • Fundamental Legal Knowledge

  • Specialized Forensic Competence

  • Role and Boundary Clarity

Objectivity vs. Advocacy: 

• Understanding that their role is to assist the "trier of fact" (judge/jury) with impartial information, not to advocate for a specific outcome like an attorney.

Conflicts of Interest: 

• Evaluating whether any personal beliefs, values, or prior relationships with any party in the case will impair their impartiality

Procedural Requirements:

• Fee Structure → ensuring fees are clearly defined and that they do NOT work on a contingency basis.

• Limits of Confidentiality → explicitly explain that the results will be shared with third parties and that traditional therapist-patient privilege may not apply.

Sexual Harassment

• APA Ethical Principles of Psychologists and Code of Conduct specifically defines it as:

  • sexual solicitation, physical advances, or verbal or nonverbal conduct that is sexual in nature, occurring in connection with a psychologist's professional activities or roles.

For conduct to be classified under this code, it must meet at least one of the following two criteria:

Unwelcome and Known Offensive Behavior: 

• The conduct is unwelcome, offensive, or creates a hostile workplace or educational environment, and the psychologist either knows this or has been explicitly told.

Sufficient Severity or Intensity: 

• The conduct is sufficiently severe or intense that a reasonable person in that same context would find it abusive

Potentially harmful multiple relationship is discovered:

• The psychologist is ethically mandated by Standard 3.05(b) of the APA Ethics Code to take reasonable steps to resolve it.

• The process focuses on protecting the client's welfare and maintaining professional integrity through these steps:

1. Immediate Assessment and Acknowledgment

• Identify the Conflict: 

  • Determine if the relationship is likely to impair your objectivity, competence, or effectiveness, or if it poses a risk of exploitation or harm to the client.

• Self-Correction: 

  • Acknowledge the situation without defensiveness.

  • Document the discovery and your initial assessment of its impact. 

2. Seek Professional Consultation

• Neutral Perspective: 

  • Consult with a trusted colleague, supervisor, or ethics committee.

    • Helps identify "blind spots" & ensures decision-making is consistent with the standard of care.

• Malpractice Carrier: 

  • In high-risk situations (e.g., legal or financial overlaps), notify your malpractice insurer for legal guidance. 

 

3. Transparent Communication with the Client

• Direct Dialogue: 

  • Address the overlap openly in the next session.

  • Explain the potential risks and the ethical requirements that must be followed.

• Collaborative Problem-Solving: 

  • Include the client in the decision-making process.

  • Reaffirm professional limits while validating any discomfort the client may feel. 

4. Take Remedial Action

• Adjust Boundaries: 

  • If the relationship is manageable, set clear new limits to protect the therapeutic space

    • e.g., agreeing not to interact in shared social settings.

• Referral as a Last Resort: 

  • If objectivity is significantly impaired or harm is likely → prepare a thoughtful referral to another provider.

  • Ensure the transition is handled to minimize distress & maintain the client's best interests. 

5. Ongoing Monitoring and Documentation

• Regular Check-ins: 

  • Continuously evaluate how the secondary role is affecting the therapy.

• Detailed Records: 

  • Maintain thorough notes of all discussions, consultations, and the rationale for the chosen resolution to demonstrate maximal compliance with the Ethics Code. 

Unpaid bills

• Psychologists must navigate specific ethical and legal requirements to collect fees while avoiding "client abandonment." 

• Under APA Ethical Standard 6.04, psychologists may take legal action or use collection agencies only after following specific procedural steps.

Ethical Requirements Before Collection

• Before involving a third party (like a collection agency or small claims court), the APA Ethics Code and Pennsylvania state law require the following: 

Prior Disclosure: 

• You must have informed the client at the start of treatment (typically in the Informed Consent) that you use such measures for nonpayment.

Notice of Intent: 

• You must provide the client with "reasonable notice" of your intent to seek collection, giving them a final opportunity to pay before the account is transferred.

Minimal Disclosure: 

• When using a collection agency, you may disclose only the minimum information necessary to collect the debt (typically name, address, and the amount owed).

  • You are strictly prohibited from disclosing clinical information. 

Termination vs. Abandonment

• Psychologists are NOT ethically obligated to provide free services indefinitely, but they cannot abruptly end treatment solely for nonpayment if it puts the client at risk. 

Clinically Appropriate Termination: 

• If you choose to terminate for nonpayment, you must do so in a way that avoids abandonment.

  • This includes providing adequate notice, discussing the termination clinically, and offering referrals to lower-cost providers.

Crisis Situations: 

• You may not terminate or withhold services if the client is in a psychiatric crisis. 

Prohibited Practices:

Withholding Records: 

• Under 49 Pa. Code § 48.77, Pennsylvania psychologists cannot withhold records that are needed for a client's emergency treatment solely because of an unpaid balance.

Bartering: 

• While the APA allows bartering if it is not clinically contraindicated, Pennsylvania law (49 Pa. Code § 48.77(b)) specifically states that licensees may not accept goods or services as payment for professional services. 

 

Risk Management

• Many experts advise against using collection agencies because they frequently trigger retaliatory licensing board complaints or malpractice suits. 

• It is often more "efficient" to negotiate a payment plan or write off the debt as a last resort to protect your professional reputation.

 Ethical responsibility regarding HIV transmission 

• The APA generally maintains that a legal duty to protect third parties from HIV infection should not be imposed on psychologists. 

  • However, the APA has established specific criteria for permissive disclosure if a psychologist chooses to breach confidentiality to prevent transmission. 

Criteria for Permissive Disclosure:

Identifiable Third Party: 

• The psychologist knows of a specific, identifiable person.

Significant Risk: 

• The provider has a compelling reason to believe this third party is at significant risk of infection.

Third Party's Unawareness: 

• The provider reasonably believes the third party has no reason to suspect they are at risk or is unaware the client is living with HIV.

Patient Refusal to Inform: 

• The client has been urged to inform the third party themselves but has either refused or is considered unreliable in their willingness to do so.

Key Considerations and Procedures:

Exhaust Other Efforts: 

• Any breach of confidentiality should only be undertaken after all clinical efforts to work with the patient to terminate high-risk behavior or encourage self-disclosure have failed.

Notification of Patient: 

• If a psychologist decides to disclose, they should generally notify the patient of this intent and take steps to repair the therapeutic relationship afterward.

Preference for Public Health Officials: 

• If state law allows, the APA suggests that disclosure to a public health official (responsible for partner notification) is preferable to the psychologist's direct notification.

Legal Mandates: 

• Psychologists must always verify their specific state laws, as some jurisdictions have mandatory reporting or "partner notification" laws that override these general ethical guidelines.

Immunity: 

• The APA advocates that any legislation regarding HIV disclosure should include civil and criminal immunity for providers who make these difficult decisions in good faith.

Conflict between ethics and law:

• While the APA Ethics Code generally requires psychologists to meet the higher standard when the code and law differ, Standard 1.02 specifically addresses these direct collisions.

Refusing to Disclose Records Under Subpoena 

• A psychologist may be ethically required to protect client confidentiality and test security, but a court may legally require disclosure of that information. 

The Ethical Mandate: 

• Psychologists must maintain confidentiality and protect the integrity of test materials (Standard 9.11).

The Illegal Act: 

• If a psychologist refuses to comply with a legally valid court order (even to protect client privacy), they can be held in contempt of court (legal violation).

• Resolution: 

  • Standard 1.02 allows psychologists to comply with the law if the conflict is unresolvable after they have made their ethical commitment known. 

Protecting Human Rights vs. Government Mandates

• This is the most significant "ethical but illegal" territory, notably revised in the 2010 amendments to the 2002 code. 

The Ethical Mandate: 

• Psychologists must never engage in or justify actions that violate human rights, even if ordered by a governing authority.

The Illegal Act: 

• A psychologist working for a government agency or military may be legally ordered to perform an action (e.g., specific interrogation techniques) that they deem a violation of basic human rights.

Resolution: 

• Under the current code, psychologists cannot use the defense of "following legal orders" to justify a human rights violation.

• They are ethically bound to refuse the order, even if it results in legal or professional consequences for "disobeying" a mandate. 

Maintaining Confidentiality in HIV Disclosure

• In some states, there are strictly defined "Duty to Warn" laws that do not include HIV status, or conversely, laws that explicitly forbid disclosure without a specific court order.

The Ethical Mandate: 

• The APA guidelines allow for permissive disclosure to protect an identifiable third party from a "significant risk" of HIV infection.

The Illegal Act: 

• If a state has strict privacy laws (like some Pennsylvania PHI laws) that forbid the disclosure of HIV status without a court order, a psychologist who warns a partner could be sued for breach of privacy or face criminal penalties. 

Civil Disobedience for Client Welfare

• A psychologist might engage in technically illegal acts to fulfill Principle A: Beneficence (Do No Harm). 

Scenario: 

• A psychologist working with an undocumented immigrant who is a victim of a crime might refuse to cooperate with federal authorities searching for the individual.

The Conflict: 

• Assisting the authorities is a legal requirement; protecting the client from a traumatic deportation that would end their therapy is an ethical priority of minimizing harm 

Nonpayment of Fees

• This specific conflict arises from a direct contradiction between the APA Ethics Code and federal law (HIPAA).

• The Ethical Standpoint (APA Standard 6.03): 

• Under the APA Ethics Code, psychologists are prohibited from withholding records only in emergency treatment situations due to nonpayment. This implies that in non-emergency situations, it is technically ethical (per APA) to withhold records until a bill is settled.

The Legal Reality (HIPAA Privacy Rule): 

• Under federal law, the HIPAA Privacy Rule strictly prohibits a "covered entity" from withholding or denying a patient access to their protected health information (PHI) because they have an outstanding bill for services.

The Result: 

• A psychologist who follows the APA's permissive stance and withholds records for a non-emergency balance is technically "ethical" by their professional code, but is violating federal law

When a psychologist's ethical responsibilities conflict with law, regulations, or other governing legal authority:

• The APA Ethics Code Standard 1.02 (2017) mandates a specific sequence of actions to resolve the issue responsibly.

Clarify the Nature of the Conflict: 

• Clearly identify exactly which legal requirement (e.g., a court order or state statute) is in opposition to a specific ethical standard.

Make Known Commitment to the Ethics Code: 

• Inform the relevant parties (such as a judge, employer, or government agency) that a professional ethical obligation exists under the APA Ethics Code.

Take Reasonable Steps to Resolve: 

• Actively work to find a solution that remains consistent with both the General Principles and Ethical Standards of the code. 

• This may involve:

  • Seeking a motion to quash a subpoena.

  • Proposing a treatment summary instead of raw clinical data to protect test security.

  • Consulting with legal counsel or ethics committees to find "creative ways" to satisfy both obligations

• If, after these steps, the conflict remains unresolvable, the psychologist is permitted to follow the requirements of the law, regulations, or other governing authority. 

• Critical limitation:

  • Under no circumstances may Standard 1.02 be used to justify or defend violations of human rights.

    • This 2010 amendment ensures that a psychologist cannot use "following orders" or legal mandates as a defense for actions that infringe upon basic universal human norms.

Confidentiality survives the death of a client. 

• Under the APA Ethics Code and federal HIPAA regulations, access to these records is NOT automatic for all family members and is primarily restricted to specific authorized individuals. 

Legally Authorized Representatives

• Executor or Administrator: The person appointed by a probate court to manage the deceased person's estate.

Limited Access for Family & Friends

• HIPAA allows psychologists to share limited information with family members or friends who were involved in the client’s care or payment for care prior to death. 

Mandatory Legal Disclosures

• Psychologists may be required or permitted by law to release records to specific officials without a representative's consent: 

  • Coroners and Medical Examiners

  • Public Health Authorities (for disease tracking or public safety mandate)

  • Court Orders (If a judge issues a direct order for the records)

Psychotherapy Notes Exception

• Even for authorized representatives, psychotherapy notes (the therapist's private process notes kept separate from the medical record) typically have higher protection and are not subject to the standard right of access unless a court orders their release.

Psychotherapy notes 

• A psychologist is not legally required to share them with a client who asks to see them. 

• Under the HIPAA Privacy Rule, they are specifically excluded from a patient’s standard right of access. 

• While clients can access their general medical records—such as diagnoses, treatment plans, and progress notes—psychotherapy notes are protected from disclosure. 

Key Considerations:

Provider Discretion: 

• Although not required, a psychologist may choose to share these notes voluntarily if they believe it is clinically appropriate.

Separation Requirement: 

• To maintain this protection, these notes must be kept physically and logically separate from the rest of the individual’s medical record.

Excluded Information: 

• Standard medical information (e.g., medication monitoring, session times, test results, and summaries of diagnosis or progress) is not considered part of psychotherapy notes and must still be provided upon request.

State Law Precedence: 

• Some states may provide greater access than HIPAA.

  • In PA, access to treatment records can only be denied if disclosure would constitute a "substantial detriment" to the patient's treatment or reveal confidential sources.

Potential for Harm: 

• Many therapists withhold these notes if they believe viewing the content—which often includes raw impressions, hypotheses, and personal reflections—could harm the client or the therapeutic relationship.

Most common ethical violations

Boundary and Multiple Relationship Violations 

• This is often cited as the most prominent and damaging category of ethical misconduct. 

Sexual Misconduct: 

• Intimate relationships with current or former clients are the leading cause of permanent license revocation and high-cost malpractice settlements.

Non-Sexual Multiple Relationships: 

• These involve "dual roles," such as a psychologist becoming friends with a client, hiring a client, or providing therapy to a close relative. 

Breaches of Confidentiality and Privacy

• These cases often arise from the accidental or improper disclosure of client information. 

Technology Pitfalls: 

• Modern complaints frequently involve unencrypted communication (text/email) or responses to negative online reviews that confirm a person is a client.

Unauthorized Disclosures: 

• Releasing records to third parties without proper authorization or a valid court order. 

Child Custody and Forensic Disputes

• Psychologists who get involved in high-conflict legal cases without proper training are at high risk for ethics complaints. 

Inadequate Evaluations: 

• Making custody recommendations without interviewing both parents or using outdated assessment tools.

Advocacy Bias: 

• Acting as a "hired gun" or shifting from a neutral clinical role to an advocate for one side. 

 Competence and Scope of Practice

• Practitioners frequently face "open" cases in which they lack documented expertise for treating conditions or using techniques. 

Unfamiliar Disorders: 

• Treating complex issues like eating disorders or severe trauma without specialized supervision.

Medication Advice: 

• Offering psychopharmacological opinions or dosage suggestions without being a medical prescriber. 

Administrative and Financial Misconduct

• These are often the easiest for state boards to investigate and prosecute. 

Continuing Education (CE) Violations: 

• Failing to meet the required hours for license renewal is the #1 reason for disciplinary sanctions in many states.

Insurance Fraud: 

• Billing for sessions that didn't occur or "upcoding" diagnoses to ensure insurance reimbursement.

Loss of Licensure in Another Jurisdiction:

• It triggers a process of reciprocal discipline, in which other states where the psychologist holds a license may take similar disciplinary actions based on the original findings. 

Board Discretion: 

• While a board in "State B" may not automatically revoke a license just because "State A" did, they have the legal authority to deny applications, suspend, or revoke a license based on the findings from the first jurisdiction.

Referral Fees

• Guidelines are strict: paying or receiving a fee solely for a referral is generally unethical and often illegal.

• The APA Ethics Code and state laws distinguish between "paying for a name" and "paying for a service."

The Ethical Standard (Standard 6.07)

• When psychologists pay, receive payment from, or split fees with another professional (other than in an employer-employee relationship), the payment must be based on the services provided (clinical, consultative, administrative, or other) and NOT on the referral itself.

Permitted: 

• Paying a percentage of a fee to a clinic owner to cover overhead (rent, billing services, marketing) for a client you are treating there.

Anti-Kickback Laws

• At the legal level, they often trigger Anti-Kickback Statutes.

Federal Law: 

• It is a federal crime to exchange anything of value to induce or reward the referral of business reimbursable by federal healthcare programs (like Medicare or Medicaid).

State Law: 

• Many states, including Pennsylvania, have "Fee-Splitting" prohibitions that prevent psychologists from sharing fees with non-psychologists or paying for referrals, as this is viewed as a conflict of interest that could compromise patient care.

The "Patient's Best Interest" Rule

• The primary ethical concern is that a referral fee incentivizes the psychologist to send a client to the person paying the fee, rather than the provider who is the best clinical match for the client's needs.

Best Practice: 

• Referrals should be made based on the recipient's competence and the client's specific requirements, not financial gain.

Exceptions: Administrative vs. Referral Fees

Psychologists can legally and ethically pay for:

• Marketing Services → paying a company to run your Google Ads or manage your SEO.

• Directory Listings → paying a flat monthly fee to be listed on sites like Psychology Today.

  • This is seen as advertising, not a "per-head" referral fee.

• Group Practice Split: 

  • In a group practice, a portion of the fee often goes to the "house" for administrative costs. This is ethical because it covers the costs of the infrastructure used to treat the patient.

Bartering

• Under the APA Ethical Standard 6.05, the acceptance of goods, services, or other nonmonetary remuneration in exchange for psychological services is not inherently unethical. 

• However, it is generally discouraged due to its potential to complicate the therapeutic relationship and create unintended conflicts of interest. 

Mandatory Ethical Criteria

A psychologist may only enter into a bartering arrangement if: 

Not Clinically Contraindicated: 

• It must not interfere with the patient's treatment or mental state (e.g., bartering with a client who has a history of boundary issues or borderline personality disorder is often ill-advised).

Not Exploitative: 

• The arrangement must be fair and equitable. The psychologist must ensure the value of the goods or services exchanged is not significantly higher than the standard fee for therapy. 

Goods vs. Services

• Ethicists often distinguish between the types of items being bartered: 

• Bartering for Goods → is generally seen as less risky because it rarely creates a multiple relationship.

• Bartering for Services → is much more complex as it establishes a dual relationship where the psychologist is also an employer.

  • This can lead to resentment if the psychologist is unsatisfied with the work. 

 

Clinical Risks & Professional Boundaries

• The "Slippery Slope": While not guaranteed, critics argue that blurring financial boundaries can lead to further boundary violations.

Loss of Objectivity: 

• If a psychologist relies on a client's service, they may find it difficult to challenge that client's behavior in therapy for fear of losing the service.

Cultural Competence: 

• In some rural or indigenous communities, bartering is a standard cultural norm. Refusing to barter in these contexts could be seen as offensive or exclusionary. 

Theoretical Orientation

• Clinical framework dictates how a psychologist views boundaries and the "transference" in the relationship.

Psychodynamic/Analytic: 

• Generally, it is strongly discouraged to barter, as therapy relies on analyzing the unconscious relationship (transference).

  • Introducing a secondary role (like being the client's "employer" if they are painting your house) creates "noise" that makes it impossible to interpret the therapeutic relationship objectively.

Behavioral/CBT: 

• May be more permissive. If the focus is on specific symptom reduction or skill-building, a clean exchange for a tangible good (e.g., a bag of produce) might be seen as a simple transactional adjustment that doesn't interfere with the technical work.

Humanistic/Social Justice: 

• May see bartering as a way to increase access to care for marginalized or low-income clients, aligning with the principle of Justice.

Client’s Diagnosis

• The client's mental health status is the most critical risk-assessment factor.

High-Risk Diagnoses: 

• Bartering is typically contraindicated for clients with Borderline Personality Disorder, severe Trauma/PTSD, or Dependency issues.

  • These clients may struggle with blurred boundaries, and a dispute over the "value" of the bartered item could feel like a personal rejection or a repeat of past exploitation.

Low-Risk Diagnoses: 

• Clients seeking help for Adjustment Disorders, mild Phobias, or Career Counseling are often better candidates, as their ability to maintain professional boundaries is usually intact.

Expected Duration of Treatment

• The length of the commitment changes the "math" of the exchange.

Short-Term/Brief Therapy:

• Bartering for a one-time good (e.g., a piece of furniture for 4 sessions) is relatively low-risk.

  • The "debt" is cleared quickly, and the relationship ends before boundary erosion can occur.

Long-Term/Open-Ended Therapy:

• This is a much higher risk. If a client is "paying" by cleaning your office every week for years, the power dynamic shifts.

• You become their long-term employer, making it very difficult to terminate therapy or challenge them clinically without affecting their "job" or your own office maintenance.

Recommended Best Practices

• To minimize risk, psychologists who choose to barter should:

  • Initiate only if the client requests it:

    • The psychologist should NOT propose bartering.

Use a Written Contract:

• Clearly define the exchange, the value of the items, and the process for resolving disagreements.

Document the Rationale:

• Record in the clinical notes why bartering was chosen and how it benefits the client's welfare.

Tax Obligations:

• Both parties must understand that bartering is taxable income and must be reported to the IRS at its fair market value

Designated Record Set (DRS) 

• It is a group of records maintained by or for a "covered entity" that is used to make decisions about an individual.

  • This set defines the exact scope of information a patient has the right to access, inspect, or amend. 

Medical/Clinical Records:

• Admission and discharge summaries, diagnoses, treatment plans, and progress notes (the standard notes detailing session dates, symptoms, and interventions).

Assessment Results:

• Results of psychological testing, raw data that has been interpreted, and formal evaluation reports.

Medication Records: 

• Documentation of psychiatric medications, dosages, and monitoring for side effects.

Billing and Financials: 

• Records of payments, insurance claims, and any financial agreements.

Administrative Documents: 

• Consent forms, authorizations for release of information, and notices of privacy practices.

Excluded from DRS:

Psychotherapy Notes: 

• Private "process notes" are kept separately from the clinical record.

  • They often contain raw hypotheses or personal reflections and are specifically protected from client access under HIPAA.

Information Compiled for Litigation: 

• Records created in reasonable anticipation of a civil, criminal, or administrative action (common in forensic work).

Test Protocols: 

• While interpreted results are included, the actual copyrighted test manuals or proprietary stimulus materials are usually excluded to protect test security.

Confidential Sources: 

• Information that would reveal the identity of a person (other than a healthcare provider) who provided information under a promise of confidentiality.

Psychological Capacity 

• When determining if a client has the psychological capacity to provide informed consent, psychologists typically assess four core functional abilities.

  • These criteria, often called the Appelbaum and Grisso model, help establish whether a person can make a self-determined choice. 

The Four Core Functional Abilities

Understanding: 

• The client must be able to comprehend the fundamental information disclosed to them.

  • This includes the nature of the condition, the purpose and risks of the proposed treatment, and any available alternatives.

Appreciation: 

• The client must recognize how this information applies to their specific personal situation.

• For example, they may understand that a medication has side effects but fail to appreciate that they are personally at risk of those effects.

Reasoning: 

• The client must be able to logically process the information to compare different options.

  • This involves weighing the potential risks and benefits of both accepting and refusing treatment to reach a conclusion.

Expressing a Choice: 

• The client must be able to clearly communicate a consistent decision.

  • Frequent, vacillating changes in a decision without a rational explanation may indicate a lack of capacity

The "Minimum Ethical" Standard: A common trick is that the correct answer is often the minimally acceptable ethical action—the baseline behavior that protects the client and follows the code, even if it isn't the "most" helpful thing you'd do in real life. 

High-Yield Ethical Topics:

• Informed Consent: Timing, content, and special populations (e.g., minors or court-ordered clients).

• Competence: Recognizing your boundaries and knowing when to seek consultation or refer out.

• Multiple Relationships: Identifying when a secondary role (social, financial, etc.) is likely to cause impairment or harm.

• Confidentiality & Mandated Reporting: Knowing the specific exceptions, such as the Duty to Protect (Tarasoff) and reporting child/elder abuse.

• Fees and Financial Arrangements: Issues like bartering, sliding scales, and waiving co-payments.

Confidentiality vs. Privilege

Confidentiality (Ethical/Professional Duty): This is your ongoing obligation to keep client information private. It is an ethical standard (APA Standard 4) that applies across almost all professional settings.

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Privilege (Legal Right): This is a legal concept that protects a client’s information specifically within legal proceedings (e.g., a trial or deposition).

• The Holder: The client typically holds the privilege, meaning only they can waive it.

• The Assertion: A psychologist may "assert the privilege" on a client's behalf if a subpoena is received, essentially saying, "I cannot release this because my client has the legal right to keep it private".

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Mandated Reporting (The "Must-Break" Rules)

Vulnerable Populations: You are legally required to report suspected abuse, neglect, or exploitation of children, the elderly (typically 60+ or 65+), and vulnerable adults (those with disabilities).

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The Standard for Reporting: You do not need "proof." You only need reasonable suspicion or "reasonable cause to believe" abuse has occurred.

Past vs. Present Abuse:

• Child Abuse: You must report even if the abuse is not current, provided the victim is still a minor or other minors are still at risk.

• Adults Disclosing Past Child Abuse: If an adult client discloses they were abused as a child, you are generally not required to report it unless you have reason to believe the perpetrator is currently abusing other children.

Duty to Protect (Tarasoff & Its Progeny)

Tarasoff v. Regents: Established that psychologists have a duty to protect (originally "duty to warn") an identifiable victim from a serious, imminent threat of physical violence.

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Hedlund v. Superior Court: Expanded this duty to include foreseeable bystanders who might also be harmed (e.g., if a client threatens a mother, the duty may extend to her child).

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Jablonski v. United States: Emphasized the duty to protect by reviewing a patient's past history of violence, even if no specific threat is made. 

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Responding to Legal Demands:

If you receive a Subpoena, the EPPP looks for a specific sequence of actions: 

1. Contact the client to see if they want to waive or assert privilege.

2. Negotiate with the requesting attorney if the client does not want the info released.

3. If a Court Order is issued by a judge (which is different from a subpoena from a lawyer), you must comply, though you should still try to limit the disclosure to only what is necessary.

Fees and Financial Arrangements 

It is governed by APA Ethics Code Standard 6. The exam focuses on your ability to maintain professional boundaries while handling the "business" side of psychology.

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Reaching an Agreement (Standard 6.04)

The EPPP often tests the timing and transparency of fee discussions.

• As Early as Feasible: You must discuss fees "as early as is feasible" in the therapeutic relationship (usually during the first session).

• What to Include: You must specify the hourly rate, charges for missed appointments, and how billing/collection will be handled.

• Anticipating Limits: If a client’s insurance or personal funds might run out, you must discuss this possibility early on.

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Bartering (Standard 6.05)

This is a favorite topic for exam "tricks." In the past, bartering was strictly discouraged, but the current code is more flexible.

• When it's Okay: Bartering (exchanging goods or services for therapy) is ethically permissible ONLY IF:

  1. It is not clinically contraindicated (won't harm the therapy).

  2. The resulting arrangement is not exploitative.

• The Trap: The exam often presents a scenario where a client offers a service (like car repair) in exchange for therapy. You must assess if this creates a Multiple Relationship that impairs your objectivity. Generally, bartering for goods (e.g., a painting) is considered less risky than bartering for services (e.g., house cleaning).

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Referrals and Fees (Standard 6.07)

The EPPP is very strict about "kickbacks."

• No "Finder's Fees": You cannot pay or receive a fee simply for referring a client.

• The Exception: Payments between professionals must be based on the services provided (e.g., clinical, consultative, or administrative) and not on the referral itself.

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Nonpayment of Fees (Standard 6.04e)

What do you do if a client stops paying?

• The Notification Rule: You can use a collection agency or legal measures, but you must first inform the person that you intend to do so and give them an opportunity to pay.

• Limited Disclosure: If you use a collection agency, you only provide the minimum necessary information (name, address, amount owed). You do not disclose clinical notes or diagnoses.

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Financial "Gray Areas"

• Sliding Scales: These are generally ethical as long as they are applied consistently and fairly.

• Withholding Records for Nonpayment (Standard 6.03): This is a HUGE exam point. Under APA ethics, you cannot withhold records that are needed for a client's emergency treatment solely because they haven't paid their bill. (Note: HIPAA laws may be even stricter, but for the EPPP, focus on the "emergency treatment" rule).

5 General Principles

It is aspirational "Spirit of the Law.” You have to look for the primary motivation behind the psychologist's action.

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Beneficence and Nonmaleficence (Do Good / No Harm)

Focus: The physical and psychological well-being of the client.

• Clinical: A therapist realizes they are too burned out to provide effective care and takes a leave of absence to avoid "impaired" practice that could hurt clients.

• Research: A scientist terminates a study early because the experimental treatment is clearly causing severe distress to the participants.

• Emergency: Providing pro-bono crisis counseling to victims of a natural disaster because the immediate need for "doing good" outweighs the typical financial setup.

• Animal Care: A lab researcher ensures that the discomfort of lab animals is minimized to the greatest extent possible.

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Fidelity and Responsibility (Trust / Professionalism)

Focus: Trusting relationships, professional standards, and "policing" the field.

• The "Snitch" Rule: You notice a colleague is drinking on the job. You have a responsibility to the profession to address it (informally first, then formally) to maintain public trust.

• Consultation: Seeking a peer consultation group to ensure you are staying objective in a difficult case.

• Community: Providing a few hours of free mental health training to a local non-profit (giving back to the community to uphold the profession's reputation).

• Clarity: Being very clear in a court-ordered evaluation about who your "client" is (the court) vs. the person being evaluated to avoid a breach of trust later.

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Integrity (Honesty / Truthfulness)

Focus: Accuracy in mapping reality and avoiding "tricky" behavior.

• Advertising: A psychologist lists their degree accurately and doesn't imply they are a "specialist" in eating disorders if they've only taken one weekend workshop.

• Deception in Research: If a researcher must use a "cover story" (deception), they only do so if it’s absolutely necessary, and they debrief the participants as soon as possible.

• Billing: Refusing to change a diagnosis code on an insurance form just so the client can get reimbursed (even if the client is struggling financially).

• Promises: Not making "guarantees" of a specific cure or outcome to a desperate patient.

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Justice (Fairness / Equal Access)

Focus: Who gets treatment and the quality of that treatment.

• Access: A clinic ensures that its building is wheelchair accessible and that they have translation services available for non-English speakers.

• Biases: A psychologist constantly checks their own internal biases to ensure they aren't giving "better" or "more attentive" care to clients who share their same political or religious views.

• Sliding Scale: Offering a few spots in your private practice for low-income clients so that "Expert Care" isn't only for the wealthy.

• Competence: Not taking on a client from a specific cultural background if you have zero knowledge of that culture, because providing "substandard" care to that group is an issue of Justice.

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Respect for People's Rights and Dignity (Privacy / Autonomy)

Focus: The client’s right to choose and their right to a secret life.

• Confidentiality: This is the big one. Vigilantly protecting a client’s records because they have a right to privacy.

• Informed Consent: Giving a client all the facts so they can decide if they want therapy. This honors their autonomy (self-rule).

• Diverse Values: Respecting a client’s religious decision to stay in a difficult marriage, even if the therapist personally thinks they should leave.

• Self-Determination: Allowing a client to terminate therapy even if the therapist thinks they "aren't finished yet."

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The "Mix-Up" Check

• Justice vs. Beneficence: If you are worried a client will be physically hurt, it's Beneficence. If you are worried a specific group of people is being excluded or treated poorly, it's Justice.

• Fidelity vs. Integrity: If it's about keeping a promise or being truthful, it's Integrity. If it's about professional duty or a colleague's behavior, it's Fidelity.

financial gray areas

Waiving Co-Payments

This is a common "trick" question. A client is struggling financially, and you want to be kind by only accepting what the insurance pays and "forgiving" their $20 co-pay.

• The Verdict: This is generally considered insurance fraud and a breach of your contract with the insurance company.

• The Exam Answer: You should not waive co-pays without the insurance company's explicit consent. If a client can't afford the co-pay, the ethical move is to discuss a sliding scale or referral to a lower-cost clinic.

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Withholding Records for Non-Payment (Standard 6.03)

• The Rule: Psychologists may not withhold records under their control that are requested and needed for a client's emergency treatment solely because payment has not been received.

• The Nuance: If it is not an emergency, the APA code is slightly more silent, but HIPAA (which usually trumps the code on the exam) says you can't withhold them for non-payment at all.

• EPPP Strategy: Look for the word "Emergency." If it's an emergency, you send the records immediately, regardless of the bill.

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"Finder's Fees" vs. Administrative Fees (Standard 6.07)

You cannot pay someone just for sending you a client (no "kickbacks").

• The Gray Area: If you work in a group practice and pay the owner a percentage of your fee.

• The Verdict: This is ethical only if the payment is based on the actual services provided (e.g., rent, billing software, scheduling, or clinical supervision). It cannot be a fee just for the name on the file.

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Sliding Scale Fees

• The Goal: To provide Justice (equal access).

• The Risk: If you offer a sliding scale to one person but not another with the same income, you are being inconsistent.

• The Exam Answer: Sliding scales are ethical as long as they are based on a fair, objective, and consistently applied policy (usually based on Federal Poverty Guidelines).

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Collection Agencies (Standard 6.04e)

If a client stops paying, can you sue them or send them to collections?

• Yes, but with two "Musts":

  1. You must first notify the client of your intent to use a collection agency and give them a chance to pay.

  2. You must only disclose the minimum necessary information (name, contact info, and amount owed). You never send the diagnosis or treatment notes to a debt collector.

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Receiving Gifts (Standard 3.05)

While not a "fee," a gift has financial value and can complicate the financial relationship.

• The Strategy: There is no rule that says "never accept a gift."

• The Criteria: You must consider the monetary value, the client's intent, the timing (beginning vs. end of therapy), and the cultural context. A $10 Starbucks card at the end of 3 years of therapy is usually fine; a $500 watch in month two is a boundary violation.

Sliding Scales

Treat this as a balancing act between the Principle of Justice (providing access to care) and Fidelity/Responsibility (maintaining professional standards and avoiding exploitation).

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It is Ethically Permissible (but not Required)

There is no APA standard that forces you to offer a sliding scale, but doing so is seen as an expression of General Principle D: Justice. It ensures that "all persons have access to and benefit from the contributions of psychology."

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Consistency is the Key

• The Rule: You cannot arbitrarily decide who gets a discount. You must have a fair and consistently applied policy.

• The Exam Scenario: If you give a discount to a client because you "really like them" but charge full price to a "difficult" client with the same income, you are in violation of ethical fairness.

• The Solution: Use an objective measure, like the Federal Poverty Guidelines, to determine the fee.

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The "Insurance Fraud" Trap

• The Issue: If you tell an insurance company your "standard fee" is $200, but you routinely charge your cash-pay clients $100 on a sliding scale, the insurance company may claim you are overcharging them.

• The Exam Answer: You must be transparent with third-party payers. You cannot represent your "standard fee" as one thing to insurance and another to the public without a clear, documented sliding scale policy.

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Impact on Multiple Relationships

If a sliding scale fee is set too low (e.g., $5 a session), the exam might suggest this creates an "imbalance of power" or leads to therapist burnout/resentment, which could eventually cause harm (Nonmaleficence).

• The Strategy: The fee should be low enough to be accessible but high enough to maintain a professional "contract" and the therapist’s ability to provide competent care.

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Documentation

In any vignette involving a fee change or sliding scale, the "correct" answer almost always includes documenting the rationale and discussing it during informed consent.

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Sliding Scale vs. Bartering

• Sliding Scale: Adjusting the amount of money. (Generally safer/preferred by the exam).

• Bartering: Swapping for goods/services. (Higher risk for multiple relationship issues).

Bartering

Bartering (Standard 6.05) is one of the most high-yield "trap" topics. In the past, the exam treated bartering as a "never do," but the modern APA Ethics Code is more nuanced.

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The Two "Golden Rules"

You can only barter if two specific conditions are met:

• It is not clinically contraindicated (it won't mess up the therapy or the relationship).

• The resulting arrangement is not exploitative (it's a fair trade and the psychologist doesn't have "the upper hand").

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Goods vs. Services (The Big Distinction)

• Bartering for Goods (Lower Risk): Trading a painting, a used car, or a bag of produce for therapy. This is generally seen as safer because the value is easier to determine and the "interaction" ends once the item is handed over.

• Bartering for Services (High Risk): Trading house cleaning, legal work, or car repairs for therapy. This is strongly discouraged because it creates an ongoing Multiple Relationship. If the client does a bad job cleaning your house, it will likely impair your clinical objectivity and cause conflict in the "therapy" room.

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Determining "Fair Market Value"

A common exam "wrong answer" involves the psychologist setting the price.

• The Ethical Way: The value of the bartered item/service should be agreed upon at the start and should match the Fair Market Value. If you trade a $500 painting for $1,000 worth of therapy, you are exploiting the client (Principle B: Fidelity).

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Cultural Context

• The Exam Strategy: In these cases, refusing to barter might be seen as culturally insensitive or a barrier to care (Justice). You are more likely to be "allowed" to barter in these specific scenarios, provided you document the rationale and ensure no harm is done.

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The "Best Practice" Steps

Best first step when a client suggests bartering:

1. Discuss the potential risks and complications with the client.

2. Determine if a multiple relationship will impair your objectivity.

3. Consult with a colleague (this is a very common "correct" answer).

4. Document everything in the clinical record, including the agreed-upon value.