The Standard of Care and Why Psychologists Turn On Each Other

There were some discussions about my article on the standard of care and to respond to some
questions I posted this followup explanation that provides my take on why psychologists so frequently turn on each other:

By way of background, someone on an email discussion group posed a question/statement that it is often difficult to ascertain the standard of care and remarked that the question of “what to do” is often murky, at best.  As an example, he remarked that he often wonders about whether he is required to have a segment of his voicemail message suggesting to callers that “if there is an emergency, please hang up and dial 911.”  He wondered what was the standard of care surrounding such messages.  In other words, is it a standard of care for psychologists that we are required to have those disclaimers on our voicemail messages?

In response, someone posted that some people do, whereas some people don’t, and bemoaned his own observation that it would be fairly easy to find a psychologist expert who would say that it would be a violation of the standard of care to not have such an outgoing greeting.  He said that he felt that psychologists were much more likely to turn on one another for alleged ethics violations than are physicians, and (rhetorically) asked why.

My response follows:

I think this is due to a number of reasons, but I’ve always suspected that two of them are primary:

1.) Psychologists use ethics as a means of regulating the profession.  Other healthcare professions, such as medicine, use data-driven science to answer questions about practice competency.  This basically means that (when it comes to questions of discipline), as a profession, we’ve decided to eschew questions about what works, and have instead decided to go with the metric of “what’s ethical.”  I think this is kind of backward, but it’s what our profession has chosen.  Not that I think ethics are bad, but I think questions of professional discipline should be determined according to the data that backs up our services, as well as professional misconduct.

Because our profession relies almost solely on ethics, that means that if you do “past lives therapy” with a patient and tell her that she’s probably depressed because she was Joan of Arc in a past life, proceed to do therapy based upon that assumption, and end up telling a colleague about your patient, you can be disciplined for the violation of confidentiality but probably not for telling your patient that she needs treatment because she used to be Joan of Arc.  In my opinion, that’s bananas.  I think the violation of confidentiality is (by far) the lesser of the two offenses, if it is even one at all.

I think that by relying solely on ethics, which are often inherently subjective, we’ve created a system where we constantly strive to be the “most ethical,” rather than to provide the most effective treatment.  I don’t think it’s an accident that the most respected members of our professional organizations are often the ones who advise on matters of ethics, as opposed to the people doing really great clinical work (or teaching how to do really great clinical work).  (Please don’t misinterpret this as a disparaging comment against those who advise on matters of ethics.  I believe they are wonderful colleagues.  I just think our focus – as a field – is misplaced.)  If we focused on data-driven science, questions of professional conduct would be answered quite differently.  But given the realities of our profession and the decisions we (collectively) have made, we are where we are.

2.)  The second reason is that many experts don’t understand the difference between “most ethical” (whatever that means) and “standard of care.”  In my opinion, the way ethics should be taught/dispensed is as a barometer for what most people are doing.  So in other words, when you consult on matters of professional conduct your ethics expert should give you advice on the standard of care.  Ethics experts should be really well-connected colleagues who know what most people are actually doing.  For example, if you go to an ethics expert and ask how to handle emails from a patient, the expert should say something like, “here’s what most people are doing……”  Unfortunately, the reality is that when most psychologists go to an “ethics expert” they receive the most conservative advice possible, and that advice is often totally independent of what people are actually doing.  To that extent, it’s very poor advice because it makes people think that practice standards are based on what people should be doing, as opposed to what people are actually doing.

So, to answer the rhetorical question, I think the answer is that for a licensing board complaint in medicine you are much more likely to get an expert that says “providing 911 on an answering machine is a good (or bad) idea because we know that…..”

In contrast, an expert in a psychology licensing board action is more likely to say that “Dr. ____, by not providing a reference to 911 on his/her answering machine, violated the APA Ethics code section __, was acting unethically, and therefore violated the standard of care. The best course of action would have been to………..”

I hope this clears things up.

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