ETHICS COMMITTEE PANEL Understanding Gray Areas of Ethics in Art Therapy Supervision Elizabeth...

ETHICS COMMITTEE PANELETHICS COMMITTEE PANEL

Understanding Gray Areas of Understanding Gray Areas of Ethics in Art Therapy Ethics in Art Therapy

SupervisionSupervision

Elizabeth Stone, ATR, LP, LCATElizabeth Stone, ATR, LP, LCATEthics Committee ChairEthics Committee Chair

November 20, 2009, 40th Annual AATA Conference,November 20, 2009, 40th Annual AATA Conference, Dallas TX Dallas TX

Are art therapists required by Are art therapists required by the American Art Therapy the American Art Therapy

Association to seek signed Association to seek signed informed consent for informed consent for

supervision?supervision?This presentation shall discuss what This presentation shall discuss what is currently required in our ethical is currently required in our ethical

code,code,““The Ethical Principles for Art The Ethical Principles for Art Therapists,” and compare The Therapists,” and compare The

American Art Therapy Association’s American Art Therapy Association’s requirements to those of six of our requirements to those of six of our sister mental health professions.sister mental health professions.

Is the wording of our own code regarding Is the wording of our own code regarding supervision sufficiently comprehensive supervision sufficiently comprehensive yet versatile enough to fit our yet versatile enough to fit our professional needs as art therapists?professional needs as art therapists?

As we review the ethical codes to follow, As we review the ethical codes to follow, let us proceed with a spirit of open-let us proceed with a spirit of open-mindedness in terms of what we can learn mindedness in terms of what we can learn from the way our sister associations from the way our sister associations address the issue… address the issue…

To understand current requirements in To understand current requirements in “The Ethical Principles for Art “The Ethical Principles for Art

Therapists,” Therapists,” the following three ethical the following three ethical

principles have to be taken together principles have to be taken together and then applied and then applied

to supervision…to supervision…

The Ethical Code of The Ethical Code of The American Art Therapy The American Art Therapy

Association (AATA): Association (AATA):

«« THE THE ETHICAL PRINCIPLES ETHICAL PRINCIPLES FOR ARTFOR ART THERAPISTS » THERAPISTS »

1.2 1.2 At the outsetAt the outset of the client- of the client-therapist relationship, art therapist relationship, art therapists discuss and explain therapists discuss and explain client rights, roles of both client client rights, roles of both client and therapist, and expectations and and therapist, and expectations and limitations of the art therapy limitations of the art therapy process.process.

« ETHICAL PRINCIPLES « ETHICAL PRINCIPLES FOR FOR ART THERAPISTS »ART THERAPISTS »

2.3 Art therapists 2.3 Art therapists do not disclose do not disclose confidential information for the confidential information for the purposes of consultation and purposes of consultation and supervision without client’s explicit supervision without client’s explicit consentconsent unless there is reason to unless there is reason to believe that the client or others are believe that the client or others are in immediate, severe danger to health in immediate, severe danger to health or life. Any such disclosure must be or life. Any such disclosure must be consistent with laws that pertain to consistent with laws that pertain to the welfare of the client, family, and the welfare of the client, family, and the general public.the general public.

« ETHICAL PRINCIPLES FOR « ETHICAL PRINCIPLES FOR ART THERAPISTS »ART THERAPISTS »

2.4 In the event that an art therapist 2.4 In the event that an art therapist believes it is in the interest of the believes it is in the interest of the client to disclose confidential client to disclose confidential information, he/she information, he/she seeks and obtains seeks and obtains written consentwritten consent from the client or from the client or client’s guardian(s) when possible client’s guardian(s) when possible before making any disclosures, unless before making any disclosures, unless there is reason to believe that the there is reason to believe that the client or others are in immediate, client or others are in immediate, severe danger to health or life.severe danger to health or life.

Now, let’s take a look at Now, let’s take a look at some of some of our sister our sister codes…codes…

The Art Therapy The Art Therapy Credentials Board (ATCB)Credentials Board (ATCB)

1 GENERAL ETHICAL PRINCIPLES1 GENERAL ETHICAL PRINCIPLES 1.1.1 Standards. Responsibility 1.1.1 Standards. Responsibility To ClientsTo Clients

1.1.1.3 At the outset of the 1.1.1.3 At the outset of the client-therapist relationship, client-therapist relationship, art therapists should discuss and art therapists should discuss and explain to clients the rights, explain to clients the rights, roles, expectations, and roles, expectations, and limitations of the art therapy limitations of the art therapy process.process.


4.1.1 Confidentiality4.1.1 Confidentiality 4.1.1.1 4.1.1.1 Art therapists shall respect Art therapists shall respect and protect confidential information and protect confidential information obtained from clients including, but obtained from clients including, but not limited to, all verbal and/or not limited to, all verbal and/or artistic expression occurring within artistic expression occurring within a client-therapist relationship.a client-therapist relationship.

4.1.1.2 Art therapists shall protect 4.1.1.2 Art therapists shall protect the confidentiality of the client-the confidentiality of the client-therapist relationship in all therapist relationship in all matters.matters.


4.1.1.3 4.1.1.3 Art therapists shall not Art therapists shall not disclose confidential information disclose confidential information without the client’s explicit written without the client’s explicit written consent unless there is reason to consent unless there is reason to believe that the client or others are believe that the client or others are in immediate, severe danger to health in immediate, severe danger to health or life. Any such disclosure shall be or life. Any such disclosure shall be made consistent withmade consistent with

state and federal laws that pertain to state and federal laws that pertain to welfare of the client, family, and the welfare of the client, family, and the general public.general public.


4.1.1.4 4.1.1.4 In the event that an art In the event that an art therapist believes it is in the therapist believes it is in the interest of the client to disclose interest of the client to disclose confidential information, he or confidential information, he or she shall she shall seek and obtain written seek and obtain written authorization from the client or authorization from the client or the client’s legal guardian, the client’s legal guardian, before making any disclosures,before making any disclosures, unless such disclosure is required unless such disclosure is required by law.by law.

American Dance Therapy American Dance Therapy Association (ADTA)Association (ADTA)

PRINCIPLE 2: THERAPEUTIC RESPONSBILITIES. PRINCIPLE 2: THERAPEUTIC RESPONSBILITIES. A dance/movement therapist establishes a A dance/movement therapist establishes a therapeutic alliance with the client, which therapeutic alliance with the client, which includes the following:includes the following:F. Collaboration with other professionals when F. Collaboration with other professionals when appropriate.appropriate.

PRINCIPLE 6: LEGAL AND PERSONAL RIGHTS. PRINCIPLE 6: LEGAL AND PERSONAL RIGHTS. A dance/movement therapist protects and A dance/movement therapist protects and respects clients' rights.respects clients' rights.B. Engages in discussion of clients for B. Engages in discussion of clients for professional purposes only, and avoids professional purposes only, and avoids revealing the identity of client except when revealing the identity of client except when essential.essential.

American Psychological American Psychological Association (APA)Association (APA)

10.01 Informed Consent to Therapy 10.01 Informed Consent to Therapy (a) (a) When obtaining informed consent to When obtaining informed consent to therapy as required in Standard therapy as required in Standard 3.10, Informed Consent, psychologists , psychologists inform clients/patients inform clients/patients as early as is as early as is feasiblefeasible in the therapeutic relationship in the therapeutic relationship about the about the nature and anticipated course nature and anticipated course of therapy,of therapy, fees, fees, involvement of third involvement of third partiesparties, and , and limits of confidentialitylimits of confidentiality and provide sufficient opportunity for and provide sufficient opportunity for the client/patient to ask questions and the client/patient to ask questions and receive answers.receive answers.

http://www.apa.org/ethics/code2002.html#3_10

http://www.apa.org/ethics/code2002.html#6_04


3.10 Informed Consent3.10 Informed Consent(a) When (a) When psychologists conduct research or psychologists conduct research or provide assessment, therapy, provide assessment, therapy, counseling, or counseling, or consulting services in consulting services in personperson or via electronic transmission or via electronic transmission or other forms of communication, or other forms of communication, they they obtain the informed consent of the obtain the informed consent of the individual or individuals using individual or individuals using language that is reasonably language that is reasonably understandable to that person or understandable to that person or persons except when conducting such persons except when conducting such activities without consent is mandated activities without consent is mandated by lawby law or governmental regulation or as or governmental regulation or as otherwise provided in this Ethics Code.otherwise provided in this Ethics Code.


3.10 Informed Consent3.10 Informed Consent(d) (d) Psychologists appropriately Psychologists appropriately document written or oral consent, document written or oral consent, permission, and assent.permission, and assent.


4.06 Consultations4.06 Consultations

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

American Counseling American Counseling Association (ACA)Association (ACA)

A.2. Informed Consent in the Counseling A.2. Informed Consent in the Counseling RelationshipRelationship

A.2.a Informed ConsentA.2.a Informed ConsentClients have the freedom to choose whether to Clients have the freedom to choose whether to enter into or remain in a counseling enter into or remain in a counseling relationship and need adequate information relationship and need adequate information about the counseling process and the counselor.about the counseling process and the counselor.Counselors have an obligation to review Counselors have an obligation to review in in writing and verballywriting and verbally with clients the rights with clients the rights and responsibilities of both the counselor and and responsibilities of both the counselor and the client. the client. Informed consent is an ongoing part Informed consent is an ongoing part of the counseling process, and counselors of the counseling process, and counselors appropriately document discussions of informed appropriately document discussions of informed consent throughout the counseling relationship.consent throughout the counseling relationship.

American Counseling American Counseling Association (ACA)Association (ACA)

F.4. Supervisor Responsibilities.4. Supervisor Responsibilities F.4.a. Informed Consent for SupervisionF.4.a. Informed Consent for Supervision Supervisors are responsibleSupervisors are responsible for for incorporating into their supervision incorporating into their supervision the principles of informed consent and the principles of informed consent and participation. participation. Supervisors inform Supervisors inform superviseessupervisees of the policies and of the policies and procedures to which they are to adhere procedures to which they are to adhere and the mechanisms for due process and the mechanisms for due process appeal of individual supervisory appeal of individual supervisory actions.actions.

National Association of National Association of Social Social WorkersWorkers

1.03 Informed Consent1.03 Informed Consent(a) Social workers should (a) Social workers should provide services to clients only in the context of a provide services to clients only in the context of a professional relationship based, when appropriate, on professional relationship based, when appropriate, on valid informed consent. Social workers should use valid informed consent. Social workers should use clear and understandable language to inform clients clear and understandable language to inform clients of the purpose of the services, risks related to the of the purpose of the services, risks related to the services, limits to services because of the services, limits to services because of the requirements of a third-party payer, relevant costs, requirements of a third-party payer, relevant costs, reasonable alternatives, clients’ right to refuse or reasonable alternatives, clients’ right to refuse or withdraw consent, and the time frame covered by the withdraw consent, and the time frame covered by the consent. Social workers should provide clients with consent. Social workers should provide clients with an opportunity to ask questions.an opportunity to ask questions.

National Association of National Association of Social Social WorkersWorkers

2.05 Consultation2.05 Consultation (a) Social workers should seek the advice and (a) Social workers should seek the advice and

counsel of colleagues whenever such consultation is counsel of colleagues whenever such consultation is in the best interests of clients.in the best interests of clients.

(b) Social workers should keep themselves informed (b) Social workers should keep themselves informed about colleaguesabout colleagues’’ areas of expertise and areas of expertise and competencies. Social workers should seek competencies. Social workers should seek consultation only from colleagues who have consultation only from colleagues who have demonstrated knowledge, expertise, and competence demonstrated knowledge, expertise, and competence related to the subject of the consultation.related to the subject of the consultation.

(c) When consulting with colleagues about clients, (c) When consulting with colleagues about clients, social workers should disclose the least amount of social workers should disclose the least amount of information necessary to achieve the purposes of the information necessary to achieve the purposes of the consultation.consultation.

Marriage and Family Marriage and Family Therapy (MFT)Therapy (MFT)

1.2 Marriage and family therapists 1.2 Marriage and family therapists obtain appropriate informed consent to obtain appropriate informed consent to therapy or related procedures as early therapy or related procedures as early as feasible in the therapeutic as feasible in the therapeutic relationshiprelationship, and use language that is , and use language that is reasonably understandable to clients. reasonably understandable to clients. The content of informed consent may vary The content of informed consent may vary depending upon the client and treatment depending upon the client and treatment planplan; however, informed consent ; however, informed consent generally necessitates that the client: generally necessitates that the client: (a) has the capacity to consent; (b) has (a) has the capacity to consent; (b) has been adequately informed of significant been adequately informed of significant information concerning treatment information concerning treatment processes and procedures.processes and procedures.

American Psychoanalytic American Psychoanalytic Association (APSAA)Association (APSAA)

Guiding General Principles:Guiding General Principles:

III. Mutuality and Informed Consent. III. Mutuality and Informed Consent. The treatment relationship between The treatment relationship between the patient and the psychoanalyst is the patient and the psychoanalyst is founded founded upon trust and informed mutual agreement or upon trust and informed mutual agreement or consent. At the outset of treatment, the consent. At the outset of treatment, the patient should be made aware of the nature patient should be made aware of the nature of psychoanalysisof psychoanalysis and relevant alternative and relevant alternative therapies. The psychoanalyst shouldtherapies. The psychoanalyst should make make agreements agreements pertaining topertaining to scheduling, fees, scheduling, fees, andand other rules and obligations of treatment other rules and obligations of treatment tactfully and humanely, with adequate regard tactfully and humanely, with adequate regard for the realistic and therapeutic aspects of for the realistic and therapeutic aspects of the relationshipthe relationship. Promises made should be . Promises made should be honored.honored.


IV. Confidentiality. Confidentiality IV. Confidentiality. Confidentiality of the patient’s communications is of the patient’s communications is a basic patient right and an a basic patient right and an essential condition for effective essential condition for effective psychoanalytic treatment and psychoanalytic treatment and research. research. A psychoanalyst must take A psychoanalyst must take all measures necessary to not all measures necessary to not reveal present or former patient reveal present or former patient confidences without permission, nor confidences without permission, nor discuss the particularities discuss the particularities observed or inferred about patients observed or inferred about patients outside consultative, educational outside consultative, educational or scientific contexts.or scientific contexts.


If a psychoanalyst uses case material If a psychoanalyst uses case material in exchanges with colleagues for in exchanges with colleagues for consultative, educational or consultative, educational or scientific purposes, the identity of scientific purposes, the identity of the patient must be sufficiently the patient must be sufficiently disguised to prevent identification disguised to prevent identification of the individual, or the patient's of the individual, or the patient's authorization must be obtained after authorization must be obtained after frank discussion of the purpose(s) of frank discussion of the purpose(s) of the presentation, other options, the the presentation, other options, the probable risks and benefits to the probable risks and benefits to the patient, and the patient's right to patient, and the patient's right to refuse or withdraw consent.refuse or withdraw consent.


Standards Applicable to the Principles of Ethics Standards Applicable to the Principles of Ethics for Psychoanalystsfor Psychoanalysts

IV. ConfidentialityIV. Confidentiality

*5. It is not a violation of confidentiality for *5. It is not a violation of confidentiality for a psychoanalyst to disclose confidential a psychoanalyst to disclose confidential information about a patient information about a patient in a formal in a formal consultation or supervision in which the consultation or supervision in which the consultant or supervisor is also bound by the consultant or supervisor is also bound by the confidentiality requirements of these confidentiality requirements of these Principles.Principles. On seeking consultation, the On seeking consultation, the psychoanalyst should first ascertain that the psychoanalyst should first ascertain that the consultant or supervisor is aware of and accepts consultant or supervisor is aware of and accepts the requirements of the Confidentiality the requirements of the Confidentiality standard.standard.


7. Supervisors, peer consultants and 7. Supervisors, peer consultants and participants in clinical and participants in clinical and educational exchanges have an educational exchanges have an ethical duty to maintain the ethical duty to maintain the confidentiality of patient confidentiality of patient information conveyed for purposes of information conveyed for purposes of consultative or case presentations consultative or case presentations or scientific discussions.or scientific discussions.

The variation we have seen among these The variation we have seen among these codes in conceiving of and implementing codes in conceiving of and implementing

the concept of “informed consent” the concept of “informed consent” reflects some differences in linguistic reflects some differences in linguistic

formulation within these sister formulation within these sister associations but also probably some associations but also probably some philosophical differences as well.philosophical differences as well.

Art therapists have historically integrated Art therapists have historically integrated philosophical approaches of different philosophical approaches of different stripes that taken together have become stripes that taken together have become the great admixture defining our field.the great admixture defining our field.

Today, not only do art therapists adhere Today, not only do art therapists adhere philosophically to other codes, but are philosophically to other codes, but are also often dually credentialed by other also often dually credentialed by other

associations. associations.

Credentialed art therapists endorse Credentialed art therapists endorse and adhere to the ethical code of and adhere to the ethical code of the ATCB, as well as any other the ATCB, as well as any other professional mental health professional mental health association to which we hold association to which we hold

membership.membership.

Sometimes a discrepancy can exist Sometimes a discrepancy can exist between the codes of the between the codes of the

associations to which we adhere as associations to which we adhere as members. In such case, the stronger members. In such case, the stronger

principle holds sway over the principle holds sway over the weaker one.weaker one.

What have we learned?What have we learned?In general, ethical requirements vary In general, ethical requirements vary considerably among our sister associations when considerably among our sister associations when it comes to informed consent for supervision and it comes to informed consent for supervision and consultation. consultation.

• • Not all of our sister associations require Not all of our sister associations require signedsigned informed consent for supervision.informed consent for supervision.

• • Only The American Art Therapy Association and Only The American Art Therapy Association and the American Counseling Association do require the American Counseling Association do require signed informed consent for supervision.signed informed consent for supervision.

• • The American Psychological Association requires The American Psychological Association requires instead that informed consent, whether written or instead that informed consent, whether written or oral, be documented by the therapist. oral, be documented by the therapist.

• • Some associations, such as the American Some associations, such as the American Psychoanalytic Association, do not consider Psychoanalytic Association, do not consider supervision to be extrinsic to the therapeutic supervision to be extrinsic to the therapeutic process and therefore do not address supervision process and therefore do not address supervision in terms of signed informed consent. in terms of signed informed consent.

No matter what personal and No matter what personal and professional beliefs we may hold professional beliefs we may hold regarding supervision and signed regarding supervision and signed

informed consent, we all must abide informed consent, we all must abide by “The Ethical Principles for Art by “The Ethical Principles for Art Therapists.” This is a given of our Therapists.” This is a given of our

profession.profession.

We must also abide by the mental We must also abide by the mental health rules and regulations health rules and regulations

governing our individual states as governing our individual states as well as the federal rules well as the federal rules

stipulated by HIPAA.stipulated by HIPAA.

That said, we are free to review That said, we are free to review our ethical statues and ask our ethical statues and ask

ourselves whether they adequately ourselves whether they adequately address both the ethical and address both the ethical and clinical concerns we have in clinical concerns we have in regard to supervision and art regard to supervision and art

therapy.therapy.

Some Further QuestionsSome Further Questions

••Are supervision and consultation Are supervision and consultation really one and the same and thus ought really one and the same and thus ought be considered interchangeable be considered interchangeable linguistically within our ethical code?linguistically within our ethical code?

••Or should they be considered Or should they be considered categorically different, thus requiring categorically different, thus requiring that somewhat different ethical that somewhat different ethical principles be applied to each?principles be applied to each?

Clinical QuestionsClinical Questions

• • Can variations in the clinical setting make Can variations in the clinical setting make the issue of the informed form easier with the issue of the informed form easier with some clients, but more difficult with others?some clients, but more difficult with others?

• • Should this issue be addressed more clearly Should this issue be addressed more clearly in our code? in our code?

• • Are we fully aware as to how our clients Are we fully aware as to how our clients view their art therapist being in view their art therapist being in supervision? Do all clients see their art supervision? Do all clients see their art therapist being in supervision as a purely therapist being in supervision as a purely neutral subject? neutral subject?

• • Should our code address this question so as Should our code address this question so as to accommodate clinical implications of to accommodate clinical implications of informed consent? informed consent?

Do you believe that seeking Do you believe that seeking supervision when one feels the need supervision when one feels the need for it is the not only the right of for it is the not only the right of every art therapist, but the ethical every art therapist, but the ethical

obligation as well?obligation as well?

Do you feel that Do you feel that not not seeking seeking supervision when one needs it can supervision when one needs it can constitute an ethical violation?constitute an ethical violation?

How can we bridge the gap between How can we bridge the gap between the freedom for every art the freedom for every art

therapist to seek supervision therapist to seek supervision whenever he or she needs it and whenever he or she needs it and

the increasingly pressing the increasingly pressing obligation to do so only once obligation to do so only once client/patient consent has been client/patient consent has been

established?established?

The American Art Therapy Ethics The American Art Therapy Ethics Committee is interested in your Committee is interested in your thoughts about art therapy and thoughts about art therapy and

supervision.supervision.• • How do you practice?How do you practice?

• • Are you using informed consent for supervision? Are you using informed consent for supervision?

• • If so, is it in written form? If so, is it in written form?

• • If you do not use informed consent, why not?If you do not use informed consent, why not?

• • Are clinical issues, related to constructing a Are clinical issues, related to constructing a therapeutic alliance or transference, getting in therapeutic alliance or transference, getting in the way of your feeling comfortable using the the way of your feeling comfortable using the signed informed consent?signed informed consent?

• • What are the therapeutic implications in your What are the therapeutic implications in your mind, both pro and con, in the use of signed mind, both pro and con, in the use of signed informed consent?informed consent?

Let’s begin a membership Let’s begin a membership dialogue to clarify both dialogue to clarify both the clinical and ethical the clinical and ethical

aspects of these questions!aspects of these questions!

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