By Anthony Love MAPS
On behalf of the APS Ethics Committee
THE APS Ethics Committee recently considered the broad question of the conduct of psychologists who are demonstrating therapeutic techniques in educational and training contexts, such as university courses. For example, a student with a public speaking anxiety might be asked to volunteer information for a demonstration of systematic desensitisation.
The matter is potentially vexed because standards have changed rapidly in recent years and it is not always clear that psychologists providing such demonstrations are fulfilling their contemporary ethical obligations in regard to conducting live exercises involving volunteer participants.
In its deliberations, the Ethics Committee addressed several problematic aspects of these activities. Aspects that were seen to raise potential for ethical conflict included the difficulties of obtaining truly informed consent from the participants, the potential for invasion of privacy, the role of the audience in the process, and the responsibilities of the demonstrator towards the participants, audience members and the profession.
In this article, we consider those points in detail, address the ethical issues raised and offer some suggestions for current best practice in this area.
Relevant provisions of the Code of Ethics
While the APS Code of Ethics (2002) does address demonstrations specifically (see clause C7), the Committee believes that various provisions of the Code, for reasons that are explained below, provide useful guidance for members. In particular, General Principles I (a) and (b), which broadly refer to members' responsibility for their professional decisions, and General Principle III (c), which relates to refraining from actions that would tend to bring the profession into disrepute, are relevant to this discussion. These General Principles need to be at the forefront of members' deliberations and decision-making on these issues.
It is also important to appreciate that participants in demonstrations are, in many respects, in a similar position to clients or research participants and that some of the specific provisions of the Code should therefore also be taken into account. These include section A, which relates to assessment procedures. Clause A2 sets out the information that must be provided to clients. Section B relates to relationships with clients; clause B1 deals with privacy issues and clause B18 gives guidance in respect of the termination of a relationship.
As these demonstrations take place in the context of teaching, the spirit of Sections C (Teaching of Psychology) and D (Supervision and Training) are important. Clauses C4, 6 and 7 respectively highlight the power differential in teaching situations, the need to make sure that no coercion takes place, and the need to act proactively to preserve the anonymity and privacy of participants by instructing students witnessing case demonstrations that they are also required to observe these ethical obligations. It states, "Members must instruct students witnessing case demonstrations that they are required to preserve the anonymity of the participant and in every way safeguard the participant's privacy." Clause D2 expressly states that self-disclosure cannot be required in the training context and that, where it is a normal expectation of a given training procedure, informed consent must be obtained prior to the training (italics added).
Section E is concerned with research. Clause E1 requires that members planning psychological research must carefully evaluate the ethical issues involved to ensure that the welfare of participants is not compromised." Clause E2 lays out members' responsibility for adhering to guidelines relevant to their settings, such as the National Health and Medical Research Council (NHMRC) Guidelines on Human Experimentation, while clause E3 outlines the need to balance benefits of the study against any discomfort or risks to participants.
The sources of potential conflicts
Obtaining truly informed consent from participants in demonstrations is difficult because, depending on the specifics of the procedure, the outcome of the exercise may be unknown. The predictability of the outcome will vary with the degree to which the participants are preselected for the exercise, the range and depth of questioning that demonstrators engage in, and the level of structure that is built into the demonstration.
In terms of seeking volunteers, the most risky scenario would be if during the session a volunteer was selected from the audience, with no prior screening by the demonstrator and no preparation for the procedure provided to the volunteer. Under these circumstances, the Committee found it difficult to imagine how a psychologist could, under the pressures experienced during the brief time available, adequately assess potential deleterious effects for the person, inform the person of those risks, and obtain informed consent for the procedure.
Risk would be minimised if the volunteer was recruited ahead of the demonstration and interviewed in private, with full disclosure of the process that would be followed and what would be entailed in that process (ideally with illustrations and behavioural rehearsal), and was provided with a summary of the likely risks and benefits that would accrue to participants.
With regard to the potential for invasion of privacy by psychologists undertaking demonstrations, the Committee concluded that risk would most likely be heightened if psychologists allowed themselves broad latitude in asking questions in the course of the exercise. Care has to be exercised to ensure consideration of the likely consequences of the line of interrogation being pursued and to maintain respect for the boundaries between disclosure and privacy that the volunteer had initially established for him or herself.
If psychologists have revealed the types and lines of questions that are in all probability going to be asked, established the boundaries that the volunteer has created, and explicitly outlined the benefits and risks of participation, then chances of an adverse outcome are minimised. A high level of structure in the exercise will also help minimise the possibility of adverse outcomes.
The lower the level of structure, or the more freedom demonstrators have to vary from a prepared script, the more likely unintended outcomes become. Foreseeability of the outcomes becomes the key test here. The higher the chance of unforeseen outcomes occuring, the lower the likelihood of obtaining truly informed consent and the greater the risk of invasion of privacy.
The potential for undue invasion of privacy is minimised when the social processes involved in a live demonstration are fully understood and carefully controlled by the demonstrators, and possible pitfalls of being exposed to such pressures are disclosed to participants. Psychology has a sound knowledge base related to the effects of group process and group dynamics on individual behaviour (e.g., the classic work of Asch on conformity). Members would be advised to familiarise themselves thoroughly with this body of literature before contemplating live demonstrations. Otherwise, they run the risk of violating General Principle II of the APS Code (essentially, "members must refrain from undertaking work beyond their professional competence").
Competent practitioners will recognise that volunteers, who might begin by discussing general issues in a broad way, might be swayed by group pressure and reveal intimate personal information that they originally had no intention of divulging. As a consequence, participants might later experience regret or distress. Audience members, too, risk vicarious identification and sharing of volunteers' distress and their welfare has to be considered. As distress is a potential risk, no matter how carefully the demonstrator controls the process, adequate debriefing and contingency plans for offering ongoing support, ideally would be factored into a proposed demonstration exercise.
The latter point may be easily overlooked but it is important to recognise that the audience is also a key player in this process. Audience members usually represent a cross-section of the professional or student communities. Therefore, there is likely to be a diversity of views as to what is appropriate in such circumstances. Demonstrators can minimise potential conflicts between their planned procedures and audience expectations by engaging the audience members in dialogue around disclosure before starting any demonstrations. This process might include explaining the procedure to be followed, stating the line of questioning that is to be pursued, declaring the participants' informed consent, and inviting the audience to raise any concerns at that point. Audience members would then be involved in assuring the quality of the demonstration, as they would become active participants in the process, rather than passive observers of events outside of their control.
The profession also has a vested interest in the conduct of therapeutic demonstrations, particularly in circumstances where the activity is earning professional development points, such as in APS-endorsed workshops and conferences. Just as any member has ethical responsibilities when conducting demonstrations, it can be argued that the profession would be expected to adhere to best possible standards of practice if it is endorsing activities in this manner.
The standards adopted by other organisations in regard to this matter are revealing. For example, many universities require instructors to apply for approval from its Institutional Human Ethics Committee if they intend to conduct any form of teaching activity that includes human participants. Applications will only be approved if they meet NHMRC guidelines for conducting research with human participants. In other words, participants in teaching demonstrations are accorded the same ethical status as participants in research. If they wished to gain approval, applicants would therefore have to provide the level of care for participants identified in the ideal scenarios outlined in the foregoing discussion.
This is clearly best practice at the organisational level, and currently the APS has no mechanisms for vetting workshop activities in a formal manner. This shortcoming is potentially problematic and the Ethics Committee intends to make recommendations to the Board of Directors that it undertake steps to correct this oversight. Until formal procedures are put in place, the Committee advises members to exercise self-management in this regard and follow the recommendations on page 28 in their own practice.
The Ethics Committee invites comment on this article; please forward responses to InPsych via firstname.lastname@example.org.
Dr Anthony Love is a senior lecturer in the School of Psychological Science, La Trobe University, Bundoora, Victoria.
Australian Psychological Society. (2002). Code of Ethics. Melbourne, Australia.
Recommendations for practice
In summary, recommended best practice guidelines would include: