MODELS FOR MAKING

DECISIONS
Erika L. Liljedahl, Psy.D.
The Chicago School of Professional Psychology

Dr. Erika L. Liljedahl will be presenting four different

ethical decision making models which will assist
mental health professionals in trouble shooting
ethical dilemmas. These models help guide the
thought process when one is faced with an issue
that is not clearcut. The objectives of this talk are to
provide a brief history of ethics, to teach the steps
of the four models, and to help mental health
professionals apply the steps in order to more
competently handle the "gray" areas when making
decisions. Dr. Liljedahl highly recommends using an
ethical decision making model and documenting
the steps in the thinking process. She believes that
this is an essential step in forensic documentation
and litigation prevention.

Students will learn several Ethical Decision

Making Models.
Students will learn how to apply the models
to classes and in their careers with youth
and adults.
Students will become more familiar with
how to handle the gray areas when
making decisions using the Ethical Decision
Making Models presented.

1.
2.
3.
4.

What are ethics? Values and ethics

Brief history of ethics
Who makes unethical decisions?
Presentation of 4 Ethical Decision Making
Models

The World English Dictionary says In

accordance with principles of conduct that are
considered correct, especially those of a given
professional or group
Merriam-Webster says Conforming to
accepted standards of conduct
Knowing the difference between right and
wrong, and choosing the right
Having virtue, good moral reasoning
Having a positive, good value system, which
might include doing good things in the world,
be hard working, be honest, treat others as
you want to be treated, be loyal to your
family.

It is possible that your values will oppose

what the ethics code or law states.
Example: You are attracted to your former
client and the client has verbalized that the
attraction is mutual.

The APA code states you must wait 2 years.

The ACA code states you must wait 5 years.

So do you develop a relationship after 2

years? 5 years? Or is having a sexual
relationship with a former client altogether
against your value system?

Origin of ethics is in Ancient Greece

~460BC
Philosophers such as Socrates, Plato and
Aristotle wished to impart knowledge on
how to argue thoughts and to be
successful, but also developed views on
being ethical and moral.

learned from the Oracle of Delphi to

know thyself. Knowing thyself (and
values) increases knowledge and
wisdom. Wisdom leads to increased
critical reasoning and problem solving
skills.

Knowledge and
wisdom
leads to acting
Ethical.

 Greek

philosophers set the stage for

ethical decision making through
examination of ideas that were
abstract, such as the virtue of
wisdom, critical thinking, Socratic
questioning such as playing Devils
advocate, and even through ethical
dilemmas presented in Greek
tragedy on stage.

So if having knowledge, wisdom and

knowing thyself assist with making
good ethical decisions, then what
kind of a person in todays time
makes unethical decisions?

who obey authority figures unethical

directives or act merely to avoid
punishment,
who manipulate others to orchestrate their
own personal gain,
who fail to see the connection between
their actions and outcomes,
who believe that ethical choices are driven
by circumstance. (Kish-Gephart, J.J., et al. 2010)

 Egotistic

work places are

more likely to promote an
everyone for themselves
environment, which promotes
more unethical behaviors.

In this talk, I will review.

3 clinically-related Ethical Decision
Making Models, and
1 non-clinically related Ethical Decision
Making Model

 Positive

Ethical Models =

The focus is on pursuing highest

ideals
Defensive

Ethical Models =

The focus is on thinking of the

worst scenario, avoiding
punishment

Source: Bush, S.S., Connell, M.A., &

Denney, R.L. (2006). Ethical Practice in
Forensic Psychology: A Systematic Model for
Decision Making. Washington D.C.:
American Psychological Association.

1.
2.
3.
4.
5.
6.
7.
8.

Identify the problem

Consider the significance of the context
and setting
Identify and utilize ethical and legal
resources
Consider personal beliefs and values
Develop possible solutions to the problem
Consider the potential consequences of
various solutions
Choose and implement a course of action
Assess the outcome and implement
changes as needed

Joe is your 16 year old client who came to

therapy because of having low self esteem
and being depressed about his parents
divorce. Both the mother and father are
fighting for custody of Joe. In the course of
therapy, Joe reported that he has begun
having thoughts of self harm.

Let us examine this case using Model #1.

 The

problem:

Suicidal thoughts. Hospitalize or

not.
Confidentiality: Is it your ethical
responsibility to talk to the parents?
Do you have a duty to tell the
parents or because Joe is a minor?
Should you monitor his progress
and not involve the parents at all?

The client is a minor. Do the parents know

about his psychological status? Do the
parents know their son is in therapy? What
would they do if they found out he is seeing
a counselor and is suicidal?
Which parent do you talk to? How do you
determine who has legal guardianship?
What harm could come if you tell the
parents? Or not tell the parents?

Look at your ethics code (APA, ACA, etc)

Look at the law about privacy and duty to
warn

HIPAA on confidentiality
State laws: Illinois Mental Health Confidentiality
Act

Look at journal articles, books, case studies

Review position statements of your
relevant national association
Consult with colleagues

 In

general, ethics codes will have

the following components
Do no harm.
No disclosure without consent (unless
mandated by law).
Limitations to confidentiality include
suicidal or homicidal ideation/intent.
Confidentiality with minors.

Any minor 12 years of age or older may request

and receive counseling services or psychotherapy
on an outpatient basis without the consent of the
minors parent or guardian. Outpatient counseling
or psychotherapy provided to a minor under the
age of 17 shall be limited to not more than 5
sessions, a session lasting not more than 45
minutes, until the consent of the minors parent
or guardian is obtained. The minors parents
shall not be informed without the consent of the
minor unless the facility director believes such
disclosure is necessary.

Permitted Uses and Disclosures: Serious

Threat to Health or Safety.
Covered entities may disclose protected
health information that they believe is
necessary to prevent or lessen a serious and
imminent threat to a person or the public,
when such disclosure is made to someone
they believe can prevent or lessen the threat
(including the target of the threat).

How do you feel about breaking confidentiality

in this case? Is it necessary? You believe that
you might alienate Joe if you broke
confidentiality.
You value life and improving relationships
imminent harm or not, you want to inform
family to intervene. In other words, is your core
value to involve family as much as possible?
You believe that more emotional distress would
enter the equation if the parents would know
that Joe is depressed and suicidal.

Utmost importance: Perform a suicide lethality

assessment.
Inform Joe what your duties are as a therapist
(your ethical duty of preserving life and the
possibility involuntary hospitalization).
Engage Joe in a logical discussion about the
pros and cons of telling his parents.
Joe could invite his parents into the session and
could inform them with the therapist.
If Joe does not want to inform his parents, have
Joe check in with you during the week and call
the suicide hotline for additional support.

During a suicide lethality assessment, you

determine whether Joe is passively or
actively suicidal. Joe could be hospitalized.
After discussing the pros and cons of telling
his parents, he can decide to tell them or
not.
If Joe does not want to inform his parents,
Joe might have less support. His parents
might continue fighting without even
considering Joes psychological status.

If passively suicidal:
Decision: To continue monitoring Joe in therapy
sessions, to have him call suicide hotlines for
support. Encourage Joe to tell his parents, seek
support form trusted friends and family.

If actively suicidal
Decision: Hospitalize. Encourage Joe to tell his
parents, and/or inform Joe hat his parents will
be informed. Seek support from trusted friends
and family.

If not actively suicidal: Is monitoring Joe in

therapy sessions sufficient to ward off
suicidal thoughts? Did he involved family or
friends for support?
Does Joe need a referral for possible
medicine management?
If actively suicidal: How did Joe react to the
hospitalization? How did his parents react?
Is there anything more you need to do as an
ethical mental health professional?

 Source:

Koocher, G.P. & Keith-Spiegel, P.

(2008). Ethics in Psychology and the Mental
Health Professions: Standards and Cases.
Oxford University Press: New York.
Chapter 2: Making Ethical Decisions and Taking
Action, written by Edmund Burke.

1.
2.

3.

4.
5.

6.
7.

8.
9.

Determine whether the matter truly involves ethics.

Consult guidelines already available that might
apply as a possible mechanism for resolution.
Pause to consider, as best as possible, all factors
that might influence the decision you will make.
Consult with a trusted colleague.
Evaluate the rights, responsibilities, and
vulnerability of all affected parties.
Generate alternative decisions.
Enumerate the consequences of making each
decision.
Make the decision.
Implement the decision.

A student told a teacher about another

student threatening her on Facebook and
the school had to decide how to proceed.

Is this an ethical issue for the teacher?

Does this case involve your ethical
standards? (E.g., APA: General Principles of
beneficence and nonmaleficence, fidelity,
responsibility, integrity, justice)
Does the teacher have to do anything at all
since the threat was online?
Is there an ethical duty to protect the
student because he/she is a minor?

What are the schools policies regarding

cyber-bullying?
Is there a decision-tree in place at the
school to deal with cyber-bullying and
harassment?
What does your ethical code state?
Do the parents need to be informed?
What are your values in such a case?

Character education. Every public school

teacher shall teach character education,
which includes the teaching of respect,
responsibility, fairness, caring,
trustworthiness, and citizenship, in order to
raise pupils' honesty, kindness, justice,
discipline, respect for others, and moral
courage for the purpose of lessening crime
and raising the standard of good character.
Sec. 2712.

(1) Safe and responsible use of social

networking websites, chat rooms, electronic
mail, bulletin boards, instant messaging, and
other means of communication on the Internet.
(2) Recognizing, avoiding, and reporting online
solicitations of students, their classmates, and
their friends by sexual predators.
(3) Risks of transmitting personal information
on the Internet.
(4) Recognizing and avoiding unsolicited or
deceptive communications received online.
(5) Recognizing and reporting online
harassment and cyberbullying.

Class B misdemeanor if person is convicted

of harassment (720 ILCS 135/2) (from Ch.
134, par. 16.5, Sec. 2. Sentence.
A second violation constitutes a Class A
misdemeanor (minimum of 14 days in jail,
or maybe 240 hours of community service).
If harassment continues (3+), Class 4
felony. If there is a threat to kill, it is an
automatic Class 4 felony.

What was the threat said on FB? Was it

vague or specific? How many times has this
happened? Is it a one time occurrence or
repeated?
Consider the harassed students safety;
ability to concentrate in school.
Consider if one student is being threatened,
other students could be in the same
situation.
Think the worst scenario could happen.

Read the law and policies appropriate to

this case.
Talk to your immediate supervisor, the
Principal of the school, your colleagues
about the school policies or lack thereof.
Consult with books, journal publications, the
law for cases that are similar.
Possibly involve the police.

Children have the right to be safe and learn

in a safe environment.
The harassing child has the right to be
heard which may lead to be tried in a court
of law.
Teachers have the right to teach in a safe
environment. They also have the right to
provide a character education component
into their curriculum.

 Some

solutions:

Ask for the student to print the FB page

Someone (teacher, counselor, Principal,
Superintendent) would talk to each child
separately
Talk to both children together
Involve the parents
Involve the police

Ask for the student to print the FB page

Decide if there is harassment.
If harassment exists: then go to the next step.
If harassment does not exist: If the wording
was misconstrued by the student, then
provide education on what constitutes
harassment. You might want to decide on
what caused the misinterpretation. Does the
student have a learning disability? Is the
student overly suspicious of people? Did
someone else influence the student?

Someone (teacher, counselor, Principal,

Superintendent) would talk to each child
separately
Each child could tell his/her story without
hesitation. This confidentiality would likely allow
each student to speak in an uninhibited manner.
Talking to the harassed student separately would
likely shield the student from some additional
unnecessary grief. Showing the grief in front of
the harasser might reinforce the harassing. The
harassing could become more covert.
There might be something going on in the
harassers life that would be useful information to
the behaviors.

Talk to both children together

Conduct a conflict resolution session without
involving the police or higher authority, such as
the Superintendent.

Involve the parents

Appraise the parents about the situation and
involve them in the conflict resolution.

Involve the police

Pros: A juvenile record is created for the student
harasser in case that the harassing will be
ongoing. This record will likely lead to
psychological intervention of forensic
psychologists, to assist the juvenile to rehabilitate
his or her behaviors.
Cons: There is a record that will follow the
juvenile, even if he or she rehabilitates, however
note that this record is sealed and can only be
accessed by some law enforcement.

What would you do?

Source: Anderson, Gail (1997). Women &

Therapy. Introduction: Children,
Adolescents and Their Powerholders in
Therapy Settings, 20, 2, 1-6.

1.
2.
3.
4.
5.
6.

7.

Recognizing a problem
Defining the problem
Developing solutions
Choosing a solution
Reviewing process
Implementing and evaluating a
decision
Continuing reflection

A 12 year old girl is forced to go into

therapy because of acting out at school.
During the first session with the adolescent,
the therapist finds out that the girl is
actively abusing marijuana and possibly
ecstasy with her friends. The parents do
not know this information.

What do you do? Do you tell the parents?

(1) Recognizing a problem and (2) Defining the

problem: You are uncertain what to do. What
are your values that interfere with a decision?
If you tell the parents, you run the risk of alienating the
girl. If you do this, more harm can come.
If you do not tell the parents, they will not be able to
intervene and get the girl treatment. They can sue you
since the girl is still a minor. You also run the risk of the
girl getting arrested, creating brain damage, and the
worst is overdosing and causing death.

You tell the parents

You tell them to assist with maintaining their
daughters safety.

You do not tell the parents

As cited in this article, Snyder believes children
are of worth and full citizens that share the basic
rights to life, safety, happiness, equality of
treatment, equality of opportunity, reasonable
self-determination and due process. This is from
a feministic approach: egalitarian.
The law is behind this decision: Illinois law allows
12 year old to hold some power for maintaining
confidentiality.

What is the best fit both emotionally and

rationally? Does the solution meet
everyones needs, including mine? Can I
implement and live with the effects?
(Anderson, 1997, p.4)

If you do not tell the parents you should

be aware of the law:

(3) the parent or guardian of a recipient who is

at least 12 but under 18 years, if the recipient
is informed and does not object or if the
therapist does not find that there are
compelling reasons for denying the access. The
parent or guardian who is denied access by
either the recipient or the therapist may
petition a court for access to the record.
Nothing in this paragraph is intended to prohibit
the parent or guardian of a recipient who is at
least 12 but under 18 years from requesting
and receiving the following information: current
physical and mental condition, diagnosis,
treatment needs, services provided, and
services needed, including medication, if any.

Would I want to be treated in this way?

Does the decision feel right?
Would this decision withstand the scrutiny
of others?
How are my values, personal characteristics
influencing my choice?
Have I taken the clients perspective into
account?

These questions are from the article.

Carry out the decision

Is this solution the best I can do?
Observe consequences
Reassess the decision
How has this decision affected the
therapeutic process?

These questions are from the article.

What did I learn?

Have I changed as a result of this process?
How?
What would I do differently?
How might this experience affect me in the
future?

These questions are from the article.

 Model:

Ethical Decision
Making Plan

Source: United States Department of

Defense

1.

2.

3.
4.

Define the problem (state the problem in

general terms and decisions to be made)
Identify the goals (short and long term
goals)
List the appropriate laws or regulations
List the ethical values at stake

5.

6.

7.

Name all the stakeholders (identify

persons who are likely to be affected by
a decision and what is at stake for each
person)
Gather additional information (take time,
ask questions, demand proof when
appropriate, check your assumptions)
State all feasible solutions (list solutions
that have already surfaced, produce
additional solutions by brain storming
with associates, note how stakeholders
can be affected by each solution)

8.

9.

10.

Eliminate unethical options (eliminate

solutions clearly unethical, eliminate
solutions with short-term advantages but
long-term problems)
Rank the remaining options according to
how close they bring you to your goal,
and solve the problem
Commit to and implement the best
ethical solution

According to Martin and Bush (2008), Knapp

and VandeCreek identified 5 common steps
after reviewing several Ethical Decision
Making Models:
1.
2.
3.
4.
5.

Identification of the problem

Development of alternatives
Evaluation of alternatives
Implementation of the best option
Evaluation of the results

Anderson, Gail (1997). Women & Therapy. Introduction: Children,

Adolescents and Their Powerholders in Therapy Settings, 20, 2, 1-6.
Bersoff, D.N. (2008). Ethical Conflicts in Psychology, Fourth Edition.
American Psychological Association: Washington D.C.
Bush, S.S., Connell, M.A., & Denney, R.L. (2006). Ethical Issues in
Forensic Psychology: A Systematic Model for Decision Making.
Washington D.C.: American Psychological Association
Kish-Gephart, J.J., Harrison, D.A. & Trevino, L.K. (2010). Journal of
Applied Psychology. Bad Apples, Base Cases, and Bad Barrels: MetaAnalytic Evidence About Sources of Unethical Decisions at Work, 95, 1,
1-31.
Koocher, G.P. & Keith-Spiegel, P. (2008). Ethics in Psychology and the
Mental Health Professions: Standards and Cases. Oxford University
Press: New York. (Chapter 2: Making Ethical Decisions and Taking
Action, written by Edmund Burke, pages 20-40).
Martin, T.A. & Bush, S.S. (2008). NeuroRehabilitation. Ethical
considerations in geriatric neuropsychology, 23, 447-454.

HIPAA: U.S. Department of Health & Human Services:

http://www.hhs.gov/ocr/privacy/
Illinois General Assembly: School Code:
http://www.ilga.gov/legislation/ilcs/ilcs4.asp?DocName=010500050HArt
%2E+27&ActID=1005&ChapterID=17&SeqStart=149700000&SeqEnd=156200000
Mental Health and Developmental Disabilities Code:
http://www.ilga.gov/legislation/ilcs/ilcs5.asp?ActID=1496&ChapAct=405%26nbsp
%3BILCS%26nbsp
%3B5%2F&ChapterID=34&ChapterName=MENTAL+HEALTH&ActName=Mental+
Health+and+Developmental+Disabilities+Code%2E
National Conference of State Legislatures on Cyber-harassment (720 ILCS
135/12): http://www.ilga.gov/legislation/ilcs/documents/072001350k1-2.htm
State laws: Illinois Mental Health Confidentiality Act:
http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=2043&ChapterID=57
United States Department of Defense: Ethical Decision Making Plan:
http://www.ryerson.ca/ethicsnetwork/downloads/model_I.pdf
U.S. Department of Health & Human Services on HIPAA:
http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html

Know your Ethics Code

Know what the law requires of therapists
Take the higher road
Do what minimizes harm to clients and
others, and to your person ethical values
Think clearly
Document your thinking process and use of
an Ethical Decision Making Model
If there are any questions, consult consult
consult!