MODELS FOR MAKING DECISIONS
Erika L. Liljedahl, Psy.D.
The Chicago School of Professional Psychology
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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.
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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.
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What are ethics? Values and ethics
Brief history of ethics
Who makes unethical decisions?
Presentation of 4 Ethical Decision Making
Models
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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.
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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.
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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?
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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.
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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.
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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 Devil’s 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 today’s time makes
unethical decisions?
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“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….
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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
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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.
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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
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Joe is your 16 year old client who came to
therapy because of having low self esteem
and being depressed about his parent’s
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.
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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?
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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?
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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
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Look at journal articles, books, case studies
Review ‘position statements’ of your relevant
national association
Consult with colleagues
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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.
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“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
minor’s 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 minor’s parent or
guardian is obtained. The minor’s 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).”
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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.
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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.
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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
Joe’s psychological status.
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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.
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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.
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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?
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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.
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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.
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A student told a teacher about another
student threatening her on Facebook and the
school had to decide how to proceed.
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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?
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What are the school’s 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?
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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. 27-12.
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(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 cyber-bullying.
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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.
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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 student’s 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.
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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.
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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.
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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
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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?
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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
harasser’s life that would be useful information to
the behaviors.
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Talk to both children together
◦ Conduct a conflict resolution session without
involving the police or higher authority, such as the
Superintendent.
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Involve the parents
◦ Appraise the parents about the situation and
involve them in the conflict resolution.
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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.
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What would you do?
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Source: Anderson, Gail (1997). Women &
Therapy. Introduction: Children,
Adolescents and Their Powerholders in
Therapy Settings, 20, 2, 1-6.
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Recognizing a problem
Defining the problem
Developing solutions
Choosing a solution
Reviewing process
Implementing and evaluating a
decision
Continuing reflection
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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.
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You tell the parents
◦ You tell them to assist with maintaining their
daughter’s safety.
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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 selfdetermination 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.
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“What is the best fit both emotionally and
rationally? Does the solution meet everyone’s
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:
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(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.
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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 client’s perspective into
account?
These questions are from the article.
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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.
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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:
Plan
Ethical Decision Making
Source: United States Department of Defense
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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
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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)
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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
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According to Martin and Bush (2008), Knapp
and VandeCreek identified 5 common steps
after reviewing several Ethical Decision
Making Models:
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Identification of the problem
Development of alternatives
Evaluation of alternatives
Implementation of the best option
Evaluation of the results
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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.
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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&A
ctID=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&A
ctName=Mental+Health+and+Developmental+Disabilities+Code%2E
National Conference of State Legislatures on Cyber-harassment (720 ILCS
135/1-2): 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
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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!