ETHICS COMMITTEE PANEL Understanding Gray Areas of Ethics in Art Therapy Supervision Elizabeth Stone, ATR, LP, LCAT Ethics Committee Chair November 20, 2009, 40th Annual AATA Conference, Dallas TX

Are art therapists required by the American Art Therapy Association to seek signed informed consent for supervision? This presentation shall discuss what is currently required in our ethical code, “The Ethical Principles for Art Therapists,” and compare The American Art Therapy Association’s requirements to those of six of our sister mental health professions.

Is the wording of our own code regarding supervision sufficiently comprehensive yet versatile enough to fit our professional needs as art therapists? As we review the ethical codes to follow, let us proceed with a spirit of open-mindedness in terms of what we can learn from the way our sister associations address the issue…

To understand current requirements in “The Ethical Principles for Art Therapists,” the following three ethical principles have to be taken together and then applied to supervision…

The Ethical Code of The American Art Therapy Association (AATA): « THE ETHICAL PRINCIPLES FOR ART THERAPISTS » « THE ETHICAL PRINCIPLES FOR ART THERAPISTS » 1.2 At the outset of the client-therapist relationship, art therapists discuss and explain client rights, roles of both client and therapist, and expectations and limitations of the art therapy process.

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

« ETHICAL PRINCIPLES FOR ART THERAPISTS »

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

The Art Therapy Credentials Board (ATCB) 1 GENERAL ETHICAL PRINCIPLES Standards. Responsibility To Clients Standards. Responsibility To Clients At the outset of the client- therapist relationship, art therapists should discuss and explain to clients the rights, roles, expectations, and limitations of the art therapy process At the outset of the client- therapist relationship, art therapists should discuss and explain to clients the rights, roles, expectations, and limitations of the art therapy process.

The Art Therapy Credentials Board (ATCB) Confidentiality Confidentiality Art therapists shall respect and protect confidential information obtained from clients including, but not limited to, all verbal and/or artistic expression occurring within a client-therapist relationship Art therapists shall respect and protect confidential information obtained from clients including, but not limited to, all verbal and/or artistic expression occurring within a client-therapist relationship Art therapists shall protect the confidentiality of the client-therapist relationship in all matters Art therapists shall protect the confidentiality of the client-therapist relationship in all matters.

The Art Therapy Credentials Board (ATCB) Art therapists shall not disclose confidential information without the client’s explicit written consent unless there is reason to believe that the client or others are in immediate, severe danger to health or life. Any such disclosure shall be made consistent with Art therapists shall not disclose confidential information without the client’s explicit written consent unless there is reason to believe that the client or others are in immediate, severe danger to health or life. Any such disclosure shall be made consistent with state and federal laws that pertain to welfare of the client, family, and the general public. state and federal laws that pertain to welfare of the client, family, and the general public.

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

American Dance Therapy Association (ADTA) PRINCIPLE 2: THERAPEUTIC RESPONSBILITIES. PRINCIPLE 2: THERAPEUTIC RESPONSBILITIES. A dance/movement therapist establishes a therapeutic alliance with the client, which includes the following: F. Collaboration with other professionals when appropriate. PRINCIPLE 6: LEGAL AND PERSONAL RIGHTS. PRINCIPLE 6: LEGAL AND PERSONAL RIGHTS. A dance/movement therapist protects and respects clients' rights. B. Engages in discussion of clients for professional purposes only, and avoids revealing the identity of client except when essential.

American Psychological Association (APA) Informed Consent to Therapy (a) When obtaining informed consent to therapy as required in Standard 3.10, Informed Consent, psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers Informed Consent to Therapy (a) When obtaining informed consent to therapy as required in Standard 3.10, Informed Consent, psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers.3.10, Informed Consent3.10, Informed Consent

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

American Psychological Association (APA) 3.10 Informed Consent 3.10 Informed Consent (d) Psychologists appropriately document written or oral consent, permission, and assent.

American Psychological Association (APA) 4.06 Consultations 4.06 Consultations When consulting with colleagues, (1) psychologists do not disclose confidential information that reasonably could lead to the identification of a client/patient, research participant, or other person or organization with whom they have a confidential relationship unless they have obtained the prior consent of the person or organization or the disclosure cannot be avoided, and (2) they disclose information only to the extent necessary to achieve the purposes of the consultation. When consulting with colleagues, (1) psychologists do not disclose confidential information that reasonably could lead to the identification of a client/patient, research participant, or other person or organization with whom they have a confidential relationship unless they have obtained the prior consent of the person or organization or the disclosure cannot be avoided, and (2) they disclose information only to the extent necessary to achieve the purposes of the consultation.

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

American Counseling Association (ACA).4. Supervisor Responsibilities F.4. Supervisor Responsibilities F.4.a. Informed Consent for Supervision F.4.a. Informed Consent for Supervision Supervisors are responsible for incorporating into their supervision the principles of informed consent and participation. Supervisors inform supervisees of the policies and procedures to which they are to adhere and the mechanisms for due process appeal of individual supervisory actions. Supervisors are responsible for incorporating into their supervision the principles of informed consent and participation. Supervisors inform supervisees of the policies and procedures to which they are to adhere and the mechanisms for due process appeal of individual supervisory actions.

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

National Association of Social Workers 2.05 Consultation 2.05 Consultation (a) Social workers should seek the advice and counsel of colleagues whenever such consultation is in the best interests of clients. (a) Social workers should seek the advice and counsel of colleagues whenever such consultation is in the best interests of clients. (b) Social workers should keep themselves informed about colleagues’ areas of expertise and competencies. Social workers should seek consultation only from colleagues who have demonstrated knowledge, expertise, and competence related to the subject of the consultation. (b) Social workers should keep themselves informed about colleagues’ areas of expertise and competencies. Social workers should seek consultation only from colleagues who have demonstrated knowledge, expertise, and competence related to the subject of the consultation. (c) When consulting with colleagues about clients, social workers should disclose the least amount of information necessary to achieve the purposes of the consultation. (c) When consulting with colleagues about clients, social workers should disclose the least amount of information necessary to achieve the purposes of the consultation.

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

American Psychoanalytic Association (APSAA) Guiding General Principles: Guiding General Principles: III. Mutuality and Informed Consent. The treatment relationship between the patient and the psychoanalyst is founded upon trust and informed mutual agreement or consent. At the outset of treatment, the patient should be made aware of the nature of psychoanalysis and relevant alternative therapies. The psychoanalyst should make agreements pertaining to scheduling, fees, and other rules and obligations of treatment tactfully and humanely, with adequate regard for the realistic and therapeutic aspects of the relationship. Promises made should be honored. III. Mutuality and Informed Consent. The treatment relationship between the patient and the psychoanalyst is founded upon trust and informed mutual agreement or consent. At the outset of treatment, the patient should be made aware of the nature of psychoanalysis and relevant alternative therapies. The psychoanalyst should make agreements pertaining to scheduling, fees, and other rules and obligations of treatment tactfully and humanely, with adequate regard for the realistic and therapeutic aspects of the relationship. Promises made should be honored.

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

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

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

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

The variation we have seen among these codes in conceiving of and implementing the concept of “informed consent” reflects some differences in linguistic formulation within these sister associations but also probably some philosophical differences as well. Art therapists have historically integrated philosophical approaches of different stripes that taken together have become the great admixture defining our field. Today, not only do art therapists adhere philosophically to other codes, but are also often dually credentialed by other associations.

Credentialed art therapists endorse and adhere to the ethical code of the ATCB, as well as any other professional mental health association to which we hold membership. Sometimes a discrepancy can exist between the codes of the associations to which we adhere as members. In such case, the stronger principle holds sway over the weaker one.

What have we learned? In general, ethical requirements vary considerably among our sister associations when it comes to informed consent for supervision and consultation. Not all of our sister associations require signed informed consent for supervision. Not all of our sister associations require signed informed consent for supervision. Only The American Art Therapy Association and the American Counseling Association do require signed informed consent for supervision. Only The American Art Therapy Association and the American Counseling Association do require signed informed consent for supervision. The American Psychological Association requires instead that informed consent, whether written or oral, be documented by the therapist. The American Psychological Association requires instead that informed consent, whether written or oral, be documented by the therapist. Some associations, such as the American Psychoanalytic Association, do not consider supervision to be extrinsic to the therapeutic process and therefore do not address supervision in terms of signed informed consent. Some associations, such as the American Psychoanalytic Association, do not consider supervision to be extrinsic to the therapeutic process and therefore do not address supervision in terms of signed informed consent.

No matter what personal and professional beliefs we may hold regarding supervision and signed informed consent, we all must abide by “The Ethical Principles for Art Therapists.” This is a given of our profession. We must also abide by the mental health rules and regulations governing our individual states as well as the federal rules stipulated by HIPAA.

That said, we are free to review our ethical statues and ask ourselves whether they adequately address both the ethical and clinical concerns we have in regard to supervision and art therapy.

Some Further Questions Some Further Questions Are supervision and consultation really one and the same and thus ought be considered interchangeable linguistically within our ethical code? Or should they be considered categorically different, thus requiring that somewhat different ethical principles be applied to each?

Clinical Questions Can variations in the clinical setting make the issue of the informed form easier with some clients, but more difficult with others? Can variations in the clinical setting make the issue of the informed form easier with some clients, but more difficult with others? Should this issue be addressed more clearly in our code? Should this issue be addressed more clearly in our code? Are we fully aware as to how our clients view their art therapist being in supervision? Do all clients see their art therapist being in supervision as a purely neutral subject? Are we fully aware as to how our clients view their art therapist being in supervision? Do all clients see their art therapist being in supervision as a purely neutral subject? Should our code address this question so as to accommodate clinical implications of informed consent? Should our code address this question so as to accommodate clinical implications of informed consent?

Do you believe that seeking supervision when one feels the need for it is the not only the right of every art therapist, but the ethical obligation as well? Do you feel that not seeking supervision when one needs it can constitute an ethical violation?

How can we bridge the gap between the freedom for every art therapist to seek supervision whenever he or she needs it and the increasingly pressing obligation to do so only once client/patient consent has been established?

The American Art Therapy Ethics Committee is interested in your thoughts about art therapy and supervision. The American Art Therapy Ethics Committee is interested in your thoughts about art therapy and 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 therapeutic alliance or transference, getting in the way of your feeling comfortable using the signed informed consent? Are clinical issues, related to constructing a therapeutic alliance or transference, getting in the way of your feeling comfortable using the signed informed consent? What are the therapeutic implications in your mind, both pro and con, in the use of signed informed consent? What are the therapeutic implications in your mind, both pro and con, in the use of signed informed consent?

Let’s begin a membership dialogue to clarify both the clinical and ethical aspects of these questions!

Thank you