Bruce Dennis Sales (Auth.), Bruce Dennis Sales J.D., Ph.D. (Eds.) - The Professional Psychologist's Handbook (1983, Springer US)
Bruce Dennis Sales (Auth.), Bruce Dennis Sales J.D., Ph.D. (Eds.) - The Professional Psychologist's Handbook (1983, Springer US)
Bruce Dennis Sales (Auth.), Bruce Dennis Sales J.D., Ph.D. (Eds.) - The Professional Psychologist's Handbook (1983, Springer US)
Psychologist's Handbook
The Professional
Psychologist's Handbook
Edited by
Bruce Dennis Sales
University of Arizona
Tucson, Arizona
Bibliography: p.
Includes index.
1. Psychology—United States—Practice. 2. Psychology—Standards—United States.
3. Psychologists—Legal status, laws, etc.—United States. I. Sales, Bruce Dennis.
[DNLM: 1. Psychology—United States—Handbooks. BF 38 P964]
BF75.P72 1983 150 .23 73
/ /
83-4038
ISBN 978-1-4899-1027-1
vii
viii CONTRIBUTORS
ALFRED M. WELLNER, Ph.D., is Executive Officer for the Council for the
National Register of Health Service Providers in Psychology, and a
Diplomate in Clinical Psychology (American Board of Professional Psy-
chology). Previously, he was in full-time private practice and consult-
CONTRIBUTORS xiii
ing work. Dr. Wellner is a former Chair and member of the American
Psychological Association's Committee on Accreditation, a member of
the AP A Commission on Accreditation, served on the task force
responsible for drafting the current Accreditation Criteria, and the first
Chair of the APA Task Force on Standards for Providers of Psycholog-
ical Service. A member of the interorganizational Steering Committee
on Education and Credentialing in Psychology, Wellner helped plan
two national conferences (1976 and 1977) and edited the committee's
reports and publications. He also served as President of the Maryland
Psychological Association, a member of the Maryland State Board of
Examiners of Psychology, and served on the APA Council of Represen-
tatives. He is immediate past President of the District of Columbia Psy-
chological Association.
xv
Contents
I. INTRODUCTION
17. The Changing and Creating of Legislation: The Political Process 601
Patrick H. DeLeon
IX. APPENDIXES
Index 767
I
INTRODUCTION
1
The Context of Professional Psychology
BRUCE DENNIS SALES
IThe term professional psychologist, although typically applied to practitioners in one of the
four recognized specialties in psychology, should also include all other psychologists who
deliver their services in applied settings. The materials discussed in this chapter are equally
applicable to these persons.
3
4 BRUCE DENNIS SALES
an intentional violation of it for even the best of reasons, can lead to a fine,
loss of license, or prison term, and equally severe consequences for our
clients. We will return to this point later. Second, laws often confer very
important benefits, but only if those laws are properly invoked.
But what are those laws? They can be categorized into three broad top-
ics-those that regulate the organization and administration of professional
business enterprises, those that regulate the delivery of our professional
services, and those that regulate the way our clients enter into the service
system and are processed through that system. Let us consider each of these
categories in turn.
By this point the reader may be shaking his or her head and feeling
overwhelmed by the amount of information that apparently has to be mas-
tered. To some extent the reaction is justified. Being a competent profes-
sional requires the acquisition and retention of more information than you
might have initially anticipated. Yet, reading stacks of materials is nothing
new to the doctoral candidate. On the contrary, it is the regular fare of grad-
uate studies. Yet it is not the status of being a graduate student that enables
one to master large amounts of reading, regularly attend classes, and sched-
ule research and practice on a weekly basis while maintaining a personal
life. Rather it is the exercise of appropriate managerial skills. Unfortunately
we usually are left to our own devices to acquire them.
These skills, as well as other business skills, are equally if not more
essential during one's professional career and constitute the fifth compo-
nent of the context. For example, how often should appointments be sched-
uled? How much responsibility should be delegated to staff. Should you
make time to participate in the activities of your local professional associa-
12 BRUCE DENNIS SALES
tion? Questions such as these should not be raised and answered on a piece-
meal basis. Rather, they should be approached with the same systematic
rigor that we apply to learning our substantive skills. In fact, there is no
reason why the acquisition of this knowledge should be approached as a
foreign task. Psychology has provided a rich scientific base for understand-
ing managerial and business behavior. In addition, not to master these skills
may very well lead to major problems in the operation of your practice or
to a successful practice with no time left for a personal life. The chapter by
Richard R. Kilburg (Chapter 15) introduces the reader to the issues and
concepts involved in successful managerial behavior.
professional psychology. But as with the other categories that are included
within the context, our training in the knowledge base on the values and
interests that guide our professional decision making is typically woefully
inadequate. In Chapter 16 Gottlieb C. Simon presents an introduction to
this important area of professional concern.
chapters that, although not essential for individuals to learn while as grad-
uate students, would be very valuable for practitioners to have access to.
Thus, we welcome your comments.
Finally, one last caveat deserves mention. The very nature of some
parts of the context is one of constant change. For example, laws are subject
to legislative or judicial revision. Professional standards are usually scruti-
nized annually and periodically revised. Professional organizations period-
ically revise their organizational structure to deliver services to the mem-
bership more effectively or to deliver new services. For this reason, the
reader should not use this book as the final authority on each issue. Rather
it is intended as the resource for building the contextual knowledge bases
that are needed in being a competent, ethical, and successful professional.
REFERENCES
This chapter attempts to condense into a relatively small space the long and
complicated history of how standards of practice evolved and the implica-
tions they have for American Psychology (Jacobs, 1976, 1977). It outlines
the rationale and the basic parameters of a standards document. The first
major section reviews the history of standard-setting attempts by the Amer-
ican Psychological Association (APA). It traces a series of events over the
past 25 years that set the stage for six major policy statements on practice
promulgated by the Association between 1974 and 1980.
The second section discusses the original Standards for Providers of
Psychological Services published in September 1974. This is followed by an
examination of critical portions of the revised Standards that were pub-
lished under the same title in January 1977. Essential similarities and dif-
ferences between the original and the revision are noted. A review of
events that prompted APA to supplement the 1977 standards with four sep-
arate specialty guidelines published in 1980 follows. These present the most
recent APA policy covering the delivery of services by clinical, counseling,
industrial/organizational, and school psychologists. The intent of the spe-
cialty guidelines is "to educate the public, the profession, and other inter-
ested parties regarding specialty professional practices ... and to facilitate
the continued systematic development of the profession." The discussion of
DURAND F. JACOBS. Jerry L. Pettis Memorial Veterans Hospital, Loma Linda, California
92357.
19
20 DURAND F. JACOBS
the guidelines points out important differences among them and pinpoints
key differences between them and the 1977 standards.
The third section compares and contrasts the purposes and differential
utility of standards of practice, ethical standards, and state licensing laws.
It points out how each in its own way attempts to protect the user of psy-
chological services.
The fourth section, "On-going Concerns," alerts the reader to several
key issues that were addressed in APA's policy statements on practice, but
which continue to challenge the profession as unfinished business. Central
among them is the question of how best to implement APA's several policy
statements.
The fifth and final section surveys the road ahead with regard to future
prospects, problems, and opportunities awaiting professional psychologists.
It predicts continuation of the trend toward more rigorous quality control
of psychological services. Psychologists can expect to feel the weight of
closer regulation of their practice, emanating from within the profession as
well as from statutory and other interest groups outside it. It looks forward
to major research efforts being initiated to develop criteria for defining
professional competence on the basis of practice outcomes. Greater use of
paraprofessionals in the delivery of psychological services is anticipated.
There will be increased demands for more fully documented case records.
Unrelenting pressures will goad the profession to demonstrate convinc-
ingly its commitment to the public welfare. The chapter closes with a
description of the preparations being made by APA to meet the anticipated
onslaught of requests from groups of psychologists who believe that their
respective practices warrant formal recognition as new specialties. In gen-
eral, this writer's view of the road ahead suggests substantially increased
benefits for those who receive psychological services and greater rewards
for those who provide them.
Historically, there are three basic rights that assure the functional
integrity and continued survival of any independent profession:
1. Self-determination of the qualifications of candidates for entry into
the profession
2. Autonomy of professional functioning within the bounds estab-
lished by social, moral, and legal responsibilities
3. Self-regulation, exercised through peer review and based on a self-
promulgated code of ethics, as well as self-promulgated standards of
practice
Standards of practice are the hallmark of a profession dedicated to pub-
lic service. Their existence serves notice to all interested parties that the
THE DEVELOPMENT AND ApPLICATION OF STANDARDS 21
There are 10 features that distinguish standards and guidelines for the
delivery of professional services:
For the next two years the Division 22 Committee on Standards con-
ducted surveys of types and numbers of psychological manpower in reha-
bilitation facilities. Their intent was to use this data to influence statements
regarding psychologists and psychological practices that would appear in
standards manuals published by non-AP A groups. During this time, addi-
24 DURAND F. JACOBS
Council for Facilities for the Mentally Retarded (1971) and in the JCAH
Accreditation Manual for Psychiatric Facilities (1972). Two task force mem-
bers represented APA's "amicus" position in the Wyatt v. Stickney judgment
(establishing the first standards for professionals in mental hospitals) issued
by the U.S. District Court in Alabama in 1972. In 1973 and 1974, the chair
of the task force collaborated with members of BPA's Committee on Health
Insurance to define the qualified psychologist in national level delibera-
tions with public and private insurance carriers. Early drafts of the task
force's statement on standards of practice contributed directly to federal leg-
islation specifying definitional and quality control guidelines for psychol-
ogists qualified to provide health services for civilian dependents of U.S.
military personnel (CHAMPUS). Task force members also were appointed
to the first APA committee organized to produce "model sets criteria" for
peer review of psychological services under the federally directed Profes-
sional Standards Review Organizations (U.s. Department of Health, Edu-
cation, and Welfare, 1974).
These interim outcomes were gratifying because they represented
increased participation by APA instrumentalites in decisions being made
by others about psychology'S professional identity and functioning. They
did not, however, replace the prime objective of formulating a set of stan-
dards through which American psychology could speak out directly and
decisively on the proper qualifications, functions, styles of operation, and
accountabilities of practicing psychologists. This finally materialized on
September 2,1974, when the APA Council of Representatives overwhelm-
ingly approved the Standards for Providers of Psychological Services as its
basic and most comprehensive policy statement on professional practice
covering both private and institutional settings (American Psychological
Association, 1974b). A detailed review of the content of the standards will
be presented later in this chapter.
Concurrent with their approval of the original standards, the APA
council voted to create the first Committee on Standards for Providers of
Psychological Services (COSPOPS) to carry on the work begun by the Task
Force on Standards for Psychologists in Service Facilities. The initial charge
to the new committee was to update and revise the standards, taking into
consideration reports of experience obtained from the membership and the
using community outside of APA. In January 1976, the APA Council of Rep-
resentatives further charged the committee to limit the scope of the revised
standards to activities ordinarily associated with the practice of clinical,
counseling, industrial-organizational, and school psychology. Membership
on the 1976 committee was rearranged so that there was one representative
from each of the four applied specialties, one member (the chair) to repre-
sent institutional practice and one to represent the public interest. It is note-
worthy that the original APA Task Force on Standards and later committees
similarly charged with developing standards of practice each sought input
from user and sanctioner groups.
26 DURAND F. JACOBS
tives in January 1979 went by the board. The deadline for council action
was delayed one full year. Council action was taken at the January 31,1980
meeting. Following some revisions, the documents were approved and
accepted as policy at this meeting.
The move toward specialty standards touched some unresolved and
tender pressure points within professional and scientific psychology. A
number of (often rhetorical) questions were raised. Is there evidence show-
ing that psychologists designated as specialists are more successful in
achieving desired client outcomes than psychologists not so deSignated?
What differences in education and training justify claims of special com-
petence to practice a specialty? Are there uniform sets of specialty criteria
that APA uses when it accredits training programs in clinical, counseling,
and school psychology? Does the American Board of Professional Psy-
chology apply a uniform set of training and experiential criteria when
recognizing individual excellence as clinical, counseling, school, or indus-
trial-organizational psychologists? Is this the appropriate time to define spe-
cialties on a uniform national scale? Will the publication of specialty stan-
dards establish role models that will prematurely freeze the potential for
growth and differentiation within designated specialties? Will specialty
deSignation of some psychologists prevent general providers of psycholog-
ical services from using the methods or dealing with the populations of a
specialty? Will the publication of specialty standards make psychologists
more vulnerable to malpractice suits should they fail to meet a given stan-
dard? What is the best way to integrate less than doctoral level providers
into multilevel psychological service delivery systems? What constitutes
adequate supervisory controls over supporting staff? What are reasonable
staffing standards for various settings? Will specialty standards aggravate
existing disagreements among professional psychologists about who is
qualified to do what? Will specialty standards concretize a "pecking order"
of recognized specialties or stifle the emergence of new applied specialties?
The material that follows provides an overview of the format and con-
tent of each of APA's major policy statements on standards of practice for
professional psychologists. Documents currently in force are reproduced in
full in the Appendix of this book. The limited aim here is to familiarize the
reader with key aspects of each document, and to point out important
changes that have evolved with each successive publication. The original
Standards for Providers of Psychological Services were published in Sep-
tember 1974. Preparation of this document offered APA a long-overdue
opportunity to consolidate references from all its previous policy statements
about profeSSional practice into a single authoritative and up-to-date source.
As a result, the standards served to resolve inconsistencies, bridge gaps, and
extend former statements of policy and principle in order to interface them
THE DEVELOPMENT AND ApPLICATION OF STANDARDS 29
DEFINITIONS
These were grouped into four topical areas: providers; programs, policies,
and procedures; accountability; and environment. The section on providers con-
tained four separate standards addressed to staffing, supervision, adminis-
trative direction of the psychology service, and the involvement of psy-
chologists in the governance of the setting. The section on programs
contained three standards stipulating major parameters for the internal
organization of the psychology service. The section on policies was com-
prised of seven standards. These specified how providers of psychological
services were expected to operate within established statutes, agency, and
professional guidelines; observe the legal and civil rights of the recipients
of their services; keep abreast of new knowledge and scientific advances in
their area of application; and utilize professional persons and resources out-
side the immediate setting that may be of benefit to their consumers. The
section on procedures included four standards. Each required a particular
aspect of written documentation that portrayed in toto the plans, proce-
dures, and methods utilized to pursue the objectives sought by the provi-
sion of psychological services, while insuring the confidentiality of infor-
mation about consumers. The section on accountability contained four
standards. These specified psychologists' concurrent responsibilities and
accountabilities to consumers, to the profession of psychology, and to others
concerned with maintenance of readily accessible, effective, economical,
and high quality psychological services.
The single standard comprising the final section on environment
required that psychologists act to promote physical and social attributes in
the work setting that facilitated the delivery of humane and effective psy-
chological services.
Immediately following the body of the standards was a set of 21 foot-
notes. They not only elaborated on specific content, but also provided the
reader with an historical commentary on how a given standard had been
influenced by previous policy statements or positions of APA. The stan-
dards ended with a bibliography of 10 key references to APA policy state-
ments concerning the practice of psychology.
DEFINITIONS
Some minor changes also were made. For instance, "supervision" was
added to the listing of psychological services; the former organizational
title Psychology Service was changed to Psychological Service Unit; and the
term consumers was replaced by users.
The final section on environment was essentially the same as that of the
original standards. Several new footnotes and references appeared in the
1977 revision that reflected recent changes in APA policies and publica-
tions. When the APA Council of Representatives approved the revised stan-
dards in January 1977, the original 1974 standards became history.
COMMENT
'The term Specialty Standards was replaced by Specialty Guidelines when the APA Council of
Representatives approved these documents in 1980. The rationale for this change is dis-
cussed later in this chapter.
THE DEVELOPMENT AND ApPLICATION OF STANDARDS 35
for the early 1980s) include modifications in the spirit of the above in order
to maintain the Association's commitment to quality assurance for the pub-
lic without running the risk of unduly compromising its practitioners.
The specialty guidelines were designed to follow the format and,
whenever applicable, the wording of the generic standards. Therefore,
there are many similarities among them. Four separate free-standing pub-
lications were issued, because each would be used by a different pUblic,
receiving psychological services in a different setting. To expedite this
review of their content the clinical, counseling, and school documents will
be discussed together. This will be followed by a review of specific depar-
tures in format and content that appear in the specialty guidelines for
industrial-organizational psychologists.
INTRODUCTION
DEFINITIONS
supervising professional psychologist that spells out the range and type of
services to be provided by the support person, the manner in which face-
to-face supervision is to be provided, the limits of independent action and
decision making accorded the support person, and the means by which the
supervised person will contact the psychologist in the event of an emer-
gency or crisis (Guideline 1.2). Guideline 1.2 also recognizes that under cer-
tain circumstances a professional psychologist of another specialty or even
a professional from another discipline may appropriately provide supervi-
sion or training in a special proficiency area.
In Guideline 1.3 the clinical and counseling documents indicate that
when two or more different specialties are integrated within a single con-
solidated psychological service unit, anyone of the involved professional
psychologists may serve as administrative head of the unit.
Guideline 1.7 sets forth the conditions under which a professional psy-
chologist may acquire specialty recognition. Unlike the counseling and
school documents which limit their requirements to acquiring necessary
supplementary specialty education and training within the doctoral train-
ing program, the clinical guidelines require an additional year of postdoc-
toral experience obtained under the supervision of a clinical psychologist.
Grandparenting Provisions. Each of the specialty guidelines contains an
extended footnote specifying the grandparenting criteria for established
psychologists who wish to seek recognition as specialists. Two broad cate-
gories of psychologists who did not obtain their original graduate training
in the specialty area where recognition is sought may be grandparented as
specialists. Category 1 accepts as specialists those persons who had com-
pleted doctoral level training in a regionally accredited program and had
acquired three postdoctoral years of "appropriate education, training, and
experience" in providing given specialty services, including a minimum of
one year in a recognized clinical, counseling, or school setting, as the case
may be. Category 2 recognizes as specialists those who on or before Septem-
ber 4, 1974, had completed a master's degree program in psychology at a
regionally approved institution, held a license or certificate granted by the
state in which they practiced, and had obtained five post-master's years of
appropriate education, training, and experience in the specialty area,
including a minimum of two years in a work setting identified with practice
in the given specialty.
The school psychology guidelines recognize a third category of persons
who would qualify as specialists under their grandparenting rules. Eligi-
bility for this third category is based on the 1977 Resolution passed by the
APA Council of Representatives acknowledging a "transition period" for
the use of the title school psychologist. Thus, persons in Category 3 may rep-
resent themselves as school psychologists so long as they restrict their prac-
tice to elementary or secondary school settings. This category is open to
persons who meet the following criteria on or before January 31, 1985: They
must (a) possess a master's degree involving at least two years of full-time
graduate study in school psychology at a regionally accredited institution,
THE DEVELOPMENT AND ApPLICATION OF STANDARDS 41
(b) have acquired at least three additional years of training and experience
in school psychological services, including a minimum of one school year
in school settings, and (c) have obtained a license or certificate conferred by
the state for practice in elementary or secondary schools.
The Programs Subsection. The guidelines comprising the programs sub-
section of the clinical, counseling, and school documents include all but one
of the substantive items that appeared in the generic standards. Former
Standard 2.3.3 was dropped, since it was viewed as less appropriate than
the delivery of service model described in Guideline 2.3.2. An entirely new
guideline (2.3.4) has been added that specifies the conditions for retention
and disposition of client records. The clinical and counseling guidelines go
further than the generic standards in the section dealing with confidential-
ity of case records (Guideline 2.3.5). This elaboration builds upon experi-
ence obtained in recent years and addresses the legal issue of who "owns"
the information in the case record. It reads:
Users have the right to information in their psychological records. However,
the records (themselves) are the property of the psychologist or of the facility
in which the psychologist works and are, therefore, the responsibility of the
psychologist and subject to his or her control. (American Psychological Asso-
ciation, 1980c, p. 12)
permissive than the generic standards or the requirements of the other spe-
cialty groups. It allows for individual psychologists to be recognized as 1-0
specialists after completing "continuing education courses and workshops
in 1-0 psychology, combined with supervised experience as an 1-0
psychologist."
The second section of the 1-0 document is titled "Professional Consid-
erations." It covers the kinds of items that are incorporated in the "pro-
grams" subsections of both the generic standards and the other specialty
documents. It omits any mention of the composition and organization of an
1-0 psychological service unit and focuses directly on guidelines that pro-
tect the user of psychological services. The second subsection, "Planning
Organizational Goals," reflects the content of two of the five generic stan-
dards. The first of these presents a guideline for establishing a mutually
acceptable understanding between the provider and user regarding mar-
keting of 1-0 psychological services. The second closely follows the generic
standard establishing a system to protect confidentiality of information
about users of services. In this section one finds two guidelines unique to
their specialty. These state:
• The 1-0 psychologist does not seek to gain competitive advantage
through the use of privileged information (Guideline 2.5) .
• The 1-0 psychologist who purchases the services of another psy-
chologist provides a clear statement of the role of the purchaser
(Guideline 2.6).
The accountability section of the 1-0 document includes two of the four
items that appear in the generic standards and in the other specialty guide-
lines. Those deleted were not seen as relevant to 1-0 settings. Of those
retained, the first reaffirms that professional activities of 1-0 psychOlogists
are guided primarily by the principle of promoting human welfare. The
second calls for periodic evaluation of the extent to which 1-0 services are
meeting identified needs and achieving projected goals. The 1-0 guidelines
do not contain an environment section. The grandparenting requirements for
recognition as an 1-0 psychologist list the same two categories as were
noted in the clinical and counseling statements.
its ethical standards, which are limited in their impact to members of APA,
the Association's standards of practice represent the most authoritative
statement available to the public at large on matters affecting quality control
of psychological services. As such, they are addressed to all who are party
to them. In addition to those representing themselves as professional psy-
chologists, this includes technical support staff, users, employers, third-
party payers, and sanctioners. As a result, standards of practice exercise
influence that extends considerably beyond that of a code of ethics.
In his treatise on Accountability Among Providers of Psychological
II
Accountability calls for making the work of the practicing psychologist acces-
sible to evaluation or inspection by some outside body or person. Webster
defines the term as "furnishing a justifying analysis or explanation." For our
purpose, what is being accounted for is the nature and quality of service pro-
vided to a patient or client .... Accountability is here, probably for keeps and
desirably so, and it behooves us to consider what may be implied in the part it
plays in monitoring quality control in our professional work. To whom should
we be accountable in our professional services? Adapting my remarks from the
APA statement, I think we can identify three groups: the client himself, the
sanctioners of services (those significant others who have a stake in the services
rendered, such as family or employers), and our professional colleagues. (p. 7)
ON-GOING CONCERNS
public and the profession. Inseparably intertwined with this are attempts
to arrive at a balanced solution for what has come to be called "resolution
of the master's issue," i.e., how best to incorporate those with less than doc-
toral training into the profession's service delivery systems.
The second consideration is how the Association will advance its stated
intention to support scientific studies that will test, and hopefully validate,
APA's position that doctoral training and related quality control measures
can assure the public of competent practitioners. The third continuing con-
cern deals with training psychologists to maintain systematic case records
in order to meet increasing demands for peer review. A fourth issue stems
from the expanding use of support personnel in the delivery of psycholog-
ical services, and the need to elaborate further the professional and legal
responsibilities of psychologists who must provide effective direction and
supervision of these paraprofessional "extenders." The fifth item requiring
corrective action is how to pursue the limited alternatives open to the help-
ing professions in order to rekindle the public's faltering trust in the
motives and skills of its helpers. This crisis in trust has reached the point
where each professional group either must institute its own highly visible
and effective regulatory mechanisms or prepare itself for the consequences
that will come when others outside the profession take regulation into their
own hands. The sixth issue urgently awaiting resolution is closely related
to the problem of improving the profession's public image. It pertains to
the need for APA to chart a course for implementing its policy statements
on practice and to do so in an even-handed manner that protects users of
psychological services while not placing unreasonable demands on the
practitioner.
The single topic that has generated the most controversy throughout
the development of standards has been APA's decision to define the
"professional psychologist" in any and all settings as one holding "a doctoral
degree from a regionally accredited university or professional school in a
program that is primarily psychological, and appropriate training and expe-
rience in the area of service offered" (American Psychological Association,
1977b, p. 4). To fully appreciate the significance of this action necessitates
an understanding of the somewhat checkered history of how the double
standard for defining the (professional) psycholgist had evolved in federal
regulations and state statutes and how these events were abetted by the
default of organized psychology.
APA played sequential roles of passive observer (1945-1954) and later
(1955-1978) active endorser of an amazing series of damaging statutory
actions that began with passage of the first psychology licensing law of 1945
and continued through 1978 when the 50th statute governing psychological
practice was passed. The upshot of all this was that the great majority of
THE DEVELOPMENT AND ApPLICATION OF STANDARDS 47
The APA guidelines for state legislation affecting the practice of psy-
chology (American Psychological Association, 1967) went on to recommend
that when the same persons provided similar professional services to the
public for a fee they should meet licensure requirements that mandated
doctoral level training:
vided by too few and often poorly trained personnel, but the status quo had
been maintained by statutory decree. To make matters worse, there were
clear indications in the late 1960s that, barring effective action by APA,
those conditions were about to be concretized by imminent actions of reg-
ulatory, standard-setting, and accreditation groups. Seen within this histor-
ical context, the standards are revealed (1) as a strong public statement of
dissent against this wholly unacceptable state of affairs and, (2) as an
unprecedented move by APA to improve the quality, effectiveness, and
accessibility of psychological services to all who required them.
With publication of the original standards for providers of psycholog-
ical services in 1974 APA finally resolved its long-standing dilemma over
what would be the minimally-acceptable qualifications for all those who
bore the title psychologist. For the first time in its history APA took the posi-
tion that the doctoral degree was the uniform training requirement for any
psychologist offering professional services in any setting, whether public or
private. Even as APA announced its higher standard, it acknowledged what
had happened in the past:
It is recognized that some statutes or regulations presently define and permit
autonomous provision of psychological services by persons with training and
experience other than that noted in Standard 2.1. Therefore, at the present time,
persons holding less than a doctoral degree from an accredited university in a
program primarily psychological in content shall also be considered as qualified
psychologists in the state in which they practice provided that they have (a)
appropriate experience in the area of service offered and (b) a license or certif-
icate from a state examining board under a "grandfather clause," or endorse-
ment by a state psychological association through voluntary certification in
states without statutory provisions. (p. 5)
Critics had argued that standards of practice should not have been
issued until they included proven competency criteria. Such critics failed to
recognize that standards affecting practice may include other useful quality
control indices. The absence of a preferred class of criteria (Le., competency
indicators) did not dissuade APA from taking steps to assure the public of
its concern for their welfare and to show its willingness to hold psycholo-
gists accountable for quality performance on the basis of presently available
indices that providers, users, and sanctioners agreed were relevant to (if not
yet demonstrably predictive of) desired service outcomes.
WRITTEN REPORTS
All the above records are intended to be available upon request to users
and (with proper safeguards of confidentiality) to sanctioners as well. These
written records, particularly those containing documentation of profes-
sional intervention, constitute the core material essential for peer review.
The first three types of records provide the information necessary for
effective administrative review. An addition~l standard (3.3) applies when
the psychological service unit is a component of a large organization (e.g.,
school, agency, hospital, corporation, etc.). This standard calls for periodic
evaluations of the effectiveness of the unit relative to accessibility of profes-
sional and support personnel and similar operational considerations.
The mandate for specific kinds of written records is seldom applauded
by professionals. It is time-consuming and it often replaces a more person-
alized and flexible style of records management. One hopes that such prob-
lems are offset by the advantages obtained through better informed users
and sanctioners and more assured accountability of psychologists for the
services they provide and supervise. Parenthetically, the writers of the stan-
dards were not insensitive to the risks posed by mandated records and
review procedures. They added the following precaution to Standard 3.3:
It is highly desirable that there be a periodiC reexamination of review mecha-
nisms to ensure that these attempts at public safeguards are effective and cost
efficient and do not place unnecessary encumbrances on the provider or unnec-
essary additional expense to users or sanctioners for services rendered. (p. 10)
THE DEVELOPMENT AND ApPLICATION OF STANDARDS 53
SUPERVISION
The issue of supervision was touched only lightly in the original 1974
standards. It stated that providers of psychological services who did not
meet the requirements for the qualified psychologist (e.g., psychological
associates, assistants, technicians) "shall work under the supervision of a
qualified psychologist" (Standard 2.2, p. 5). The 1977 revision went consid-
erably further. It elevated the status of supervision to the level of a formal
"Psychological Service" (p. 4) and added that the supervising psychologist
"shall assume professional responsibility and accountability for the services
provided. The level and extent of supervision may vary from task to task so
long as the supervising psychologist retains a sufficiently close supervisory
relationship to meet this standard" (Standard 1.2, p. 5).
Subsequent experience has revealed that merely specifying the locus of
control is not sufficient to assure either the user or the person being super-
vised of adequate professional guidance for services being provided. For
instance, a widely cited case (Brown and Associates Psychological Clinic v. Geor-
gia State Board of Examiners of Psychologists, 1970) decided by the Georgia
State Board of Examiners of Psychologists held the psychologist at fault
because services were being provided by a technician without prior direc-
tion and without adequate review of results of evaluation and therapy activ-
ities. Moreover, the board found violations of their standard requiring that
professional-related "activities of the 'technician,' 'assistant,' or 'intern'
must be conducted in a setting whereby the professional supervisor could
personally intervene in a crisis situation requiring his immediate attention"
(p. 10).
In response to such demands for increased accountability in the psy-
chologist's supervisory role, the specialty guidelines enumerated key com-
ponents of the supervisory process. These were discussed earlier in this
chapter. As presented in the specialty guidelines, supervision has become a
function that now is readily assessable for review and evaluation by peers,
users, accreditation groups, and third-party payers alike. This anticipates
the expanded use of paraprofessional support staff within multilevel deliv-
ery of psychological service systems in all manner of settings. The trend is
toward even more rigorous and explicit controls by professionals over tech-
nical support personnel, including formal certification for specific activities
(e.g., biofeedback technician). It also is reasonable to expect that the func-
tions of support personnel and the manner of supervisory controls applied
within the profession will be augmented by statutory action and by require-
ments included in operations manuals issued by third-party payers.
decade and a half. It has produced mounting demands for tough policing
of product quality and safety, elimination of environmental pollutants,
clearly explained lending and labeling practices, and an end to "rip-offs"
by large corporations and professional groups acting in arrogant self-
interest.
An accompanying loss of faith in society's established institutions to
treat the "little guy" with consideration has produced an accelerated move-
ment to guarantee explicitly human dignity and personal rights through
new legislative and statutory initiatives and through landmark decisions by
state and federal courts (Jacobs, 1974b). Matters have reached the point
where consumers and their advocates have successfully challenged the
professional's presumptive right to decide alone the content, staffing, man-
ner of and site for service delivery. Nowhere on the current scene to do
these two movements, i.e., to seek recourse for past wrongs and to demand
assurances for future good treatment, converge and complement one
another more strongly than in the concern for adequate human services
(Jacobs, 1975).
It was neither providers nor consumers, but those at least once
removed from direct service delivery who first developed means for
enhancing conditions believed to contribute to improved service delivery.
The first kind of standards that evolved were promulgated by governmental
and private accreditation groups. The standards compiled by these groups
addressed matters such as requirements for basic staffing, organizational
structure, range and type of services and procedures, and a safe environ-
ment. They required a trail of documents that recorded the need, goals, and
process of service delivery. Such standards assumed that consumers would
stand to benefit if service providers were well trained, well organized, kept
good records of what transpired in their work, engaged in peer review,
remained abreast of new information in their field, and had adequate staff
and supporting resources.
Criteria for the evaluation of professional judgment and competence in
performance were not included in the first type of standards. Such matters
were seen as properly the domain of the concerned profession to be ascer-
tained through peer review and improved continuing education programs.
The early standards required only that the structure for review of such activ-
ities be in place and operable. The underlying rationale for this approach
was that, while quality of service is not directly measurable, its level can be
accurately estimated by direct observation of selected structural and proce-
dural components of the service delivery system.
The AP A standards were based on the same line of thinking. They
addressed most of the dimensions covered by standards issued by major
educational, health, and environmental groups. The unique features of the
APA standards were: (a) they were initiated and written by and for the pro-
viders themselves as a means for self-regulation and (b) their scope was
greater in that it aimed to "serve the respective needs of users, providers,
and third-party payers and sanctioners of psychological services" (Ameri-
can Psychological Association, 1977b, p. 1). Viewed in this light, the stan-
THE DEVELOPMENT AND ApPLICATION OF STANDARDS 55
CAFCOE (items 4 and 8), it was confirmed that to the extent an APA policy
statement was enforced at all, only CSPEC (i.e., the APA Ethics Committee)
can exercise this power. Such enforcement in turn is limited to psycholo-
gists who are members of APA.
The report of the task force commented on the extreme diversity
among the policy statements. Several had never been formally reviewed by
the membership nor approved by the Association's governance. Yet all had
been endorsed by APA. The policy statements revealed no consistent for-
mat. They ranged in length from 1 page (item 3) to 104 pages (item 5). There
was considerable overlap and a obvious lack of coordination among them.
Each seemed to be the product of an isolated action. For instance, there were
broad ethical principles contained in the standards for providers and
detailed standards of practice contained in the ethical standards. In no
instance had APA articulated a program for systematically disseminating its
policy statements to the consuming public or to the scientific and profes-
sional communities for whom they were designed. Finally, APA had not
specified a course of action for informing the public, the profession, and
others with a need to know about the manner in which the policy state-
ments were to be enforced.
To ameliorate the foregoing difficulties the task force recommended
that:
1. Once a policy statement is promulgated, an explicit mechanism
should be established for implementing and, where appropriate, for
enforcing it.
2. APA should develop a mechanism for periodically evaluating the
manner in which each policy statement has been disseminated, uti-
lized, and enforced.
The recommendations of the task force were accepted with thanks but,
as of this writing, no action to apply them has been taken.
There are two broad avenues open for implementing the standards and
specialty guidelines. The first is to increase general awareness of the pur-
pose and content of these policy statements through a program of educating
providers, potential users, and others with a need to know. The second is
to establish procedures for direct regulation and enforcement of the policy
statements by way of peer or other review. Either or both of these methods
could be exercised by the profession, by governmental entities, or by orga-
nizations in the voluntary or the private sector, acting independently or in
concert.
indicates that the activity under review failed to meet the intent of the stan-
dard(s) as evidenced by direct observation and/or documentation.
Following this type of section-by-section review, providers typically
receive an overall rating that remains in effect until their next accreditation
review. A written summary statement noting the strengths and weaknesses
in various aspects of their professional activities is appended. Characteris-
tically, there is opportunity to discuss one's ratings with the rater and to
offer an explanation of extenuating circumstances that are beyond the con-
trol of the person being evaluated. In this regard, the reader is reminded
that the generic standards (p. 2) hold that "fulfillment of the requirements
to meet these standards shall be judged by peers in relation to ... the cir-
cumstances that prevail in the setting at the time the program or service is
evaluated." Traditionally, those involved in peer review activities are per-
mitted a limited grace period wherein major deficiencies can be corrected
without prejudice. Those found in partial compliance typically are given a
time-definite (e.g., six months to one year) during which they may upgrade
their activities to a level of substantial compliance and, thereby, avoid sanc-
tions entirely. The cost for APA independently to administer a peer review
system based on the accreditation model clearly would be prohibitive.
Therefore, APA has considered having its standards of practice imple-
mented by having them included as part of the review of psychological
services already being conducted by national accreditation groups such as
the JCAH.
Frequently eclipsed by the stress engendered in most people when
subjected to a performance review are the advantages that accrue by virtue
of the feedback received from the reviewer. Indeed, the primary purpose
of accreditation through peer review is educational. Therefore, the potential
for enforcement of a set of standards acts more to gain and hold the atten-
tion of the person being reviewed than to constitute any real threat to the
income or position of the well intentioned practitioner. The limited expe-
rience acquired by APA over the past few years through peer review of case
records under the CHAMPUS and AETNA insurance plans has been
enlightening. It was reported that being subject to review served to encour-
age psychologists to firmly and successfully defend their procedures and,
particularly, to upgrade their documentation. Even in the absence of immi-
nent peer review, APA's standards and specialty guidelines provide the
well intentioned practitioner with an excellent self-evaluation tool.
The specialty guidelines offer a somewhat more benign approach to
potential enforcement than do the generic standards. This is so because all
references to "minimally acceptable" levels of performance have been
dropped, along with other obligatory language that appeared in the stan-
dards. Nonetheless, the guidelines reaffirm that they have been developed
"as a means of self-regulation to protect the public interest." They go fur-
ther than the standards in volunteering that guidelines may be used inde-
pendently ''by boards and agencies that find such criteria useful for quality
assurance."
62 DURAND F. JACOBS
For the benefit of psychologists and members of the public who are in doubt as
to the formal bases for its evaluation of acceptable professional behaviour, The
Ontario Board of Examiners in Psychology announces that it had formally
adopted and makes broad use of the Ethical Standards of Psychologists (1977
Revision), Standards for Providers of Psychological Services (1977 Revision),
Ethical Principles in the Conduct of Research with Human Participants and
Standards for Educational and Psychological Tests and Manuals. The documents
are published by the American Psychological Association and are available from
its office at 1200 Seventeenth Street, N.W., Washington, D.C. or directly from
the Board.
In addition, the Board has adopted a set of Standards for Professional Con-
duct (OntariO Board of Examiners in Psychology, 1978) which outlines in spe-
cific terms standards of professional practice. Copies have been sent to all psy-
chologists registered in Ontario. Extra copies are available from the Board office
at cost. (p. 27)
LEGAL CONSIDERATIONS
Shortly before the four proposals for specialty guidelines were for-
warded to APA governance for final action, they were subjected to inten-
sive scrutiny by APA's legal advisors. (Although the review that follows
focuses on the content of the specialty documents, the attorneys' comments
may be interpreted to apply equally to the generic standards.) Among the
matters under consideration were: (a) the extent to which APA might
THE DEVELOPMENT AND ApPLICATION OF STANDARDS 63
just, and fair. They pointed out that this judgment could be made only by
peers. The wide distribution of preliminary drafts of the documents and
their repeated reviews by divisional professional standards committees and
approval by elected representatives to the Council of Representatives
appeared to satisfy the consideration regarding adequate notice of publi-
cation and implementation of the policy statements. The attorneys were of
the opinion that if APA decided to enforce the specialty guidelines in a
manner consistent with the procedures used by the APA Ethics Committee,
this would satisfy the due process requirement.
The attorneys also concluded that for the most part the specialty guide-
lines "appear to provide a clear guide to psychologists as to the conduct
which their profession expects of them." It was their considered opinion,
however, that APA could anticipate certain problems should it attempt to
enforce each and every guideline in a similar manner. Examples of possibly
troublesome items where precise measures of compliance might be difficult
to ascertain included those that referred to psychologists maintaining cur-
rent knowledge of scientific and professional developments that are related
to the services they render; those encouraging psychologists to develop
innovative theories and procedures that they would be prepared to support
on an appropriate theoretical or empirical basis; those that stipulated that
psychologists maintain a continuing cooperative relationship with col-
leagues and co-workers; and the item specifying that psychologists promote
the development of a physical, organizational, and social environment that
facilitates optimal human functioning. This was not meant to imply that
such guidelines could not be enforced. Indeed, it was the attorneys' opinion
that all the guidelines were technically enforceable. What concerned them
was the enormous potential burden that administering an enforcement
mechanism might have on APA staff and financial resources. They raised
the questions as to whether a voluntary professional association should
itself assume the task of policing the conduct of its members to the extent
envisioned by the standards and specialty guidelines. Or should it instead
present its policy statements on practice in a manner that prOVided clear
guidance to the profession and the public while leaVing the job of enforce.:
ment to state licensing authorities? They concluded with the observation
that, should the profession ultimately decide to enforce some or all of the
standards and guidelines of practice, they highly recommended the peer
review mechanism outlined in the Professional Standards Review Committee
Procedure Manual (American Psychological Association, 1975).
SUMMARY
APA has several major options to consider when deciding about future
implementation of its policy statements on practice. At one extreme it could
decide that it would be sufficient to offer its policy statements as guidance
to its members, the profession at large, and the public, and leave the task
of enforcement entirely to others. At the other extreme it could decide to
THE DEVELOPMENT AND ApPLICATION OF STANDARDS 65
In forecasting what the next five years will bring to affect the content
and application of standards and guidelines of practice, one can anticipate
important developments in at least five areas. These are: competency assess-
ment, written documentation of service activities, use of paraprofessionals,
new moves toward regulation of practice, and the emergence of new spe-
cialties in professional psychology.
COMPETENCY ASSESSMENT
DOCUMENTATION of SERVICES
USE OF PARAPROFESSIONALS
to better understand their limits and to hew to defined functions and scope
of operations. On the other hand, psychologists must become more sensi-
tive to their professional accountabilities for the activities of those they
direct and supervise in the course of providing psychological services.
More pervasive and profound than these workaday adjustments are the
professional role changes that will evolve for psychologists as they make
more use of paraprofessionals. These go considerably beyond the pragmatic
question of who will do what for whom, and subsequent division of labor
among the two groups (Jacobs, 1972, 1974). As the broad service functions
that comprise professional practice are systematically subdivided to identify
those methods that can be applied by trained paraprofessionals, the "laity"
acquires skills that previously had been the exclusive prerogative of the
professional. A critical indicator of professionalism is the high degree of
autonomy and exclusiveness that professionals enjoy in the performance of
their work. A potential source of strained relations between professionals
and their paraprofessional assistants is concern that the latter group may
usurp a measure of this independence, thereby blurring the professional's
role and status. This problem will become more acute as the overlap
between historical professional functions and delegated paraprofessional
duties increases. One can expect future revisions of APA standards and
guidelines for practice to show expansion of those sections dealing with the
three-cornered relationship between the professional, the paraprofessional,
and the client. State statues (e.g., in California) have already begun to
address these issues. While organized psychology must wait for accumu-
lated experience to cast more light on these matters, in the final analysis the
key factor determining future use of paraprofessionals will be whether or
not the client has benefited.
REGULATION OF PRACTICE
their own roles in exercising greater control over psychological (and other
professional) services, they likely will give cognizance to the profession's
efforts to do likewise. What is certain is that in the absence of meaningful
and effective self-regulatory actions conducted by the profession, psychol-
ogists are much more vulnerable to controls promulgated by others.
ing group of psychologists was organized to do so. Called the Council for
the National Register of Health Service Providers in Psychology, it devel-
oped criteria to screen voluntary candidates and has published a recurring
directory listing psychologists qualified to provide health services.
Impressed by the success of the National Register, other groups of psychol-
ogists have become convinced that specialty credentialing of this sort
would help them compete with their noncredentialed peers and with spe-
cialists in other professions who were providing similar services to the pub-
lic. These groups included psychologists whose practice had come to be
concentrated on select problems, settings, or populations, e.g., rehabilita-
tion, forensics, mental retardation, gerontology, alcoholism, psychoanaly-
sis, neuropsychology, women, and child clinical. In recent years each of
these groups has petitioned APA for recognition as a specialty of
psychology.
By late 1978 the sum of these pressures from within and outside of APA
prompted the Board of Professional Affairs to convene a Task Force on Spe-
cialty Criteria, charged with reviewing this matter in depth and returning
definitive recommendations for action. In May 1980, the task force submit-
ted its final report, "Characteristics and Criteria of a Specialty in Psychol-
ogy." Sections of that report are quoted below:
Specialties grow out of a history and tradition of service, research and scholar-
ship which identify a relationship between an area of need and a body of rel-
evant knowledge and skills within the profession. The Task Force on Specialty
Criteria recommends creation of a committee, to be called the Committee on
Specialty Designation (CSD), which will recognize specialties in psychology
using the following criteria. All of the criteria must be met by any group wishing
recognition for a specialty in psychology.
I. Criteria for Identification of a Specialty
In order to be designated as a Specialty in psychology, a group applying to
the Committee on Specialty Designation must:
A. Define the specialty in terms of a body of knowledge and a set of skills
related to the knowledge base. The skills of this specialty must have dem-
onstrated efficacy for dealing with particular problems, service populations,
and settings. This demonstration of efficacy would not be restricted to out-
come studies, but would include a variety of research designs and methods.
B. Specify the knowledge and skills of the specialty to be acquired through a
sequential academic curriculum and a professional training program which
include the core knowledge of psychology but go well beyond it. The spe-
cialty academic courses and training may overlap those of other specialties.
However, it is expected that a significant portion of the predoctoral educa-
tion and training of one specialty will be different from the education and
training of another specialty. Ordinarily this entails at least one year of
coursework and supervised training in the specialty predoctoral program
and may require additional postdoctoral specialty training. Psychologists
who wish to "add an additional area of applied specialization must meet
the same requirements with respect to subject matter and professional skills
that apply to doctoral (and post-doctoral) training in the new specialty."
(Standards for Providers of Psychological Services, American Psychological
Association, 1977b)
THE DEVELOPMENT AND ApPLICATION OF STANDARDS 71
chology, and the American Society for Clinical Hypnosis. The task force
recommended that APA adopt the term special proficiency to recognize the
mastery of a special skill, special technique, or indepth knowledge of the
needs of a specific population or problems of a specific setting. A special
proficiency is not bound to anyone specialty of psychology. Some are not
even unique to the profession of psychology. Working with certain popu-
lations (e.g., the aged, children, women, or the developmentally disabled)
or in some settings (e.g., schools or prisons) may require one or more special
proficiencies. The task force noted examples of special proficiencies com-
monly utilized in three major areas of psychological practice:
1. Behavior change (e.g., psychoanalysis, hypnosis, group therapy, bio-
feedback, behavior modification, marriage and family therapy, sex
therapy, vocational counseling)
2. Evaluation or assessment (e.g., neuropsychological assessment, com-
petency evaluation, program evaluation, market surveys, consumer
research and product evaluation)
3. Consultation (e.g., management consultation, organizational devel-
opment, and consultation to organizations such as police, schools,
military, community agencies, industries, courts and health
facilities)
The criteria finally proposed by the task force emphasized that a spe-
cialty of psychology represented an integration of basic knowledge ,and
skills, acquired during doctoral preparation for practice within a broad sub-
ject matter area of psychology. Many special proficiencies could be sub-
sumed within a given specialty area. The task force endorsed APA's posi-
tion that general providers of psychological services should not be
prevented from using the methods or dealing with the populations of any
specialty except insofar as they voluntarily refrained from prOviding ser-
vices that they were not competent to render. (American Psychological
Association, 1980c, p. 1)
EPILOGUE
One might conclude from the above discussion that the road ahead for
professional psychology is beset with challenges on all sides. Although lit-
erally true, such a conclusion would fail to recognize that the issues asso-
ciated with the development and implementation of standards and guid-
lines for practice are but necessary stepping stones on the way to full
maturation of the profession. Psychologists are not alone in being held
increasingly accountable for the efficacy and quality of the services they
provide and for the adequacy of outcomes obtained by virtue of their inter-
ventions. This reflects the tenor of the times. It represents the new relation-
ship that a much more sophisticated public is demanding between itself and
each of the helping professions. APA's continuing commitment to develop
THE DEVELOPMENT AND ApPLICATION OF STANDARDS 73
and revise its standards and guidelines for practice is the hallmark of a
responsible profession. It reflects the high ideals of American psychology
and the confidence it has in its own vitality and ability to achieve the goals
it has set. For these reasons, the road ahead should lead to substantial
rewards both for those who will receive psychological services and for
those who will provide them.
REFERENCES
Midwestern Psychological Services, Inc. et al. v. Potts and Potts, 79 AP-339 (Court of Appeals,
Franklin County, Ohio. 1979). (Decision rendered December 13, 1979.)
National Association of School Psychologists. Standards for the provision of school psychological
services. Washington, D.C.: Author, 1978.
National Federation of Societies for Clinical Social Work. Standards for health care providers in
clinical social work. Washington, D.C.: Author, 1976.
Ontario Board of Examiners in Psychology. Standards for Professional Conduct. Ontario, Canada.
Author, 1978. (Revised June 1980)
Ontario Board of Examiners in Psychology. Psychologists registration act: Regulations and guide-
lines. Ontario, Canada: Author, 1980.
U.S. Department of Health, Education, and Welfare. Standards for rehabilitation facilities and
sheltered workshops. Washington, D.C.: Vocational Rehabilitation Administration, 1967.
U.S. Department of Health, Education, and Welfare. PSRO Program Manual. Washington,
D.C.: Office of Professional Standards Review, 1974.
Wyatt v. Stickney. Constitutionally required minimum standards for adequate treatment of
the mentally ill. Judgment issued by U.S. District Court, Alabama, April 21, 1972.
3
Ethical and Professional Standards in
Psychology1
GERALD P. KOOCHER
IThis chapter was completed early in 1979, shortly after the APA Council of Representatives
approved the revisions of the 1979 Ethical Standards of Psychologists. Unforeseen delays by
other authors of this volume postponed submission of the manuscript to the publisher until
mid-1981. On January 24,1981, the APA Council of Representatives adopted a new revision
retitled: Ethical Principles of Psychologists. This document was published in the June, 1981,
issue of the American Psychologist (36, 6, 633-638).
The 1981 revision includes both substantive and grammatical changes over the 1979
version. The basic principles and thrusts of the ethics code as discussed in this chapter, how-
ever, remain unchanged. Behavior considered problematic in 1979 is not suddenly approved
and this chapter is by no means obsolete. The changes basically revolve around which issues
77
78 GERALD P. KOOCHER
HISTORICAL PERSPECTIVES
were of most current concern to the governance of the APA. There are, however, four new
twists that are deserving of the reader's notice.
First, a 10th principle, "Care and Use of Animals," has been added. This was drafted by
a special subcommittee and was intended to formalize in the ethics code what had hereto-
fore been less explicit guidelines without substantial enforcement mechanisms. Principle
nine, "Research with Human Participants," was also reworked substantially in keeping with
federal guidelines and current practices. Principle seven, "Professional Relationships," was
also made more explicit. This is especially true of section 7c which defines "sexual harass-
ment" as a specific ethical violation. Finally, and perhaps most reflective of recent changes
in American culture, Principle four, "Public Statements," has been rewritten in much more
explicit fashion. Advertising in the broadcast media and participation in broadcast talk
shows are among the areas impacted. In general the new principle is based on the concept
that relevant consumer information may be communicated via the media. So long as adver-
tisements are now explicitly announced as such and are not false, deceptive, based on mis-
interpretation, testimonials, appeals to fear, exaggerated claims, or direct individual solici-
tations, they may be appropriate. In the past there was also a prohibition against the giving
of "personal advice" by means of the public media. This blanket ban is now lifted on the
basis that such advice is likely to be demanded in a variety of quarters and it is preferable
that it come from well-trained colleagues rather than from others who might not meet the
standards of adherence to the ethics code. Psychologists who choose to provide such advice,
however, are enjoined to exercise the highest standards of professional judgment.
ETHICAL AND PROFESSIONAL STANDARDS IN PSYCHOLOGY 79
annual reports available to the APA membership. The reports appear in the
December issues of the American Psychologist beginning with the 1979 vol-
ume. In addition to reporting on the types of cases investigated these
reports will include suitably disguised descriptions of different or recalci-
trant cases in a fashion that hopefully will prove useful in guiding psy-
chologists and preventing similar problems in the future.
Whereas the Ethical Standards and Rules and Procedures are generated by
CSPEC, many other boards and committees of the APA are concerned with
professional and scientific ethics and standards. Thus, although CSPEC is
the main organizational structure for dealing with ethical infractions, the
various policy statements noted previously are products of other boards,
committees, or task forces. Given this level of complexity it is important to
recognize how these different groups, and policy statements they evolve,
interact. When it comes to drafting policy statements, the board or commit-
tee initiating the project invariably will circulate draft copies to the mem-
bers of the other panels for comment. Each board or committee has staff
member liaison at the APA central office, thus making it possible for coop-
erative sharing of policy formulations between the different groups whose
members may meet formally only a few times per year.
Within the APA there are at least three different standing boards or
committees empowered to receive and investigate various complaints on
ethical matters-CSPEC and two other groups known by the acronyms
BSERP and CAFCOE.
CSPEC currently consists of seven APA members elected for staggered
3-year terms by the Council of Representatives. The members must be cho-
sen to reflect the range of interests characteristic of psychology in all of its
aspects and be drawn from different geographical areas (American Psycho-
logical Association, 1976). In addition to being the point of origin for
amendments to the Ethical Standards, this body is broadly empowered to
receive complaints against individual members, investigate those complaints,
and take a wide range of disciplinary actions (Committee on Scientific and
Professional Ethics and Conduct, 1974). CSPEC meets at least three times a
year in Washington, D.C., to review cases and issues, but between meetings
correspondence and coordination is managed by the administrative officer
for ethics, who is a doctoral-level psychologist on the senior staff of the
APA. All investigations of CSPEC are confidential and focused on individual
members.
CSPEC has wide discretion in decisions about actions to be taken when
charges of an ethical infraction are sustained. These may range from a "cen-
sure" or "reprimand," which are confidential admonitions to the member
psychologist from CSPEC, to a recommendation of expulsion to the board
of directors of APA.
ETHICAL AND PROFESSIONAL STANDARDS IN PSYCHOLOGY 81
Up to now this chapter has focused on the various ethical codes and
related policies of the American Psychological Association. Although all
APA members, nearly 50,000 as of this writing, are bound by the organi-
zation's Ethical Standards of Psychologists, they have chosen to abide by them
voluntarily. That is to say, they choose to uphold these standards as a func-
tion of organizational membership. Since many psychologists do not
belong to APA, it would seem that they are not bound by the same stan-
dards. In the jurisdictional sense that is quite true, although technically
most licensed psychologists in the United States ultimately become respon-
sible for upholding the same standards or very similar analogues.
82 GERALD P. KOOCHER
The ideal manner for coping with ethical dilemmas is preventive antic-
ipation, and that is the main purpose of this chapter. By giving careful con-
sideration to the sorts of problems that may confront the professional psy-
chologist from time to time, it should be possible to avoid many common
pitfalls, especially since, as noted earlier, many ethical violations result
without malicious intent or awareness on the part of the psychologist
(Keith-Spiegel,1977).
For the purposes of this chapter, ethics are defined as the principles of
conduct governing an individual or group, including the specific duties and
obligations that are a part of the professional psychologist's role. These will
be discussed in more explicit detail later in the chapter. First, consider the
circumstances wherein the psychologist is faced with a situation recognized
as posing some ethical questions. An initial step would be to seek consul-
tation with colleagues about the problem and discuss the ethical issues and
alternatives. When colleagues are not readily available for such discussions,
state association ethics committees can generally be quite helpful. Often the
chair of such committees will be willing to offer informal consultation
ETHICAL AND PROFESSIONAL STANDARDS IN PSYCHOLOGY 83
For this reason APA and most state associations permit resignations to be
accepted only by their boards of directors and such boards will not permit
resignation by members under investigation for ethical infractions until the
investigation is completed. Otherwise, a member being investigated for an
ethical infraction could choose to resign, thereby dropping out of the orga-
nization's jurisdiction.
For the sake of illustrating the process, I shall assume that is has
become necessary to pursue a complaint against an APA member by com-
plaining to CSPEC. The complainant should write a confidential letter to
the administrative officer for ethics including the following information:
the name of the member psychologist being complained against, the spe-
cific behavior found objectionable, and the reasons why this was considered
to be unethical. Information about unsuccessful attempts to resolve the mat-
ter informally or reasons why this was not attempted also would be helpful,
as would any documentary evidence supporting the complaint. The admin-
istrative officer will share this information with the chair of CSPEC in order
to determine whether the behavior described would, if true, constitute an
ethical infraction. If there seems to be some doubt about this, the full com-
mittee is asked for an opinion. Once it is determined that the matter could
fall within the committee's purview the complainant will be asked to
authorize the use of his or her name in contacting the psychologist com-
plained against. The complainant also will be provided with documents
outlining the procedures to be followed in the investigation (Committee on
Scientific and Professional Ethics and Conduct, 1974; APA, 1977a). This per-
mission is required because a person has a right to know the name of the
accuser, and unless such permission is granted the case cannot go forward.
One exception to this rule is that the CSPEC may act sua sponte (i.e., without
a specific complainant) when it has information available from a public
source (e.g., a newspaper report of a psychologist who has pleaded guilty
to insurance fraud, a questionable advertisement that was sent through the
mail, or questionable public statements reported over the broadcast media
that are called to CSPEC's attention). In such cases, however, the party com-
plained against may be told the source of the data (e.g., newspaper clipping,
pamphlet, or broadcast) on which the complaint is based.
When a case is opened, the secretary writes to the psychologist con-
cerned requesting a written response to the ethical concerns in question.
CSPEC need not share all the data it has available with the party com-
plained against, but does detail in the· inquiry letter all of the potential eth-
ical issues it is concerned with and provides copies of the same procedural
documents sent to complainants. Inquiry letters generally are sent by cer-
tified mail, are considered confidential correspondence between the party
complained against and CSPEC, and usually require a response within 30
days. It is not unusual, however, for extensions of time to be granted for
reply when extenuating circumstances require it.
Occasionally CSPEC will receive a response from an attorney rather
than the psychologist member or will be notified that litigation is pending
ETHICAL AND PROFESSIONAL STANDARDS IN PSYCHOLOGY 85
on matters related to the case. While responses from the attorney of the
psychologist being complained against are often substantive, CSPEC gen-
erally requires a personal response from the psychologist in recognition of
the fact that professional ethics revolve on the cornerstone of peer review
rather than legal process per se. If litigation is pending on a matter that
CSPEC is investigating the case will be opened and tabled pending the out-
come of the litigation. Although every effort is made to ensure fairness and
due process to all parties involved in an ethics inquiry, strict legal rules of
evidence do not apply. In one recent case, for example, a psychologist who
was convicted of a misdemeanor involving an assault on a patient admitted
committing the act but expressed the opinion that an ethics charge should
not be sustained against him since the evidence presented at his court hear-
ing on the charge was obtained illegally. While a court of law may ulti-
mately clear the psychologist of the charge on that technicality, CSPEC
determined that the behavior was unethical regardless of the circumstances
under which the charge of assault was brought.
Only rarely is it necessary to proceed with a formal hearing or fact-
finding panel as discussed in the rules and procedures of CSPEC (1974).
Such hearings are convened chiefly when CSPEC determines that the accu-
sations against the member psychologist might warrant, if true, expulsion
from the APA. In such cases the member psychologist may be asked to
appear before CSPEC sitting as a hearing panel in Washington, D.C., or par-
ticipate in an ad hoc fact-finding procedure arranged locally for the con-
venience of the member and witnesses. Often CSPEC is able to reach a deci-
sion on the basis of evidence collected through correspondence, court
transcripts, or other documentary materials.
Formal sanctions are rarely needed since most ethics panels consider
themselves to be educative first and punitive only when absolutely neces-
sary. In many instances psychologists simply may consent to change certain
questionable practices, desist from others, obtain supervision or consulta-
tion in the community, take some remedial actions, or otherwise improve
the circumstances that led to the initial complaint. When a spirit of coop-
erative colleagiality is demonstrated, ethics panels are generally inclined to
avoid a formal fault-finding process. The critical variable is generally
whether or not a client has been harmed and the extent to which that can
be remedied or prevented in the future. The word client as used above also
may be interchanged with student, patient, colleague, or any other person
or group with whom the psychologist interacts in a professional capacity.
It should be noted that any person may complain to CSPEC, not simply
APA members. This causes difficulty from time to time when, for example,
a person who seems to be psychotic or otherwise severely disturbed issues
a rambling complaint against a member psychologist. The investigation
proceeds in exactly the same sequence as if the complaint came from a lead-
ing colleague in the profession. CSPEC members obviously may take the
bizarreness of the complaints into account in reaching a decision as to
whether an ethical violation has in fact occurred, but every potential com-
86 GERALD P. KOOCHER
plainant is given a fair hearing. CSPEC members realize that the nature of
our profession is such that not all of our clients (and colleagues) are fully
rational at all times.
The most difficult cases facing CSPEC are those in which the parties
involved exchange claims and counterclaims while presenting little palpa-
ble evidence. Often such claims come down to being the word of one per-
son against another, and CSPEC has no choice but to close the case with no
finding. It is also not unusual for some cases to drag on for years because
they are interrupted by litigation, delays in obtaining information, and the
fact that the full CSPEC meets just three times per year. Both sides in the
dispute may become angry at the committee members for the long time
needed to collect all the data, and angrier still when their particular views
are not upheld.
There are certain circumstances when CSPEC acts more swiftly than
usual. For example, when APA is notified that a member psychologist has
been expelled from a state psychological association or has been convicted
of a felony related to his or her practice as a psychologist, the administrative
officer for ethics and chair of the CSPEC may act immediately upon a review
of the hearing or court transcript to suspend temporarily the member's APA
membership and send a "show cause" letter. This letter asks the member to,
"show cause why you should not be expelled from the American Psycho-
logical Association" for the same reasons that led to the precipitating action
at the state level. The full CSPEC will then proceed to evaluate the case as
outlined above.
As noted earlier, the most severe penalty that CSPEC can recommend
is expulsion from the APA, just as the most severe penalties at local levels
may involve expulsion from a state association or suspension of licensure.
While loss of license to practice has clear economic impact, the impact of
disciplinary action by a professional association may be less obvious, but
still substantial. To begin with, APA and most state associations are permit-
ted by their by-laws to notify each other, relevant state licensing boards,
and the American Board of Professional Psychology regarding any ethical
charges that have been sustained against a member. Therefore, even if a
psychologist is simply censured in a confidential letter from the local or
national ethics committee, this information may be shared with other rel-
evant bodies at the discretion of the originating group. In some cases the
psychologist must report being found guilty of an ethical infraction since a
question aimed at this point is asked on virtually every license application,
license renewal form, professional association membership form, and mal-
practice insurance application. Giving false information on such forms after
one has already been found guilty of a prior infraction would be viewed
very harshly by ethical review panels. When the ultimate sanction of a
professional association, expulsion, is invoked, the members of the associ-
ation often are sent a confidential notice of that action. This may make it
very difficult for an expelled psychologist to work effectively in the profes-
sional community.
ETHICAL AND PROFESSIONAL STANDARDS IN PSYCHOLOGY 87
nuances in training and may assume that the practitioner skilled in indi-
vidual psychotherapy also is competent in group therapy practice or that
any licensed psychologist automatically has been qualified to work with
child clients. Unfortunately, some psychologists make the same mistake and
treat their degree(s) as license to practice in any aspect of applied psychol-
ogy whether or not they have had specific training with the technqiues or
special client populations concerned. It is essential that the ethical psychol-
ogist be self-limiting in this respect, since the public at large will generally
be unable to do so.
Example: A licensed psychologist whose practice was limited to psychotherapy
with adults was asked to give testimony in a child custody hearing in support
of the child's father who was the psychologist's client. During the course of the
hearing an attorney and the judge asked specific questions about the emotional
status of the child, with whom the psychologist had only had transitory contact.
The psychologist proceeded to give his opinions which were accepted by the
court as "expert" testimony. The psychologist who actually had treated and
evaluated the child called the matter to the attention of an ethics panel. After a
careful review of the trial transcripts the panel concluded that the father's psy-
chologist had gone well beyond the bounds of his professional competence in
offering his opinions when he should have advised the court that he was not
competent to address those issues.
indicating that formal hiring by the governing board of the center was a mere
technicality. When the latter psychologist and her spouse visited the town for
a final interview, some local eyebrows were raised by virtue of the now evident
fact that theirs was an interracial marriage. Following the visit, the psycholo-
gist-director responded to the wishes of those on the governing board by with-
drawing the job offer. He told the applicant, "Your values are clearly out of line
with community standards and you just wouldn't fit in well," thereby condon-
ing and supporting unethical and illegal discriminatory practices.
PUBLIC STATEMENTS
should strive for honesty, modesty, and the scientific caution appropriate to
the context. In some ways the issue of public statements in general relates
quite closely to the general issue of responsibility as discussed previously.
That is to say, the psychologist must be especially careful not to mislead the
public using his or her role as a professional in the community. This
includes not only the statements made by the psychologist her/himself, but
also statements made in the psychologist's name by advertising agencies,
talk-show hosts, magazine editors, or others. As with many types of poten-
tial ethical problems, a bit of forethought can forestall considerable diffi-
culty later on.
Maintaining control of how one's name is used will be a critical point to
remember. If a psychologist is involved in helping to devise a new instru-
ment, a textbook, or similar product, it would be wise to insist on the right
to review advertising copy in advance. If an article is written for a popular
magazine with the understanding that the editors "reserve the right to edit
for style," the psychologist should in turn insist on reviewing the final copy
for accuracy. In granting interviews, especially on live broadcast programs,
it is a good idea to meet with the interviewer and discuss the topic material
in advance. The same holds true for granting interviews with the writing
press. If you cannot fully trust the accuracy and judgement of those who
will be reporting on the interview, it might be best not to grant it.
Colleagues and members of the public frequently will call bizarre or
outrageous media "comments" by psychologists to the attention of ethics
panels. Often an investigation reveals that the psychologist who was
"quoted" or interviewed is equally shocked or embarrassed by the context
in which the comments were misinterpreted or reported. Whenever a psy-
chologist suspects that his or her name may be used in public, especially
when linked to a product or potentially sensational story, the thought
"How can I ensure accuracy?" should come to mind.
Advertising by psychologists has become an issue of considerable interest
since the Federal Trade Commission began taking steps to remove barriers
to public advertising that professional associations had tended to erect
(Koocher, 1977). Essentially, advertising by psychologists will probably be
considered "ethical" if the material uses appropriate modesty, due scientific
caution, and full respect for the limitations of our current state of knowl-
edge and represents the psychologist's qualifications and credentials accu-
rately. In that light, most simple factual statements about services being
offered to the public are probably reasonable. Advertising by psychologists
should avoid direct solicitation of individual clients, except that industrial
and organizational psychologists whose clients usually are corporations are
generally permitted to solicit these clients directly.
Example: The industrial/organizational psychologist who has designed an
assessment center program (e.g., Bray, 1976, 1977) for evaluating potential can-
didates for corporate executive positions would not be out of line by sending
pamphlets about the program to personnel managers at potential client corpo-
rations (assuming that the material in the pamphlets was accurate and not mis-
ETHICAL AND PROFESSIONAL STANDARDS IN PSYCHOLOGY 91
manner. The use of due caution, scientific modesty, and avoidance of sen-
sationalism or undocumented claims will go far in preventing careless eth-
ical infractions.
legal fashion may actually enhance the emotional climate of the relation-
ship by involving the client actively and helping the psychologist to con-
sider the client's welfare in greater detail. Specific illustrations of ways in
which psychologists can use contracting to provide clients with informa-
tion needed to make informed decisions, to respond to challenges to one's
competence by clients, and to handle client's complaints may be found in
a recent paper by Hare-Mustin and her colleagues (1979). Their article is
based on an open-communication model that attempts to foster more effec-
tive client-psychologist interactions by modeling techniques. A sample
contract and client-psychotherapist dialogue are provided to illustrate ways
in which ethical standards can be applied in an effective fashion.
Privilege and confidentiality are frequently confused concepts presenting
controversies to which the professional psychologist should be sensitive.
Privilege (or privileged communication) is a legal term characterizing the
quality of specific types of relationships that prevent information learned
as part of such relationships from being disclosed in court or other legal
proceedings. Privilege is granted by law and belongs to the client in the
relationship. Where privilege exists the client is protected from having his
or her communications revealed without explicit permission. If the client
waives this privilege, the professional may be compelled to testify on the
nature and specifics of material discussed. Traditionally, such privilege has
been extended to the attorney-client, husband-wife, physician-patient,
and priest-penitent relationships. Some jurisdictions now extend privilege
to psychologist-client or psychotherapist-client relationships, but the
actual laws vary widely, and it is incumbent on each practitioner to inves-
tigate the status of communications with clients locally. Privilege is also not
absolute, as in the case when a professional may be legally obligated to
report child abuse, gunshot wounds, or communicable diseases (Siegel,
1979; Swoboda et al., 1978).
In contrast with privilege, confidentiality refers to a general standard
of conduct that obliges a professional not to discuss information about a
client with anyone. Confidentiality also may be based in law (Swoboda et
al., 1978) but, as far as this chapter is concerned, focuses on ethics instead
of law and implies an explicit contract or promise not to reveal anything
about a client, except under certain circumstances agreed to by both source
and subject. Although confidentiality began as an ethical principle, it does
have legal recognition. For example, a client could sue a psychologist in a
civil action for breach of contract based upon a violation of confidentiality.
The controversy comes into play chiefly around the issue of whether
or not a psychologist may be ethically permitted to breach confidentiality
under certain circumstances. The focus of the controversy is centered on the
"clear and imminent danger" clause of the Ethical Standards (American Psy-
chological Association, 1977a, p. 4). This refers to the consideration of risks
posed by the client of psychologists to themselves or to other persons.
Essentially, the point is that a psychologist is not considered unethical for
a limited disclosure of confidential material (without consent of the client)
ETHICAL AND PROFESSIONAL STANDARDS IN PSYCHOLOGY 97
to the extent that such disclosure was necessary to prevent harm in the face
of a clear and imminent danger.
Example: The client of a psychologist telephoned his office "to say goodbye" and
related that she had just ingested a quantity of sleeping pills. She lived alone
and had sought help in dealing with a number of depressive issues. She related
that she was now feeling "too helpless and tired to go on and am going to sleep
permanently," hanging up before the psychologist could engage her in a dia-
logue. The psychologist immediately dialed the client's number and got a "busy
signal." A call to the telephone operator led to information that the phone was
"off the hook," so the psychologist immediately telephoned the police. He
informed the police of the client's name, address, ana his concern that she was
attempting suicide at the moment. When the police arrived at the client's apart-
ment she was discovered to be well and unharmed, although depressed and
overtly angry at the psychologist for sending them to "check up on me." She
subsequently filed an ethics complaint against the psychologist in question.
Given the very real risk of possible suicide, the limited nature of the psychol-
ogist's disclosure, and the potential danger of inaction, the ethics panel deter-
mined that the psychologist'S response was entirely appropriate given the
circumstances.
Not all psychologists agree with the "imminent danger" concept, and
some assert that a psychologist should never disclose confidential informa-
tion, without the informed consent of the client (Dubey, 1974; Sigel, 1976,
1979). Siegel in particular argues that one should strive at all costs to keep
the therapeutic relationship intact and use it as a means to reduce the immi-
nent danger or risk, claiming that this is almost invariably possible (1976).
This extreme position could easily land a psychologist in jail because it may
be in direct violation of the law in some cases. Although this position is
clearly a minority viewpoint, it has its share of proponents. The reader with
strong interests in this dilemma will want to read the American Psycholog-
ical Association Task Force on Privacy and Confidentiality Final Report
(1977) for an overview of recent developments.
When law and ethical principles diverge (e.g., when a confidential
communication is not privileged in the eyes of the law) the situation
becomes extremely complex, but it would be difficult to fault a psychologist
ethically for divulging confidential material if ordered to do so by a court
of competent authority after exhausting appropriate appeals. On the other
hand, is it unethical to be in violation of the law if you believe that you are
behaving ethically by violating it? Students of ethical philosophy will
immediately recognize a modern version of the controversy developed in
the writings of Immanuel Kant and John Stuart Mill. Is it the intention of
the actor that should be judged or solely the final outcome of the behavior
that matters? Clearly, the answer will not be found in these pages. Each
situation is different but the most appropriate approach to evaluating a case
would be to consider the impact of alternative courses of action and choose
in terms of what outcomes might reasonably be expected. In general, how-
ever, it will be an extremely rare situation that justifies violating the law in
order to behave ethically.
98 GERALD P. KOOCHER
action. There may be no single ethically correct answer in such cases, but
the psychologist also must consider what is required by law.
Perhaps the ultimate irony of the Tarasoff case in terms of outcome is
what happened to Poddar. His original conviction for second degree mur-
der was reversed because the judge had failed to give adequate instructions
to the jury concerning the defense of "diminished capacity" (People v. Pod-
dar, 1974). He was convicted of voluntary manslaughter and confined to the
Vacaville medical facility in California. He has since been released from
confinement and "has returned to India, and by his own account is now
happily married" (Stone, 1976, p. 358).
If there is a prospective means to avoid such dilemmas in one's practice,
three separate aspects are probably involved. First, each psychologist must
come to terms with the circumstances under which she or he will breach
confidentiality or privilege. Consultation with an attorney about the law in
the jurisdiction where the psychologist practices would be a very helpful
part of this process. Second, the psychologist should make these conditions
or limitations clear to potential clients from the outset of any professional
relationship either orally or in written form (Hare-Mustin et ai., 1979).
Finally, should an actual circumstance arise bearing on these issues, a con-
sultation with colleagues to sort out alternatives that may not have come to
mind initially might be appropriate. These steps will not solve all such
problems but might reasonably be expected to reduce their potential
occurrence.
Third-party access to confidential information is a relatively recent problem
as far as the profession of psychology is concerned, but as insurance cov-
erage to psychologists as health care providers increases, so will the poten-
tial dangers. When insurance coverage is used to pay the psychologist's bill
a claim form must be filed listing dates and types of services rendered along
with a diagnosis. Insurance companies routinely exchange personal data on
policyholders with central records facilities, and the claim forms pass
through the hands of secretaries, clerks, computer programmers, and insur-
ance agents. Such individuals are not accountable to a code of professional
ethics and few people know how carefully or carelessly such confidential
information is handled once it leaves the psychologist's office. While it may
seem that the stigma has gone out of seeking mental health care, that is
often not the case. For example, Senator Thomas Eagleton was forced to
resign as a vice-presidential nominee when his past history of treatment for
depression became public knowledge.
Some psychologists believe that they are helping their clients in this
respect by submitting claim forms with diagnoses of "adjustment reaction."
Aside from the potential fraud inherent in listing a false diagnosis, the prac-
tice of using such benign diagnoses to protect the client may result in a
hearing before a professional standards review committee (see Chapters 9
and 10). For example, an insurance company may become suspicious when
a patient requires hospitalization or months of protracted psychotherapy
for the treatment of an "adjustment reaction."
The whole question of providing information on clients to third parties
100 GERALD P. KOOCHER
is a controversial one (Jagim et al., 1978), but it seems wise to let the client
make an informed choice whenever possible.
Example: Part of the dialogue with a new client may go something like this: "As
you know, your health insurance company will help to cover the cost of psy-
chological services for you. In order for me to collect my fees from them, I shall
have to complete some insurance forms that will create a record in the insurance
company's files that I treated you, including the dates of our appointments and
the diagnosis or name of the problems I treated you for. Insurance companies
usually claim to keep such information confidential, but once it is in their hands
I have no control over what they do with it or who may see it. If you are con-
cerned about that you may want to check with your insurance company before
authorizing me to bill them. You have the option of paying me directly, if you
wish, rather than using your insurance coverage and creating a record outside
of this office."
Spiegel (1977) notes that a secret shared in confidence may seem quite mun-
dane to many but be extremely important or embarrassing to the client. She
also observes that sharing someone else's secret with a third party has the
effect of reducing its impact. That is to say, it is easier to pass on a once-
removed secret than a secret received directly from the source.
Example: A psychologist in a small town let out information about a client's
physical illness to another psychologist in the course of conversing about that
illness in general. While most people would agree that the illness in question
was no cause for shame, the client suffered considerable anguish at having been
"discovered." The psychologist who was told the information let it out to a
more general audience at a cocktail party attended by one of the client's friends.
The client brought ethical charges against the first psychologist. He was deeply
regretful over the incident and fortunately was able to resolve the matter infor-
mally apologizing to the client, who graciously accepted it. Unfortunately other
psychologists too often learn their "keep-your-mouth-shut" lesson with consid-
erably more agony. (Keith-Spiegel, 1977)
PROFESSIONAL RELATIONSHIPS
In some circumstances the case cited above may lead the psychologist
into a double bind situation. Some jurisdictions may have laws that require
the reporting of felonies. In this case the behavior of the former therapist
may constitute felonious assault and there may be a risk to future patients
who seek him out. I would argue that even if the law reqUired reporting
the felony "for the greater good of society," this could cause substantial
emotional stress for the client who has come seeking confidential treatment.
To violate her wishes in favor of the more diffuse "public good" would be
tantamount to inflicting a second emotional assault to a specific victim in
the hope of preventing harm to persons unknown. I would therefore favor
respecting and protecting the vulnerable client, even if that meant com-
mitting a technical violation of the law. I would encourage and support her
in reporting the situation, if she felt able to do so, but I would not undertake
this myself without her full informed consent.
In other situations where possible ethical violations come to the atten-
ETHICAL AND PROFESSIONAL STANDARDS IN PSYCHOLOGY 103
matter with the questioner. Ideally, however, such a step should rarely be
necessary.
CONCLUSION
By this point I hope that the reader is left with at least four principal
strategies for maintaining a practice with high ethical standards. First, be
informed. Be familiar with the policies, techniques, practices, and issues that
can be expected to crop up as a part of delivering psychological services.
Keep abreast of current developments and be aware of the changing nature
of professional psychology. Second, be sensible. Common sense, a cooperative
spirit, openness, and honesty will go far to enhance relationships with
clients and fellow professionals alike. Third, think preventively. Attempt to
identify potential ethical dilemmas before confronting a crisis situation.
Formulate the best approach to the problems based on the nature of your
own skills and the nature of your practice. Take anticipatory steps to min-
imize the likelihood of ethical infractions and potential related conflicts. Do
not be afraid to use written agreements or understandings to clarify rela-
tionships with clients and colleagues and by all means do not presume that
your own assumptions about the nature of your relationships with others
automatically will be understood and supported by them. Finally, ask for
advice. Seeking guidance from colleagues, ethics panels, professional stan-
dards review committees, and others is an important means of validating
108 GERALD P. KOOCHER
ACKNOWLEDGMENTS
REFERENCES
111
112 ROBERT M. GUION
information. This chapter, unlike the Standards, will place the emphasis on
the development of measurement instruments, if for no reason other than
the seemingly widespread use of individualized, personalized measures by
individual practitioners. What will be presented is a set of principles for the
development and use of techniques for making quantitative inferences,
whether the techniques are to be widely distributed or retained for the pri-
vate use of the developer. As in the Standards from which they are derived,
the principles can be adhered to fairly rigidly if one is developing a paper-
and-pencil test of an attribute that has been well defined in the research
literature and measured successfully in the past. If, however, one is devel-
oping a novel technique for assessing characteristics less well established,
or if one is required to use measurement techniques that must be developed
quickly for an immediate need, one cannot follow these principles at all
closely. In the latter case, however, one can examine the Standards and these
principles and use them as a guide to the best professional practice circum-
stances will permit. They identify the questions that one ought to be asking
when setting out to develop even an informal approach to assessment-
even if the questions prove unanswerable.
This chapter builds on the official documents, particularly on the 1974
version, plus the experiences of the author over the years subsequent to the
publication of that document. A brief demurral is needed. Since this author
was identified in the foreword of the 1974 Standards as its principal author,
some readers might confuse the statements here with the official positions
of the three sponsoring organizations. This would be unwise. In the first
place, this author was only one member of the joint committee, even
though a recording member. The document is the result of long delibera-
tions, arguments sometimes bordering on the acrimonious, and compro-
mise. It is more than likely that different members of the committee would
still interpret specific provisions in different ways. Moreover, the choice of
principles to be emphasized and the inferences about principles of test
development are based on this author's opinions and points of view that in
many cases have been developed subsequent to the publication of the 1974
Standards. This chapter, then, must be recognized as solely the expressions
of this one author, not those of the committee that developed the 1974
Standards.
1. The attribute to be measured should be defined and stated clearly. One does
not measure people; one measures attributes of people. A measurable attrib-
ute is considered to exist in differing degrees; that is, it is a variable or a
dimension. Measurement should result in a numerical designation or score
that will be taken as a measure of that variable. The person who develops
the methods of arriving at that number should have fairly clearly in mind
what that number is supposed to mean. The measurement should be
planned and articulated well enough that the resulting measurement can
be used by other people without likelihood of misinterpretation.
It is helpful to distinguish between the operational definition of a var-
iable and a conceptual definition of that same variable. A conceptual defi-
nition can be stated in words. These words describe, as well as the devel-
oper can, the nature of the attribute and, perhaps, defining relationships of
that attribute to other dimensions. Operational definitions are the proce-
dures by which the attribute is actually measured. There ought to be some
congruence or agreement between the operational and the conceptual def-
initions. Informed people should be able to examine a set of operations and
reach an informed agreement that these operations lead to numbers that
116 ROBERT M. GUION
1 References in this chapter to particular statements of Standards are to the numbered state-
ments in Standards for Educational and Psychological Tests, APA et al., 1974. Since the chapter
is written largely as a summary or precis of that document, it should be close at hand while
one is reading this chapter. Even after a subsequent revision is prepared, which seems inev-
itable, the reader should try to identify its relevant provisions and see how the most current
version of the Standards treats these principles.
STANDARDS FOR PSYCHOLOGICAL MEASUREMENT 117
variety of item types. A test developer can specify these and, perhaps, limit
the test content domain to one or two types of items that have been espe-
cially effective in defining the factor. In short, in developing any test,
checklist, or inventory, a test developer should be able to specify the kinds
of items that best reflect the attribute being measured.
If there are several categories of items fitting the domain, then relative
frequency, relative importance, or relative complexity of the categories
could be invoked in setting rules for sampling from the more general con-
tent domain. The rules or procedures for sampling should be so well spec-
ified that other observers or test developers, including those who may pre-
fer a different domain definition, can judge whether the domain as defined
has been adequately sampled.
Special effort should be taken in test construction to avoid inappro-
priate bias in selecting or creating items. Two kinds of bias should be mat-
ters of concern. One is content bias, in which some content areas have a
representation in the test that is inconsistent with the rules for domain sam-
pling. The other consists of an interaction of response tendencies to indi-
vidual items with subgroup identification.
Relevant Standards include E9, E12, E12.2, E12.1.2, and E12.4. While
most of these Standards were written explicitly for evaluating measures in
terms of so-called content validity, the test developer should recognize that
the validity of any measure depends in part on how well the content of the
measuring instrument can be justified in terms of the purposes of
measurement.
2. Items and item responses should be analyzed so that contaminating items
may be eliminated. Conventional item analysis consists of using a set of
responses to items to compute item difficulty and item discrimination sta-
tistics. A more complex item analysis might estimate the parameters of item
characteristic curves relating the probability of a correct response to level
of latent ability (Hambleton & Cook, 1977). In either case, the intent is to
identify items that will arrange themselves along a Single continuum. That
is, the intent of such item analysis is partly to select items for inclusion in
a final form to assure that the measuring instrument will distinguish
between people with varying degrees of a single homogeneous attribute.
The requirement of homogeneity has often been misunderstood.
Homogeneity might be synonymous with factorial purity, but it need not
be. Homogeneity refers simply to unidimensionality, the notion that a
dimension can be identified in which transitive relationships constitute the
rule. A transitive relationship is one in which b > a, c > b, and therefore
and necessarily, c > a (Coombs, Dawes, & Tversky, 1970). If these relation-
ships are not consistent, then the fundamental measurement requirement
of transitivity has not been met, and the numbers used to imply measures
are influenced by various competing dimensions (or contain unacceptable
error).
Transitivity may occur in any combination of variables where there is
a functional unity binding them together. In physical measurement, a use-
STANDARDS FOR PSYCHOLOGICAL MEASUREMENT 121
ful example is the measurement of volume, which may be analysed into the
three component dimensions of length, width, and depth. Nevertheless, if
Box B has a greater volume than Box A, and Box C has a greater volume
than Box B, then unarguably Box C is greater in volume that is Box A. The
requirement of transitivity has been satisfied and a unidimensional scale
exists.
Items that reflect an overarching unity in such a case can be assembled
to create a homogeneous set of items. Items that may represent a "factorially
pure" measure of one of the component dimensions may fail to contribute
to that homogeneity; if so, the fact can be identified through item analysis.
If most of the items in a pool of items tend to measure a single dimension,
then any other items measuring any other aspect of that overall unity will
probably be excluded as a result of item analysis.
There have occasionally been arguments over the need for homoge-
neity in measurement. Cronbach (1971) has argued that homogeneity is not
an essential component of a measuring instrument intended to lead to
inferences of degree of mastery in an overall content domain. If this point
of view is accepted, a different form of item analysis is necessary: an anal-
ysis of each component item for its relevance to the content domain. This
is done through expert judgments. One statistical approach to the quanti-
fication of such judgments has been the content validity ratio proposed by
Lawshe (1975):
n, - N/2
CVR = N/2
in which n, equals the number of judges who identify the item as essential
to a representation of the domain, and N is the number of judges.
The purpose of either of these kinds of item analyses is to identify item
contaminants, either as sources of heterogeneity (items measuring attri-
butes other than the one intended) or as outside of the defined content
domain. A different kind of analysis may be necessary to identify biased
items, those involving an interaction between responses to the item and
attributes external to the measuring instrument. External attributes include
race or sex or age bias, but many other kinds of potential interactions
deserve investigation. There has not been enough experience with item bias
studies to justify a requirement that such investigations be conducted, but
investigations of item bias are certainly among the kinds of item analyses
worth considering (Ironson, 1977; Rudner, 1977).
3. Adequacy of content sampling should be based on the competent, indepen-
dent judgments of people who are genuinely qualified to make them. The principle
here has been described as providing a paper trail of the judgment process.
Such a record is necessary to whatever extent the finished measuring instru-
ment will be evaluated in terms of the adequacy of its content sampling.
Where this is important (for example, where there is a possibility of litiga-
tion), conventional practice calls for the convening of a panel of experts on
the content area; they make judgments about the value or appropriateness
122 ROBERT M. GUION
time. The interval between the two periods of data collection is ordinarily
uncontrolled; different things happen to different people, with differing
intensities; over time, there will be many influences on criterion perfor-
mance. Recidivism among hospital patients, for example, is influenced in
part by the patients' attributes at the time of release, but it is also partly
determined by home environments, opportunities for employment, com-
munity pressures, and a host of other variables of which the researcher may
never have an inkling. The longer the period of time, the greater the oppor-
tunity for the influence of these extraneous and uncontrolled variables. Ide-
ally, of course, the most influential variables in any given time interval
would be identified, measured, and made a part of the predictive equation.
Nevertheless, there always remains a residual of uncontrolled and unmea-
sured variability.
The difficulty is that the professional psychologist typically wants to
make long-range predictions. Vocational counselors want to predict occu-
pational adjustment after long years of educational preparation, specific
training, and occupational experience. Industrial psychologists want to pre-
dict performance of journeymen tradesmen on the basis of characteristics
that can be measured before they begin their apprenticeship programs. In
neither case is the predictive validity likely to be very high. Nevertheless,
substantial abbreviation of time periods-or, indeed, the absence of any
time period at all in concurrent validation studies-represents a fairly
severe departure from the realistic situation of the intended use. Test devel-
opers should be aware of such a departure from reality, and it should be
evaluated with great care. (See in particular Standards E7.4.2 and E7.4.3 All
of the standards under the general Standard E7, requiring that validation
procedures be consistent with the purposes of the study, are relevant to this
discussion.)
6. Results of empirical validation studies should be expressed, insofar as feasible,
as population estimates rather than as merely sample statistics; moreover, statistics
should be verified by either replication or cross-validation. The results of a study
of the validity of a measuring instrument are expressed in terms of statistics
derived from the specific sample studied. A full statement of the research
results would include descriptions of the distributions of both the predictor
and the criterion variables and straightforward statements of both the kind
(for example, linear or nonlinear) and degree of relationship. These descrip-
tive statistics are extremely important and account for an entire series of
statements of standards under the general Standard E8 (requiring that sta-
tistical analyses be reported so readers or users can determine the confi-
dence they will have in the results).
Nevertheless, sample statistics can be misleading. Factors that have
biased the sample, inadvertently or inevitably, tend also to bias statements
of validity. Implicitly, the Standards suggest statistical corrections of
obtained validity coefficients to provide estimates of population parameters.
If, for example, there has been a severe restriction of range in the sample,
either from prior selectivity or through selective factors operating during
128 ROBERT M. GUION
the time interval enclosed by the study, a correction might be made for the
reduced variance. If particular difficulties have been encountered with cri-
terion measures, corrections for the unreliability of the criterion might be
desired. In either case, the purpose of the correction is to obtain an estimate
of the population value that the investigator considers to be a better state-
ment of validity than that derived from the sample itself.
The Standards have indicated (in the comment under Standard E8.2.1)
that "it is ordinarily unwise" to set up chains of corrections. That is, the
comment is made that, in the opinion of the committee, it is a poor practice
to correct a sample statistic for restriction of range and then to use that esti-
mate of the parameter as if it were a sample statistic and make a further
"correction" for unreliability of the criterion, and so on. The committee
considered these corrections highly fallible, often requiring questionable
assumptions. This point of view has been challenged, as "simply in error"
by Schmidt et al. (1976, p. 475), who proceeded to make these two correc-
tions consecutively for each of several validity coefficients.
The point is not one on which members of the committee felt so
strongly that they would establish a standard that would in effect prohibit
the practice. What is of extreme importance, however, is that corrected coef-
ficients not be used for making significance checks, particularly if correc-
tions have been piled on top of each other.
Perhaps the main point of this discussion is that one should not con-
fuse validity with an obtained validity coefficient. Corrections, whether
based on obtained coefficients or previously corrected ones, are made in the
realization that the obtained coefficient is to some degree subject to error.
Some of that error is sampling error, and nothing is going to be as effective
in reducing reliance on results from nonrepresentative samples as doing the
study over. Verification through replication is a time-honored method in
scientific inquiry for evaluating the dependability of results and it should
be applied to studies of the validity of measurement.
Such verification is especially important in multivariate studies; in
these, the replication is ordinarily called cross validation. Where the vali-
dation research is intended mainly to assess the practical usefulness of a
test, it may be appropriate to include other variables in a multiple regres-
sion analysis. A population estimate might be based, for example, on an
equation that partials out the effect of certain uncontrolled variables. Or one
might want to assess the usefulness of the predictor being validated in rela-
tion to other available predictors in a linear composite predictor (Darling-
ton, 1968). Such research requires cross validation. (See particularly Stan-
dards EI0 through EI0.2.)
Cross validation is particularly important if the number of cases is
small, or the number of variables is large, or complex or nonlinear relation-
ships are observed, or negative regression weights are found. Cross vali-
dation is needed in all of these cases because the relative contribution of
the measure being evaluated is unreliable to some degree and therefore
requires verification. Cross validation is also essential when an empirical
scoring key for a test or inventory has been developed against some exter-
STANDARDS FOR PSYCHOLOGICAL MEASUREMENT 129
implicit in many of the statements made in this chapter. Again, its intent is
clarified by expressing it in a negative form: Don't make substantial changes
in the way a test is used without revalidation to determine whether those
changes have enhanced, maintained, or destroyed validity (Standard E2.3).
On occasion, circumstances require modification of a test. Where this
happens, the user should apply the modifications consistently across all
examinees and serious attempts should be made to evaluate the effects of
the modifications.
The standardization problem should, incidentally, include standardi-
zation of materials and equipment. If paper is likely to become yellow with
age, or if holes in pegboards are likely to become larger through wear, the
test has changed in visual demands or in physical tolerances. Such changes
in a test as a stimulus can effect, often quite negatively, the validities of the
interpretations of the scores.
Where judgments are required in scoring, standard scoring guides are
typically available. Standardization of scoring procedures in such cases is
just as important as the standardization of administration procedures. (See
Standards 11, 11.1, 11.2, and 11.3.)
4. Test security should be maintained. This is a responsibility, according to
Standard IS, that the test user shares with the developer or distributor of
the test. It is a responsibility that should not be taken lightly.
A case study in the problems of test security is the controversy between
the Detroit Edison Company and the National Labor Relations Board (Ros-
kind, 1979). The case began when a promotion grievance was filed by the
union against Detroit Edison. As part of the grievance negotiations, the
union requested copies of the test, the scoring key, and the scores of indi-
viduals who, according to allegation, had either been promoted or passed
over for promotion on the basis of the test scores. Detroit Edison refused to
divulge test scores without written authorizations from the individuals
involved or to turn over to the union, without security safeguards, the test
and scoring keys. The union subsequently filed a charge of an unfair labor
practice with the National Labor Relations Board. Both the NLRB and the
Sixth Circuit Court of Appeals upheld the union position. The Detroit Edi-
son Company appealed the case to the Supreme Court, where the compa-
ny's professional responsibility to maintain test security was accepted and
the union request was denied.
Relatively few test users are likely to find themselves before the
Supreme Court. It is very common, however, for test users to be in situa-
tions where files may be left laying around, available for casual perusal, or
where the testing situation permits people to memorize and sell test ques-
tions or otherwise compromise the integrity of the test. Users should be as
diligent in avoiding these kinds of security problems as Detroit Edison was
in its litigation.
5. Tests should be accurately scored. Standard 13 calls for checking the
accuracy of all scoring, coding, or recording of scores. The responsibility for
avoiding what amounts to routine clerical error extends even to situations
STANDARDS FOR PSYCHOLOGICAL MEASUREMENT 133
where mechanical scoring aids are used. Samples of machine scored tests
should be checked by hand to be sure that no error has crept into the scor-
ing process.
6. Test users should be careful and thoughtful in the interpretation of individual
test scores. A test score is obtained under a specific set of circumstances, and
it is subject to unknown and often idiosyncratic sources of error. It is not,
according to Standard Jl, an "absolute characteristic" of the person tested.
Neither is it permanent or generalizable to all other kinds of circumstances
in which the person might find himself. Therefore, the total measurement
situation needs to be considered in interpreting obtained scores before deci-
sions are made about people. In particular, interpretations should be com-
plete enough that the shorthand of descriptive, general labels (e.g., organic,
retarded, incompetent) will not be applied to individuals. (See Standard
J2.3.) Just as the process of construct validation calls for the systematic
investigation of alternative interpretations for sets of test scores, a test user
should consider alternative interpretations for any specific individual score.
Possible alternative interpretations would include anxiety, language hand-
icaps in understanding instructions, faking, and others. (See Standard J7.)
Special care is needed where interpretations are reduced to a pass-fail
or accept-reject dichotomy, that is, where some form of cutting score is
applied. A test user who establishes a cutting score has, in effect, reduced
the distribution of possible scores to two. Any score is either above or below
the cutting score. A validity coefficient obtained on a two-level distribution
will almost certainly be different from one obtained on a full range of pos-
sible scores. Moreover, the validity coefficient changes as the point at which
a distribution is dichotomized changes. Therefore, users who wish to inter-
pret scores on a pass-fail basis should determine the validity of the scores
using the particular dichotomy intended. (See Standard 14.)
Finally, the interpretation of an individual's score should take into
account its currency. In many organizations, test scores are routinely kept
as a matter of file long after they are obtained. People change. The scores
they obtain become obsolete. It is better to purge the files of obsolete data
than to try to interpret them. (See Standard J9.)
7. Interpretations, not merely numbers, should be reported when the results of
measurement are reported to examinees or other interested persons. A number by
itself, such as a raw score, means very little. Translating a raw score to the
percentage of the items answered correctly will provide a content-refer-
enced interpretation, but it is also purely numerical. The addition of verbal
interpretive aids (for example, describing the percentage score in terms of
levels of mastery or achievement) is much more informative.
Raw scores can be transformed into centiles or standard scores. Again,
these norm-referenced interpretations are purely numerical. To be infor-
mative, they need to be accompanied by deSCriptions of the normative pop-
ulations used and their appropriateness for the individual or for the pur-
poses of the testing. Of the two, centiles fit the intent of this principle better
than standard scores because they are more readily understood. Expectancy
134 ROBERT M. GUION
CONCLUDING COMMENT
their narrow focus to a more global applicability, the possibilities for mis-
interpretation (or disagreements over interpretation in specific applica-
tions) also have become greater. Precisely how a principle mayor should
be applied is not, either in this chapter or in the Standards themselves,
made clear. That is proper. These statements are intended for the guidance
of the profession, not for enforceable law.
It would be hard to be legalistic about measurement in specific exam-
ples of psychological practice, even if it were desirable. The problems in
which testing is used are diverse. So are the attributes to be measured. So
are the methods of measurement-and they are growing ever more diverse.
So are the skills and the levels of psychometric sophistication among the
professional psychologists who try to apply these principles. With such
diversity, the first task of the individual psychologist is to come to the best
possible general understanding of the principles. Then the task is to find
specific ways in which the principles might be applied in a specific mea-
surement situation or to articulate reasons why certain principles are not
applicable. If the measurement problem often has been faced before, and
over a long period of time, by psychology in general, these tasks are not
likely to be difficult. If the measurement problem represents new ground
to plow, however, it can be a challenging task indeed. In the former case,
the professional psychologist is admonished to follow the best practice that
has evolved. In the latter, the professional psychologist is admonished to
do the very best he or she can.
REFERENCES
Until quite recently there was no recognized source document that delin-
eated a set of standards or principles for the practice of what is commonly
known as industrial-organizational (1-0) psychology. During 1980 the
American Psychological Association (APA) finally adopted a set of Specialty
Guidelines for the Delivery of Services by Industrial/Organizational Psychologists
(1981). The reader will note that the title refers to "Guidelines" rather than
"Standards." APA characterizes these guidelines as "supplements to the
generic Standards for Providers of Psychological Services." The birth of these
guidelines was preceded by a long period of gestation during which abor-
tion frequently was proposed as the best solution. However, APA con-
cluded that, "The knowledge base in each of these specialty areas has
increased, refining the state of the art to the point that a set of uniform
Specialty Guidelines is now possible and desirable." Four professional spe-
cialties were recognized in this fashion: clinical, counseling, school, and
industrial/ organizational.
This is not to say that there were no standards or principles before
adoption of the Specialty Guidelines. However, it was necessary to derive
such standards or principles from a variety of sources. The diversity of fields
for which 1-0 psychologists are trained and the variety of applications to
which 1-0 psychology may be put have been the greatest deterrents to
development of a coherent and definitive set of standards or principles.
Industrial and organizational psychology is a taxonomic classification
given to a group of psychological specialties; it is not an entity. The Amer-
ican Psychological Association (1978) outlined 1-0 psychology as:
141
142 C. PAUL SPARKS
Personnel
Selection and Placement
Career Development and Training
Development and Training
Performance Evaluation
Job Satisfaction, Morale, and Attitudes
Retirement
Management and Organization
Organizational Behavior
Labor-Management Relations
Position and Task Analysis
Compensation
Human Relations
Organizational Development
Employee /Vocational Counseling
Environment & Quality of Life
Alluisi and Alluisi (1978) made a detailed analysis of the APA mem-
bership as of November 1977. One of their tabulations was the major field
of training reported. Industrial-organizational was the declared field of
6.65% of the members who declared a major field, a figure that ranked fifth
among all the major fields. Of those who declared their major field to be 1-
a psychology, 55.12% belonged to Division 14 (industrial and organiza-
tional psychology) if they belonged to any division, although I-a majors
also belonged in substantial numbers to other divisions: personality and
social (9.18%), general (6.27%), evaluation and measurement (5.93%), con-
sumer (5.59%), SPSSI (5.00%), military (4.47%), consulting (4.42%), and coun-
seling (4.03%). On the other side of the coin, 79.93% of all Division 14 mem-
bers had I-a psychology as their major field of training with social (4.23%)
a very distant second. Based on these data, the majority of those who were
trained in I-a psychology maintained a deep interest in I-a as evidenced
by membership in Division 14, but a large minority developed and main-
tained other interests. On the other hand, the Division 14 membership is
characteristically made up of persons who had their roots in I-a
psychology.
It must be noted that (given the taxonomy presented earlier) a substan-
tial number of I-a theoreticians and practitioners are either not psycholo-
gists or operate with little attention to psychological principles per se. Yet,
those persons who would identify themselves as psychologists must sub-
scribe to different standards and principles than those who would operate
under a different aegis. As psychologists, they are clearly bound by the
generic standards and principles of the profession. Not only is this neces-
sary to conform to the existing APA mandates, it is also necessary to con-
form to the bylaws of Division 14. There are also the new specialty guide-
lines of which more will be said later.
Even without the new Specialty Guidelines, and possibly a reflection
of the lack thereof, professional attention has been given to large segments
of I-a practice. Mirvis and Seashore (1979) concerned themselves with the
ethical problems encountered when social and behavioral scientists conduct
organizational research in real organizations. Among other things, the
authors suggested preparation of a casebook on ethical standards for orga-
nizational researchers. In another area of concern to many I-a psycholo-
gists, London and Bray (1980) considered ethical issues in testing and eval-
uation for personnel decisions. They considered formally published
professional standards and governmental guidelines but also wrote at
length on such topics as the psychologists' obligations to the profeSSion, to
those who are evaluated, and to the employer, and the obligations of
employers. An even narrower area of concern was addressed by the Task
Force on Assessment Center Standards which developed Standards and Eth-
ical Considerations for Assessment Center Operations (1978).
State laws also regulate the practice of psychology and are a source of
guidance for I-a psychologists. These vary widely in content and coverage
and each I-a psychologist must study those of his or her state and any other
states where he or she may wish to practice. The new Specialty Guidelines
144 C. PAUL SPARKS
APA STANDARDS
Though approved in January 1980, formal publication did not occur until
June 1981.
What follows is a digest of the Specialty Guidelines. Quotations are
used liberally since communication of content is the principal purpose. Sig-
nificant interpretations or implications must await further professional dis-
cussion after the Specialty Guidelines have been placed in effect.
The initial portions of the Specialty Guidelines are concerned with pur-
pose and coverage. The key provisions include the fact that they:
STANDARDS FOR INDUSTRIAL-ORGANIZATIONAL PSYCHOLOGISTS 145
are designed to define the roles of I I 0 psychologists and the particular needs
of users of 1/0 psychological services.
are intended to educate the public, the profession, and other interested parties
regarding specialty professional practices. They are also intended to facilitate
the continued systematic development of the profession.
are intended to apply only to those psychologists who wish to be designated as
industrial Iorganizational psychologists. They do not apply to other psychologists.
[Italics in original.)
represent the profession's best judgment of the conditions, credentials, and
experience that contribute to competent professional practice. (p. 664)
In some states the doctoral degree from other than a department of psy-
chology precludes licensing, regardless of the psychological nature of the
degree.
146 C. PAUL SPARKS
This provision clearly approves the PhD model and rejects the PsyD model.
The I/O psychology doctoral program provides training in (a) scientific and
professional ethics, (b) general psychological science, (c) research design and
methodology, (d) quantitative and qualitative methodology, and (e) psycholog-
ical measurement, as well as (f) a supervised practicum or laboratory experience
in an area of I/O psychology, (g) a field experience in the application and deliv-
ery of I/O services, (h) practice in the conduct of applied research, (i) training
in other areas of psychology, in business, and in the social and behavioral sci-
ences, as appropriate, and (j) preparation of a doctoral research dissertation. (p.
665)
Six examples are given, each with a major heading and listing several spe-
cifics. The reader may wish to compare these with the several classifications
provided earlier.
A. Selection and placement of employees
B. Organization development
C. Training and development of employees
D. Personnel research
E. Improving employee motivation
F. Design and optimization of work environments (p. 666)
The document concludes with specific guidelines that are intended to
be controlling. Each guideline is followed by interpretation and explana-
tion, frequently quite extensive. The guideline statements are given below
without the interpretive material.
STANDARDS FOR INDUSTRIAL-ORGANIZATIONAL PSYCHOLOGISTS 147
LICENSING
This last caution is quite important since there are various reciprocity pro-
visions, various kinds of exceptions, and limitations on the amount of time
that the 1-0 psychologist may be permitted to practice in a state where he
or she is not licensed. Though a detailing of differing requirements has
been eschewed, the major features of one state are described here for illus-
trative purposes. The state of Texas has been chosen since it is the one in
which the author has been both certified and licensed and is accordingly
the one with which he is most familiar.
The Texas law, "Psychologists' Certification and Licensing Act," was
approved June 12, 1969, became effective September 1, 1969, and provides
that violation of the Act is a misdemeanor, punishable upon conviction by
a fine of not less than $50 nor more than $500, and by imprisonment in
county jail for not more than 30 days, with each day of violation considered
a separate offense. The hearings that led to an almost unanimous passage
by both houses of the legislature were characterized by testimony on the
need to protect an uninformed and naive public against charlatans and
unqualified persons. The law initially covered any person who used the
terms psychology, psychological, or psychologist when making any offerings of
service to the public. It was later amended to include "psychological ser-
vices" and defined these as "acts or behaviors coming within the purview
of the practice of psychology, including, but not limited to, the application
of psychological principles to the evaluation and remediation of learning,
.emotional, interpersonal, and behavior disorders."
Administration of the law was vested in the Texas State Board of Exam-
iners of Psychologists. The six members of the board were to be certified
psychologists and were to represent independent practice, teaching, and
research. (Many states require one or more public members.) The board was
instructed to make rules and adopt and publish a code of ethics. (The APA
Ethical Standards of Psychologists was adopted and is published annually in
its roster of licensed and certified psychologists.) (Texas State Board of
Examiners of Psychologists, 1982) The board was empowered to certify spe-
cialties including clinical, counseling, industrial, and school. To date this
has not happened for these specialties but specialty licensing for health ser-
vice providers has been established. (p. 112) In addition, the board has enor-
mous rule-making powers. For example, to be licensed or certified an appli-
cant must have received the doctoral degree from "a program of studies
whose content is primarily psychologicaL" (p. 100) if the degree was not
from a department of psychology, e.g., business or education degrees. It
chose to define the quoted phrase by a listing of required content areas, if
the degree was not from a department of psychology, e.g., business or edu-
cation degrees. It might interest 1-0 practitioners to know that physiological
psychology and psychopharmacology are among the subjects required.
The Act specifically exempted certain classes of individuals from the
certification or licensure requirement. These are paraphrased here in the
interest of space. Clarifying detail should be obtained from the law itself.
Specifically exempted were: persons employed as psychologists by any gov-
150 C. PAUL SPARKS
GOVERNMENTAL REGULATION
The final area of regulation of 1-0 psychologists are those rules pro-
mulgated by the federal government. Since 1964 and 1965 those 1-0 psy-
chologists whose work includes employee selection have had specific per-
formance requirements prescribed by the federal government, and, in
many instances, by state and municipal governments as well. The current
key regulation in the area is Uniform Guidelines on Employee Selection Proce-
dures (1978) (Equal Employment Opportunity Commission, Civil Service
Commission, Department of Labor, & Department of Justice, 1978). These
were further amplified by Adoption of Questions and Answers to Clarify and
Provide a Common Interpretation of the Uniform Guidelines on Employee Selection
Procedures (Equal Employment Opportunity Commission, Office of Person-
nel Management, Department of Justice, Department of Labor, & Depart-
ment of the Treasury, 1979) and by still more questions and answers in
1980. These Uniform Guidelines are the latest in a series that has seen issuance
of a new or revised regulation in 1966, 1968, 1970, 1971, 1976, and 1977.
Each regulation has been longer, more detailed, and more restrictive than
the last. The basic thrust of each is a definition of when an employer must
show that his or her employment procedure is valid, i.e., job-related, and a
delineation of what is an acceptable showing of this validity. Paper-and-
STANDARDS FOR INDUSTRIAL-ORGANIZATIONAL PSYCHOLOGISTS 151
pencil tests, particularly standardized commercial tests, were the initial tar-
get of such regulations but this was modified and expanded as early as 1968.
Currently, Selection Procedure is defined in the Uniform Guidelines as:
Any measure, combination of measures, or procedure used as a basis for any
employment decision. Selection procedures include the full range of assessment
techniques from traditional paper-and-pencil tests, performance tests, training
programs, or probationary periods and physical, educational, and work expe-
rience requirements through informal or casual interviews and unscored appli-
cation forms. (p. 38308)
Note the "not limited to" phrase. Compensation, disciplinary actio1).s, and
assignment of overtime have all been included in charges and investiga-
tions as employment decisions. The various selection guidelines have fre-
quently been interpreted to require that all selection procedures must be
validated for all employment decisions. This is not true. A selection proce-
dure must be validated only if it has an adverse impact on the employment
opportunities of persons by identifiable race, sex, or ethnic group. In other
words, if a selection procedure in use results in disproportionate hiring of
blacks vs. whites or men vs. women it must be discontinued or modified or
validated. The Uniform Guidelines state:
The provisions of these guidelines relating to validation of selection procedures
are intended to be consistent with generally accepted professional standards for
evaluating standardized tests and other selection procedures, such as those
described in the Standards for Educational and Psychological Tests prepared by a
joint committee of the American Psychological Association, the American Edu-
cational Research Association, and the National Council on Measurement in
Education (American Psychological Association, Washington, D.C., 1974) (here-
inafter 'A.P.A. Standards') and standard textbooks and journals in the field of
personnel selection. (p. 38298) [See Chapter 4, this volume.]
Despite that statement, many 1-0 psychologists believe that one could com-
ply with the Standards and still not be in compliance with the Uniform Guide-
lines. A good example of this conflict is the treatment of intergroup differ-
enc~s in selection ratios. The Uniform Guidelines treat a hiring ratio of less
than .8 to 1.0 (.16 to .20; .024 to .030) as presumptive evidence of adverse
impact against the less-preferred group. The Standards insist on an appro-
priate level of statistical significance before drawing any conclusions. Sim-
ilarly, the Uniform Guidelines require the researcher to conduct a search for
suitable alternatives with a lesser adverse impact, even if the selection pro-
cedure studied had been shown to be valid. On the other hand, although
the Standards do indicate that psychologists should be aware of the fact that
multiple procedures may be available for accomplishing a given selection
152 C. PAUL SPARKS
decision, this principle is stated in the context of making the most valid or
the most accurate selection decision; it is not given in the context of mini-
mizing group differences. Increasing the researcher's dilemma, test manuals
and journal articles almost never have data on adverse impact as defined in
the Uniform Guidelines, even where good validation studies are reported.
This is true in many instances because adverse impact is a function of the
use of the selection data, not simply a matter of test score differences.
Despite these concerns, guidelines issued by the EEO enforcement agencies
have been upheld by the federal courts, up to and including the U.S.
Supreme Court (Albemarle Paper Company v. Moody, 1975; Griggs v. Duke
Power Co., 1971). It remains to be seen how the Uniform Guidelines will fare
with their added technical requirements and the extensive documentation
requirements.
In order to clarify the Standards with respect to the specific problems of
employee selection, placement, and promotion, Division 14 published in
1975 Principles for the Validation and Use of Personnel Selection Procedures. These
were revised in 1980, prompted in large part by much recent research in
the area of selection device validation and use. A joint review committee of
APA, AERA, and NCME has recommended that the Standards also be
revised and steps to that end are being undertaken. It remains to be seen if
these revisions will have any effect on the Uniform Guidelines. One hopeful
sign, however, is the U.S. Supreme Court (Gilbert v. General Electric Co., 1976)
ruling that a federal agency's regulation need not be controlling where it
is in conflict with a recognized body of professional opinion. This case did
not involve selection procedures but it was cited in U.S. v. South Carolina, a
case involving the examination of teachers. A three-judge panel heard the
case and cited both the Standards and the Principles as professional authori-
ties in upholding a validity study proffered as evidence by the State. The
lower court finding was affirmed without a hearing by the U.S. Supreme
Court (U.S. v. South Carolina, 1977, 1978). Many other cases could be cited
but it should be obvious from the sampling presented that the 1-0 psy-
chologist involved with personnel selection in any of its many phases must
study the Uniform Guidelines intently and be very attentive to court decisions
interpreting them.
The 1-0 psychologist working for or consulting with a federal contrac-
tor should also become familiar with the Federal Contract Compliance Manual,
issued by the Office of Federal Contract Compliance Programs of the U.S.
Department of Labor (1979). With respect to selection procedures, the OFCC
cites compliance with the Uniform Guidelines as the contractor's responsibil-
ity. However, the Manual amplifies the Uniform Guidelines in several
respects, particularly with respect to recordkeeping. For example, (pages 3
through 37) provide the following instructions, among others:
Interviews
A chronological list of the applicants interviewed for the last three or
four years showing:
STANDARDS FOR INDUSTRIAL-ORGANIZATIONAL PSYCHOLOGISTS 153
CONCLUSION
REFERENCES
HISTORY
No brief review can ever do justice to the richness and complexity that
have marked the course of APA's development. Since excellent descriptions
of the earliest decades are readily available (Fernberger, 1932, 1943; Napoli,
157
158 RICHARD R. KILBURG AND MICHAEL S. PALLAK
1975), this account will focus on some central aspects of APA's and orga-
nized psychology's investment in professional and applied issues.
Beginning with a clinic established by Lightner Witmer in 1896,
applied psychology has conSistently matched strides with the pure science
that provides the common bond for all that psychology has come to mean-
ingfully encompass. Today, the by-laws of the organization emphasize that:
The objects of the American Psychological Association should be to advance
psychology as a science and a profession and as a means of promoting human
welfare by the encouragement of psychology in all its branches in the broadest
and most liberal manner; by the promotion of research in psychology and the
improvement of research in methods and conditions; by the improvement of
the qualifications and usefulness of psychologists through high standards of
education and achievement; by the establishment and maintenance of the high-
est standards of profeSSional ethics and conduct of the members of the Associ-
ation; by the increase and diffusion of psychological knowledge through meet-
ings, professional contacts, reports, papers, discussions, and publications;
thereby to advance scientific interests and inquiry, and the application of
research findings to the promotion of the public welfare. (American Psycholog-
ical Association, 1979b, p. 22)
In the complex tapestry that psychology has become, the remarkable inter-
weaving of scientific and professional developments can be traced to the
earliest beginnings of this discipline. For example, in 1895, the Committee
on Physical and Mental Tests was formed by APA to try to develop guide-
lines and norms for the generation of tests and measurements (Centor,
1975). This focus on measurement and testing has continued as a central
concern of APA even to today.
In 1915 the first major effort to address standards of practice was under-
taken by APA. APA Council passed a resolution stating "this Association
discourages the use of mental tests for practical psychological diagnosis by
individuals psychologically unqualified for this work" (Napoli, 1975). A
committee was established to develop a certification program for "consult-
ing psychologists." After 12 years of wrestling with the complexity of the
regulation of practice, this committee and the certification program were
discontinued in 1927.
In the meantime, psychology and the U.S. government discovered each
other during World War I. In a memorable if not celebrated role, Robert
Yerkes, one of psychology's foremost scientists, led psychology'S initial
fight to establish itself as independent from the field of medicine. The lines
of battle were drawn over who should determine who was fit to serve in
the U.S. Army. As detailed by Napoli (1975), the battle fought then closely
resembles many of the struggles' currently facing APA. Psychology won
that battle and the first large-scale psychological testing program in history
was undertaken by the Army.
In the years between the wars, psychology continued to grow. The
membership of APA increased eightfold. The Association and the field
struggled with organizational and economic issues in the 1930s. The pub-
lication program was well established during 1925 with the acquisition of
the Psychological Review Company and its five journals, the Psychological
A GUIDE TO THE AMERICAN PSYCHOLOGICAL ASSOCIATION 159
increased role in APA governance. For instance, in the 1920s and 1930s a
handful of states had established local psychological associations that pro-
vided support and information to the small communities of psychologists
spread around the country. As the number of psychologists exploded in the
1950s and 60s, the size and vigor of these state organizations increased
remarkably.
This growth provided a foundation for much of the professional orga-
nization that continues today. It culminated in the adoption of the Report
from the Albee Commission in 1968 which modified the rules for election
of members to Council. The new rules dramatically increased the represen-
tation of state associations in Council. Because these associations were over-
whelmingly professional in their orientation, this development provided
the impetus for a dramatic shift in the decision consensus in Council toward
professional psychology. The strains of growth and differentiation were
met by the development of a complex governance structure and increasing
central office staff which have tried to meet the demands of increasingly
vocal and demanding constituencies. Separate Boards for Scientific, Profes-
sional, and Education and Training Affairs were instituted. Committees on
Ethics, Accreditation, and Tests and Measurement were established. The
professional and scientific goals of the organization were debated with
increasing regularity and vigor. Professional psychology had finally
achieved an equal footing with the science and a new era was begun.
In the 1970s APA guided, implemented, and witnessed achievements
that were mere fantasies in the minds of a few psychologists three decades
earlier. The U.S. government has recognized psychologists as service pro-
viders in 19 different federally funded programs (American Psychological
Association, 1979a). A permanent national organization, the Association for
the Advancement of Psychology (AAP), was established to represent psy-
chology in the Congress. APA developed and approved Standards for Pro-
viders of Psychological Services. Specialty guidelines for providers of clin-
ical, counseling, school, and industrial/organizational psychological
services also were developed and approved in January of 1980. In 1978, the
last of the 51 major political jurisdictions passed a law regulating psychol-
ogy, fulfilling the dream of the first committee on certification. The size of
its membership, its central office, and its complex problems and programs
have surpassed the wildest imaginings of its founding fathers.
As APA moves into its ninth decade, it faces new challenges, com-
pletely unforseen several years ago. The licensing and certification statutes
are under attack in many states due to the passage of "sunset legislation"
(see Stigall, Chapter 11). A Commission on the Organization of APA is con-
sidering modifications in the governing structure that would meet the
growing demands for influence and autonomy of major constituencies in
psychology. Another major task force is developing new approaches to
defining education and training in psychology. The struggle with orga-
nized medicine continues unabated. However, the battleground has wid-
ened and now encompasses state and federal legislative, executive, and
A GUIDE TO THE AMERICAN PSYCHOLOGICAL ASSOCIATION 161
COUNCIL OF REPRESENTATIVES
Board of Directors
Finance Committee
Investment Committee
Membership Committee
Committee on Scientific and Professional Ethics
Committee on Academic Freedom & Conditions of Employment
Committee on International Relations in Psychology
Committee on Employment and Human Resources
Committee on Ethnic Minority Affairs
Committee on Public Information
Representatives to Other Organizations (BOD)
Ad Hoc Committee and Task Force (BOD)
TABLE 1 (continued)
Governance Structure
Publications/Communications Board
Council of Editors
PsycInfo Advisory Committee
Ad Hoc Committee & Task Forces (P&C)
Psychologists. These policies are designed to give guidance for the practice
of psychologists who voluntarily designate themselves as operating in one
of these four specialty areas.
As will be the case for all of the descriptions of the governance units,
information on gaining access to their deliberations, etc. will be summa-
rized later.
Board of Directors
The Board of Directors acts as the executive committee of Council. It
can operate in lieu of Council in certain situations and can make public
statements on any issues in accord with APA policy or by-laws provided
the statements reflect the sentiment of the majority of the six elected direc-
tors. The board also has the other elected APA officials as members: presi-
dent-elect, president, past-president, treasurer, and secretary: The executive
officer sits as an ex officio member of the board. Two directors are elected
annually, as is the president-elect. The treasurer and secretary are elected
for five-year terms.
The board meets five times a year. Two major meetings are held in June
and December which provide the focus for the policy work in the rest of
the governance structure. Abbreviated sessions are held before each meet-
ing of the Council, and the board conducts a retreat meeting for several
days, usually in the spring. Frequent updates and briefings allow the Board
to act responsibly in the face of challenging time constraints and ever-
changing political, economic, and organizational issues. The board has
164 RICHARD R. KILBURG AND MICHAEL S. PALLAK
This nine-member board was created in the late 1940s with the major
function of considering the current and long-range policies of APA. It
recommends
to the members, Board of Directors, and Council of Representatives such
changes in existing policy and such extensions or restrictions of the functions
of the Association, its Divisions, or State Associations as are consonant with the
purposes of the Association. (American Psychological Association, 1982, p. 60)
This board has been struggling with several major issues recently. APA
Council has mandated that convention be held only in states that have
passed the Equal Rights Amendment to the U.S. Constitution. This has
restricted the number of cities that can host a meeting as large as APA's.
The board also has made efforts to improve the accessibility of the conven-
tion for handicapped psychologists.
Committee on Films and Other Media. This four-member committee
reports to the Board of Convention Affairs and is responsible for reviewing
films and productions involving other communication media of interest
and relevance to psychologists and for selecting from them and assembling
a film and other communication media program for presentation at each
annual convention. It also develops other displays of interest to
psychologists.
Committee on Research and Evaluation. This four-member committee
reports to the Board of Convention Affairs and collects and evaluates "data
concerning the characteristics and conduct of the different kinds of conven-
tion activities, with particular reference to the characteristics of convention
attendees and their frustrations and satisfactions with the variety of con-
vention program activities" (American Psychological Association, 1982, p.
76). It makes recommendations on its findings to the board in order to make
the convention "more useful and attractive to the greatest number of mem-
bers" (American Psychological Association, 1982, p. 76).
Committee on Program Innovations. This committee of the Board of Con-
vention Affairs has four members and is "charged with generating, eliciting
and collecting ideas for new program formats and contexts" (American Psy-
chological Association, 1982, p. 76). It works closely with divisions, groups,
and other units of APA governance to "assure adequate assessment of pro-
A GUIDE TO THE AMERICAN PSYCHOLOGICAL ASSOCIATION 169
This committee has been working with various arms of the federal gov-
ernment to further refine existing policies regarding the use of human sub-
jects~ Of special concern has been the clarification of the risk factors asso-
A GUIDE TO THE AMERICAN PSYCHOLOGICAL ASSOCIATION 171
ciated with various forms of research such as that conducted with data
retrieved from archives or simple behavioral observation as opposed to that
which requires some form of biological invasion of the human body.
This nine-member board reports to the board of directors and has broad
responsibility for overseeing and making policy recommendations in mat-
ters pertaining to the education and training of psychologists. It supervises
the efforts of a number of committees specifically focusing on various
aspects of education and training. The accreditation and continuing edu-
cation programs are operated under its auspices. In addition, the board
reviews activities for high school, undergraduate, and graduate studies in
psychology. We shall focus on these activities in a little more detail below.
Recently, the board has been working with a number of groups includ-
ing the Council of Graduate Departments of Psychology (COGDOP) and
the Association of Professional Schools of Psychology (APSP) on the prob-
lems related to graduate education and training. As a result of this work
and the evaluation of its own operations and functions, the E&T Board has
reorganized itself in several important ways. It will meet fewer times dur~
ing the coming years and place members of the board on its major commit-
tees. In addition, it has developed a new Committee on Graduate Education.
The board is responsible for publishing, in conjunction with the Publica-
tions and Communications Board, a list of training programs in psychology
as well as a list of training programs approved by its Committee on
Accreditation.
Committee on Undergraduate Education. This committee has six members
and is "concerned with undergraduate students and their teachers." It col-
lects, analyzes, and reports information concerning undergraduate stu-
dents, teachers, and programs and makes recommendations to the Educa-
tion and Training Board regarding these issues. The committee has recently
undertaken a new program at the annual APA convention. The G. Stanley
Hall lecture series was approved by the Council and will attempt to provide
annual overviews of developments in the major subfields of psychology as
a way of orienting and supporting undergraduate faculty.
Committee on Accreditation. This ten-member committee reports to
Council through the Education and Training Board. It evaluates "doctoral
programs and facilities for internships in professional psychology, such as,
clinical, counseling and school" (American Psychological Association, 1982,
p. 84). It performs these evaluations in light of the APA accreditation cri-
teria which were recently revised by Council. These criteria present the best
present thinking about what standards training programs in psychology
should meet. The Accreditation Procedures Manual lays out the steps that the
committee uses in its deliberations and insures that the training programs
seeking accreditation will be accorded due process in APA decision making.
172 RICHARD R. KILBURG AND MICHAEL S. PALLAK
This nine-member board is the focal point for all major issues that affect
the profession of psychology. It is
charged with the formulation of recommendations for the Association's general
policy in professional matters, including establishing standards of professional
practice, maintaining satisfactory relations with other professional groups, and
fostering the application of psychologic<ll knowledge to the promotion of the
public welfare at both state and national levels. (American Psychological Asso-
ciation, 1982, p. 91)
The board reorganized its committee structure in 1980 and has two
major groups reporting to it, the Committee on Professional Practice and
the Committee on Professional Standards. Both will be described in more
detail below.
During the past year, the board has focused on a variety of activities
including the complex set of issues involved in the multilevel training and
A GUIDE TO THE AMERICAN PSYCHOLOGICAL ASSOCIATION 173
The committee has written and disseminated a report on the status of homo-
sexual psychologists.
This is the last of the nine member operating boards that report to
Council through the board of directors. Its principal function is "to make
recommendations on current and innovative plans on the acquisition, man-
agement, initiation or discontinuance of journals, separates, bibliographic
and related publications, and information services" (American Psychologi-
cal Association, 1982, p. 60). It also appoints Editors of all AP A journals
except the American Psychologist.
During 1980, this board has been involved with a number of issues
including searching for editors for several journals; establishing editorial
policies; reviewing technical innovations in the publishing business; and
considering changes in journal names, prices, and page allocations.
Council of Editors. This is the only continuing committee of the Publi-
cations and Communications Board. It consists of the editors of all journals
published by APA. It meets regularly "to discuss common editorial prob-
lems and to make recommendations particularly with regard to range of
coverage, limits of editorial responsibility, common problems of style and
the like" (American Psychological Association, 1982, p. 62). It also reviews
issues involving office expenses and editorial page allotments and makes
recommendations to the board.
176 RICHARD R. KILBURG AND MICHAEL S. PALLAK
As can be seen from the foregoing presentation, the major units of the
APA governance cover an enormous range of issues and concerns in Amer-
ican psychology. We will not discuss the equally large number of ad hoc
committees, task forces, and subcommittees that are more narrowly focused,
time-limited groups, working in concert with these major units. This is a
complex, democratically operated organizational structure. It works in a
cooperative spirit even though disagreements on policy matters occur with
some regularity. These differences are identified, sharpened, debated, and
ultimately, almost always, negotiated to a mutually acceptable conclusion.
In a later section of the chapter, we will track briefly the origin and dispo-
sition of several typical kinds of professional issues that confront APA as
an organization.
The roles and functions of APA's divisions and affiliated state associa-
tions have been alluded to at several points in this chapter. A brief review
of these organizations seems to be in order to clarify their status and rela-
tionship to APA.
There are presently 40 official divisions of APA. These are autonomous
organizations that can be developed if a validated petition with signatures
of 1% of the membership of APA is presented to Council. The divisions vary
widely in size and interests. Most provide a newsletter/communication ser-
vice to their membership. Divisional status guarantees 18 hours of conven-
tion program time for the particular interest area. The apportionment ballot
for election of representatives to Council allows divisional representation
within this important body. These divisions operate within the confines of
APA's overall policies and have varying degrees of relations with central
office.
The 51 state associations affiliated with APA are similar in operation to
the divisions. A petition from 10 members of APA filed from any state is
sufficient to gain that organization affiliated status. States also gain council
representation through the apportionment ballot, operate newsletters, pro-
vide state and local meetings, organize legislative efforts, and conduct eth-
ics and peer review operations in their jurisdictions. They relate to APA
through CAPASAR (see above) and the State Association Program of the
Office of Professional Affairs (see below).
CENTRAL OFFICE
Figure 1 presents the organizational chart for the central office of APA.
This is the core of the organization's operations on an administrative and
programmatic level. The staff numbers approximately 225 and is housed in
two separate buildings owned by the Association, one in Washington, D.C.,
and one in Arlington, Virginia.
EXECUTIVE OFfiCE
EXECU1'IVE ASSOCIATE
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IExECUTIVE OFFICE I I AMERICAN CJ
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COMMUN ICATION~ PSYCHOLOGIST
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DEPUTY EXECUTiVE OFFICE FOR BUSINESS ANOCOMMUNICATIQN$ ;;::
DEPUTV ExECUTIVE OFFICE FOR GOVERNANCE AfFAIRS
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;.-
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ASSOCIATE DIRECTOR HUMAN RESOURCES I CONVENTIONIMEETlNGS+ l
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ACCREDITATION LEGiSlA fiVE STUOIES PROGAAMMING.I$VSTEIJIS r GOVERNANCE SERV,CES' l or--
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POLICV STuDIES Pi
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As can be seen in the figure, there are two major units in central office,
Governance Affairs and Business and Communications. In Governance
Affairs there are two major offices, Programs and Planning and National
Policy Studies. Within Programs and Planning, there are a series of separate
program offices that provide the staff support and fulfill liaison responsi-
bilities to most of the major boards and committees. Detailed presentations
on each area will not be made. The Office of National Policy Studies coor~
dinates APA's contacts with most of the major federal executive agencies. It
also coordinates APA policy and legislative strategy with the Association
for the Advancement of Psychology in the U.S. Congress.
The Office of Business and Communications covers a large array of pro-
gram areas. Providing the traditional business and logistical support for the
Association's accounting, personnel, and administrative services are major
aspects of its activities. This office also operates a large behavioral publica-
tion business. Sixteen APA journals, Psychlnfo, and the APA Separates Pro-
gram form the core of these activities. The structure is differentiated so as
to provide clear lines of accountability for the various publishing
endeavors.
The remainder of the central office reports directly through the exec-
utive office, a small cadre of professionals who support the day-to-day func-
tioning of the executive officer. The editor of the Monitor, and the directors
of public information and membership services all report directly to the
executive officer.
The names of the incumbent staff also appear in the figure. Because of
staff turnover and promotions, however, the organizational chart is always
in a state of flux. Frequent turnover occurs because the psychologists who
work in the central office sign only two-year contracts which are renewable
for up to six years. This has been done in an effort to recruit individuals
who wish to be trained in public policy development and the issues and
operations of the national professional organization and who will then
return to other jobs and help cultivate a broader appreciation of the chal-
lenges confronting psychology in America.
Perhaps you have been in the position where you have had an expe-
rience or confronted an issue large enough and serious enough that you felt
you should share it with your colleagues in the hope of developing a joint
strategy for addressing the problem. If you were fairly assertive, you would
discuss it with some friends and you might do something together. If you
were knowledgeable about the structure of American psychology, you
would increase your ability to have a dramatic impact. Let us examine a few
of the more common ways of getting a response to such a concern. For
didactic purposes, we will use several recent examples that APA has
confronted.
A GUIDE TO THE AMERICAN PSYCHOLOGICAL ASSOCIATiON 179
sicians have been working for hundreds of years to improve the health of
people and to advance their own profession. They have been extraordinar-
ily successful at both tasks. Not only has the health of the country
improved, but medicine enjoys a virtual monopoly at the apex of the health
care industry. Virtually no care can be administered without the approval
of a physician. This presents enormous difficulty for any group of practi-
tioners that wishes to provide services in this sector of the economy.
For example, even after the passage of a licensure act in a given state
which allows psychologists to "diagnose and treat mental and nervous dis-
orders," third-party payors are not required to reimburse psychologists
directly. Many do so only after the physician "orders" the care. This is the
so-called medical necessity clause of many health care plans. It is promul-
gated as a quality assurance mechanism. In operation, it guarantees that
physicians are the only gatekeepers to health care. A second type of law
called "direct recognition legislation" (or freedom-of-choice legislation) has
been developed to get around this problem. It modifies state insurance
codes to require insurance companies to reimburse psychologists directly if
they are licensed to provide the care. Even this does not go far enough,
however, as insurance policies written outside of the state where the direct
recognition laws are in effect are not, according to many companies,
required to comply with the law. An extraterritoriality clause must then be
written into the statute to force the companies to comply fully with the law
by stating that even policies written outside of the state are subject to these
statutes. These are just some of the problems psychology is confronting in
the health care industry.
A final major issue facing psychology concerns how we are to be orga-
nized to advocate, educate, and regulate the discipline in the future. In the
past, APA as an organization was criticized for tilting too far toward science
and ignoring the real needs of the professionals. In the mid-to-Iate 1970s,
the reverse became true as scientists have threatened to leave the organi-
zation in droves if APA resources and policy were not more responsive to
their needs. In 1978, a Blue Ribbon Commission on the Organization of
APA was formed to address these issues. Over the past two years, a series
of proposals has been formulated which the commission feels will address
the major problems facing APA.
Central to the concerns of all constituencies in these deliberations are:
(1) Who speaks on behalf of American psychology? (2) How shall resources
be allocated within the organization to meet the needs of the constituen-
cies? and (3) How can the most effective and efficient type of organization
be retained? The commission's proposals, which are still being revised,
would retain much of the central office and the major boards and commit-
tees and the goals of the organization would remain unchanged. Council
would be divided into several interest sections (professionally, scientific,
public welfare) that would consider the issues of major concern to those
constituencies. Problems affecting all groups would be considered by Coun-
cil as a whole in a manner similar to the present scheme. In addition, the
A GUIDE TO THE AMERICAN PSYCHOLOGICAL ASSOCIATION 183
REFERENCES
American Psychological Association. Joint report of the APA and CSPA Committee on Leg-
islation. American Psychologist, 1955, 10,727-756.
American Psychological Association. A model for state legislation affecting the practice of
psychology 1967: Report of APA Committee on Legislation. American Psychologist, 1967,
22, 1095-1103.
American Psychological Association. Guidelines for conditions of employment of psychologists.
Washington, D.C.: Author, 1972.
American Psychological Association. Ethical principles in the conduct of research with human par-
ticipants. Washington, D.C.: Author, 1973.
American Psychological Association. Standards for educational and psychological tests. Washing-
ton, D.C.: Author, 1974.
American Psychological Association. Standards for providers of psychological services. Washing-
ton, D.C.: Author, 1977.
American Psychological Association. Psychology as a health care profession. Washington, D.C.:
Author, 1979.(a)
American Psychological Association. Bylaws of the American Psychological Association. Wash-
ington, D.C.: Author, 1979.(b)
American Psychological Association. Principles for the care and use of animals. Washington,
D.C.: Author, 1979.(c)
American Psychological Association. Ethical standards for psychologists (rev. ed.). Washington,
D.C.: Author, 1981.(a)
184 RICHARD R. KILBURG AND MICHAEL S. PALLAK
American Psychological Association. Specialty guidelines for the delivery of services by clin-
ical psychologists. American Psychologist, 1981, 36, 640-681.(b)
American Psychological Association. Specialty guidelines for the delivery of services by
counseling psychologists. American Psychologist, 1981, 36, 640-681.(c)
American Psychological Association. Specialty guidelines for the delivery of services by
industrial/organizational psychologists. American Psychologist, 1981, 36, 640-681.(d)
American Psychological Association. Specialty guidelines for the delivery of services by
school psychologists. American Psychologist, 1981,36, 640-681.(e)
American Psychological Association. Rules of Council, Washington, D.C.: Author, 1982.
Berger v. Board of Psychologist Examiners, 521 F.2d 1056 (1975).
Centor, A. American Psychological Association. In Wolman, B. B. (Ed.), International encyclo-
pedia of psychiatry, psychology, psychoanalysis, and neurology. New York: Van Nostrand
Reinhold, 1975.
Fernberger, S. W. The American Psychological Association: A historical summary 1892-1930.
Psychological Bulletin, 1932, 29(1), 1-89.
Fernberger, S. W. The American Psychological Association 1892-1942. Psychological Review,
1943,50(1),33-60.
Napoli, D. S. The architects of adjustment: The practice and professionalization of American psy-
chology, 1920-1945. Ann Arbor, Michigan: University Microfilms International, 1975.
7
The National Register of Health Service
Providers in Psychology
ALFRED M. WELLNER and CARL N. ZIMET
185
186 ALFRED M. WELLNER AND CARL N. ZIMET
BACKGROUND
referral. The following states have enacted freedom of choice or direct rec-
ognition legislation:
Alabama Missouri
Arkansas Montana
California Nebraska
Colorado Nevada
Connecticut New Jersey
District of Columbia New Mexico
Georgia New York
Illinois North Carolina
Kansas Ohio
Louisiana Oklahoma
Maine Oregon
Maryland Pennsylvania
Massachusetts Tennessee
Michigan Texas
Minnesota Utah
Mississi ppi Virginia
Washington
New Jersey established the first law in 1968. Yet, in the absence of a well-
established system of identifying psychologists as health service providers,
third-party carriers had to review the credentials of psychologists. The pro-
cedures they used tended to be unreliable and of questionable validity. This
provided further justification for developing a system to identify health ser-
vices in psychology.
The issues of national health insurance and third-party reimbursement
obviously are important ones and were significant factors in the need for
and the development of the National Register. However, there was also a
more basic and in many ways a more important aspect of this undertaking.
Since the early to mid-1960s, more and more psychologists were moving
into areas of functioning that could best be described under the label health
care. There were those involved in psychotherapy and that number swelled
every year. Others were dealing with a variety of harmful-substance abuse
problems such as alcohol, drugs, and tobacco. An increasing number of psy-
chologists began taking active roles in physical rehabilitation and in a vari-
ety of medical problems that have major psychological concomitants (e.g.,
cancer, diabetes, and asthma). Yet there was no recognition of these devel-
opments within American psychology. It seemed that the time had come to
make it clear to psychology and to the public at large that among the many
and varied activities engaged in by psychologists, the area of health service
provision was an important and a growing one. Just how important and
how much of a growth area it was was emphasized even further by the
petition for and the acceptance by AP A in 1978 of a new division, Health
Psychology.
NATIONAL REGISTER OF HEALTH SERVICE PROVIDERS 189
In a previous report (Zimet & Wellner, 1977), the authors noted some
of the developments in psychology that led to the establishment of the
Council for the National Register of Health Service Providers in Psychol-
ogy. Briefly, the APA Committee on Health Insurance (COHI) had initially
discussed the possibility of establishing a system to identify health service
providers in 1973 and had asked the American Association of State Psy-
chology Boards (AASPB) to implement this project. Because the basic legal
mission of the State Boards is generic licensing and certification, AASPB did
not feel that the compilation of a list of selected state-licensed/certified psy-
chologists would be appropriate. Indeed, it was felt that it might not even
be permissible.
Coinciding with these developments, the American Board of Profes-
sional Psychology (ABPP) was considering an alternative plan involving
the development of a specialty designation certificate below the formal
diplomate status. Under that plan an individual would be eligible to take
an examination for this "junior diplomate" or "board eligible" status two
years after the doctorate in anyone of the four traditional areas of clinical,
counseling, school, and industrial/organizational.
One of the authors, Carl N. Zimet, then a member of the ABPP Board
of Trustees, was appointed to develop a plan for such a program and to
consider alternate approaches. Out of this came a recommendation for the
development of a National Register for Health Service Providers which was
discussed by several of the trustees of ABPP and a few other professional
psychologists who had a particular interest in this area.
The concept of the Register was agreed to and was adopted at an ABPP
Board of Trustees meeting. At this point ABPP discussed this formal pro-
posal with APA. In October 1973, the APA Board of Professional Affairs
formally voted to recommend that APA request ABPP to establish a
National Register of Health Service Providers in Psychology. The request
was endorsed by the APA board and at the annual meeting of the board of
trustees of ABPP in March 1974, action was taken to implement the project.
ABPP called a meeting for May 31 and June 1, 1974, of a group of 12 psy-
chologists who were familiar with the range of health services, standards
of practice, and the various specialties in psychology. This group evolved
190 ALFRED M. WELLNER AND CARL N. ZIMET
into the board of directors of the Register. At the first meeting of the
National Register Board it was decided to add three nonpsychologist mem-
bers who would add a public point of view to the board.
It should be noted that there were concerns about the desirability of
forming the National Register. For example, at the 1974 annual convention
of APA some members of state licensing boards argued that the state pre-
rogatives were being usurped since the National Register could serve as a
national "licensing" body. In response, it was made clear that the National
Register was in effect oriented toward strengthening state boards by requir-
ing licensing as a basic criterion for inclusion in the National Register and
by working closely with the boards in the enforcement of the laws. It did
not wish to, nor could it legally, replace state licensing boards. Others were
concerned about how individuals would be listed if they resided in a state
in which they did not have a license. The format of the listing in the Reg-
ister makes clear to the reader that the individual is not licensed in that
state. In addition, no registrant is shown for more than two years under the
geographic listing in a state where he or she does not hold a license/certif-
icate to practice. In recognition of these and other concerns, the National
Register's position was that given the need for the establishment of a list of
health service providers in psychology for various purposes (see above) the
Register when developing such a roster would be fully mindful of the exist-
ing standards of the profession and the various jurisdictional issues present.
The Council for the National Register of Health Service Providers in
Psychology was incorporated as a separate, nonprofit organization in the
fall of 1974. ABPP advanced the Council for the National Register seed
money, in the form of a loan, to initiate the project.
Since the National Register was designed to be a self-supporting
professional activity, there were many financial uncertainties regarding it
as there are with any new venture. In order to encourage early applications
that would permit the board of directors to determine the feasibility and
financial viability of establishing the National Register, information and an
application form were sent to all licensed/certified psychologists in the
United States. This mailing included an announcement of an early registra-
tion fee schedule. The normal fee of $100 ($50 for the application and cre-
dential review and $50 upon approval for listing) was reduced to $60 for
the early registration (a three-month period).
Within the three-month period, over 5,000 applications were received.
Obviously, this was a very strong and positive response and clearly
expressed the confidence of professional psychologists in the goals estab-
lished and in the viability and the need for a National Register of Health
Service Providers.
The definition has served the National Register well and has provided
a reasonable basis upon which to evaluate the credentials of applicants for
listing in the Register. It also has served as a definition that has been found
helpful by various governmental agencies and health organizations.
One of the first tasks of the group was to establish appropriate criteria
for listing. On the basis of the standards of the profession, the policy state-
ments established by APA, AASPB, and the general standards for the state
statutes, the following criteria were established for listing:
1. Licensed or certified by the State Board of Examiners in Psychology
at the independent practice level.
2. A doctoral degree from a regionally accredited university.
3. Two years of supervised experience in health services in psychology
of which at least one year is in an organized health service training
program or internship and one year is postdoctoral.
For a period of three years, until January 1978, applications
were accepted from psychologists without a doctoral degree if the
applicant had (a) been licensed or certified as a psychologist for the
independent practice by the State Board of Examiners of Psychology
by January I, 1975 and (b) had his/her graduate degree granted a
minimum of six years prior to January 1975 and had at least six years
of experience in psychology with at least two years of supervised
experience in health services, one of which was in an organized
health service training program.
Although the doctoral degree was the basic degree requirement, the
criteria also established the requirement that there be one year of postdoc-
toral supervised experience in health services in psychology. In order to
conform to due process of law, however, a "grandparent" period of approx-
imately three years was established to end January I, 1978. During this
192 ALFRED M. WELLNER AND CARL N. ZIMET
grandparent period persons with other than the doctoral degree were
accepted and predoctoral experience was accepted in lieu of postdoctoral.
The need for a grandparent period in such an effort is clear. Although there
are some who wish to see the establishment of the highest standards at the
earliest possible time, such an interest must be tempered by the reality of
colleagues who have been in practice for some time and who have, in fact,
been licensed or certified to practice. State boards of examiners in psychol-
ogy also have worked with a grandparent principle upon enactment of state
legislation. It is a very common and well accepted practice which seems fair
to all in the development of a new system.
Applications Cumulative
TABLE 2
Number of Psychologists Listed in National
Register
Edition Total
Although the criteria are fairly specific, there are individuals who
apply who do not meet them and are, therefore, not acceptable for listing
in the National Register. As of June 1982 approximately 85% of the appli-
cants have been approved. Table 2 shows the number of psychologists listed
in each of the publications and a cumulative total of all psychologists listed
in the National Register, now approximately 13,500.
In order to compare some characteristics of those licensed/certified
psychologists who are, or are not, included in the National Register, the
Register compiled an accurate list of these individuals that eliminated dou-
ble references where a psychologist was licensed/certified in more than one
state. This was the first such unduplicated list of licensed psychologists ever
compiled. On the basis of the analysis it was determined that as of the fall
of 1976 there were approximately 25,000 to 26,000 licensed/certified psy-
chologists. Survey forms were sent to all with a follow-up form to those
who had not responded after several months. By early 1977,75% of those
surveyed responded. Data obtained from that survey was initially quickly
disseminated through Register Research Reports and more recently devel-
oped in a more comprehensive manuscript (Mills, Wellner, & VandenBos,
1979). The data that follow were obtained in the survey.
1. Number of health service providers. An item on the survey asked if the
respondent was a "health service provider." This was a self-definition not
necessarily consistent with the criteria for listing in the National Register.
It was determined that approximately 74% of the respondents identified
themselves as health service providers with another 14% trained but not
currently providing such services. Projecting to the population of all
licensed/certified psychologists it was found that there were approximately
19,000 health service providers in psychology at that time.
2. Providers in private practice. The data showed that approximately 25%
of the providers were in private practice on a full-time basis and another
57% on a part-time basis.
3. Highest academic degree. A comparison of the highest academic
degrees for those listed and not listed in the National Register:
Listed 88% Doctorates
Not Listed 78% Doctorates
196 ALFRED M. WELLNER AND CARL N. ZIMET
With the listing of over 13,000 highly qualified health service provid-
ers in psychology by the summer of 1982, it is clear that the National Reg-
ister is a major resource tool. In fact, recognition of the National Register
has been achieved through the utilization of Register data by several fed-
eral, state, and private agencies for manpower planning purposes. For
example, over the past several years a number of federal agencies including
the recent President's Commission on Mental Health requested data from
the National Register on the number of health service providers in psy-
chology, their distribution, etc. Similarly, the Federal Employee Health
Benefit Program of Blue Cross/Blue Shield had long sought a procedure
that would identify appropriate providers of psychological services. Upon
hearing of the development of a National Register and upon review of the
criteria for listing, the Blue Cross/Blue Shield FEHB evaluated the Register
and its procedures and determined that listing in the Register would meet
their requirements. If the psychologist is not listed, the local Blue Cross/
Blue Shield office would have to conduct the usual investigation to deter-
mine if the provider is qualified. That is, the National Register as a volun-
tary listing served to facilitate the identification of qualified health service
providers for the Blue Cross/Blue Shield offices. In 1976-1977, the Aetna
Life Insurance Company also conducted a study of the National Register
and concluded that it provides an acceptable system of identifying qualified
health service psychologists for their FEHB plans. The directors of the
Aetna program made a formal statement of their study and presented their
conclusions at the open meeting of the National Register held during the
APA Convention in San Francisco in 1977.
The Civilian Health and Medical program (CHAMPUS) administered
by the Department of Defense also formally recognized the Register. And
NATIONAL REGISTER OF HEALTH SERVICE PROVIDERS 197
the Model Direct Recognition Bill jointly developed by APA and the Health
Insurance Association of America (HIAA) for states to use in enacting direct
recognition (Freedom of Choice) legislation, refers to the National Register
as a means of identifying qualified providers of service.
The California legislature incorporated the National Register in iden-
tifying the credentials of psychologists in workers compensation legisla-
tion. The Maryland legislature recently enacted a law to give psychologists
recognition as expert witnesses and for the evaluation of individuals for
commitment purposes and uses the National Register as a reference for
identifying the credentials of psychologists under the law.
On the basis of the subscriptions to the Register, it seems clear that the
National Register also has been of great value to any number of organiza-
tions in identifying qualified providers of health services. It also seems clear
from information obtained through surveys of the subscribers that the Reg-
ister has facilitated the identification of psychologists in the health service
field in a wide variety of areas.
of that year and includes approximately 785 programs which were deter-
mined to meet the guidelines developed at the 1977 National Conference
on Education and Credentialing in Psychology. The National Register's
project was developed through numerous sources of information including
a survey of all doctoral programs listed in the AP A publication, "Graduate
Study in Psychology", collaborative efforts with the American Association
of State Psychology Boards (AASPB), and the State Boards of Examiners in
Psychology, contacts with the Council of Graduate Departments of Psy-
chology, information from over 15,000 applications for listing in the
National Register, transcripts of academic work, and communications with
department chairs, program directors, and other faculty. The National Reg-
ister's List of Designated Doctoral Programs in Psychology has been found
to be useful to prospective graduate students in psychology, to educational
institutions interested in developing a program which meets the standards
of the profession, and has also clearly served the review process for listing
in the National Register.
REFERENCES
Shortly after World War II, federal agencies such as the Veterans Admin-
istration, the United Stated Public Health Service, and the Surgeon General
of the United States Army needed to identify appropriately trained psy-
chologists, (initially clinical then counseling psychologists). They also
needed to determine which training programs were worthy of federal sup-
port. In response to these expressed needs, to fulfill its responsibility to the
public, and to regulate the development of rapidly growing applied train-
ing programs, the American Psychological Association (APA) launched its
accreditation programs (Sears, 1947). By accreditation, we mean a recog-
nized system of establishing standards for professional training and for
publicly identifying programs that meet those standards.
Since its beginnings, growth in psychology accreditation has been
steady with respect both to numbers of programs and to areas of psychology
accredited. Starting with a few dozen university programs in the early
1950s, the number and scope had increased by 1968 to encompass 95 clinical
and counseling doctoral programs in universities and approximately 100
internship programs in service settings (Boneau & Simmons, 1970). By 1975
there were 128 accredited doctoral training programs, including 6 in school
psychology (a specialty area first accredited in 1970), and 115 predoctoral
internships accredited by the APA (Kurz, 1977b). In January 1983, the APA
listed 187 doctoral training programs (127 clinical, 35 counseling, 20 school,
and 5 in the combined category) and 243 internships (American Psycholog-
ical Association, 1983). At that time, the APA also reported active applica-
tions in process for 6 doctoral programs and 13 internships.
203
204 RONALD B. KURZ AND ALFRED M. WELLNER
ACCREDITATION PROCESS
SO only after they have engaged in self-study and are satisfied that they
meet the standards set forth in the criteria (American Psychological Asso-
ciation, 1979b). Self-study is most easily accomplished by inviting a psy-
cholOgist who is knowledgeable in the general substantive area of the pro-
gram and in the accreditation criteria to make a consultative visit to the
program. Such an advisory visit is often helpful to the staff, students, and
administration by offering an objective view of the program. Such a visit
also can highlight the strengths and weaknesses of the program and offer
advice as to when to apply, how to maximize the resources, and how to raise
the probability of a successful application being submitted.
The application for accreditation provides information on the goals and
philosophy of the program, staff, students, curriculum, facilities, support
from the institution's administration, and the general climate of the insti-
tution. If after review of the application the Committee on Accreditation
feels further consideration is warranted (as opposed to immediate rejec-
tion), a site visit to the training program is arranged. These visits typically
require a day and a half to two days, with teams being composed of from
two to five visitors depending upon the number and size of the programs
involved. Site visitors are most often chosen from the ranks of department
chairs, chief psychologists, program directors, past and current members of
the Committee on Accreditation and the Education and Training Board, and
other psychologists who are knowledgeable in the training and evaluation
of professional psychologists. Each team member is expected to be thor-
oughly familiar with the accreditation procedures and criteria, the appli-
cation submitted by the training program, and the characteristics and his-
tories of psychology training settings. Well in advance of the visit, the
visitor receives relevant background material on the program, including
reports of previous visits and annual reports. The visitor is also supplied
with guidelines that provide suggestions on conducting various phases of
the visit and for writing the site visit report.
The Committee on Accreditation suggests the follOWing plan for visits,
although it expects visitors to adapt themselves to varying local
circumstances:
Following the site visit, a detailed report is written describing the pro-
gram in the areas set forth in the criteria. Prior to consideration by the Com-
mittee on Accreditation, the report is sent to the institution for review, com-
ment, and correction of factual errors. The Committee on Accreditation
then uses the report and the response from the institution as well as other
information from the program as the basis for making a decision about the
program's accreditability.
Given the array of information, the range of judgments, the diversity
of criteria, and the dynamic aspect of an active program, it is reasonable to
expect that the Committee on Accreditation's decision will be a group pro-
cess based on its best judgment of the available data. Some criteria lend
themselves more easily to verification, while others require professional
judgments on the adequacy or degree to which a specific criterion is met.
As a result, the committee is now developing a site visitor's handbook
that will provide a more uniform data collection effort, serve to better
inform programs on the areas of evaluation and the nature of the infor-
mation sought, permit the committee to assess the characteristics of
accredited programs and evaluate all programs upon comparable data, and
more effectively plan for the future.
New programs are considered for one of two classes of accreditation. If
the program meets all of the criteria, it is placed on full accreditation status.
If it meets most but not all of the criteria, it may be provisionally accredited
if it can be expected to meet all of the criteria in a reasonable period of time
(usually three years). Thus provisional accreditation can serve the purpose
of a candidacy category for emerging programs that are strikingly innova-
tive and, therefore, deviate somewhat from the criteria. If a program is
granted full or provisional accreditation, the name of the institution is pub-
lished in the listing of accredited institutions that appears annually in the
American Psychologist.
Training programs that are already accredited but show evidence of
failing to meet the criteria may be placed on probation for specified periods
of time. Probationary actions are also reported in the listing in the American
Psychologist. If a program that is on probation fails to improve within the
ACCREDITATION OF PROFESSIONAL TRAINING PROGRAMS 209
trainees are to function optimally within our pluralistic society. (American Psy-
chological Association, 1979b, p. 4)
INTERNSHIP ACCREDITATION
Since internship settings are far more varied than academic depart-
ments of psychology in universities, it is more difficult to set out accredi-
tation criteria that can encompass the range of possible training experiences
and models with the kind of specificity found in the criteria for academic
doctoral programs. The current criteria state some general points that are
considered essential for accreditation and which probably also serve as
guidelines for internship training centers that are not accredited. An intern-
ship comprises at least one calendar year of full-time experience or two cal-
endar years of half-time experience. Internship programs are expected to
develop a set of goals and a philosophy of training that are realistic and
consonant with the goals of the broader agency. The program should not
be overspecialized, but rather should provide supervised experience in a
range of activities in the general areas of assessment, intervention, and
research applications. Adequate supervision of the intern's activities is the
cornerstone of the internship training enterprise. The training staff should
provide a variety of role models and be relatively stable, with most well-
developed programs offering the interns the opportunity to interact with a
wide range of other professionals and disciplines. Programs involving a
very small staff and only one or two interns probably do not have sufficient
mass and capacity for varied training interactions and intertrainee stimu-
lation to offer adequate training. The trainees should have completed prior
practicum level experience and be enrolled in a doctoral training program
in the relevant area of professional psychology. Agency support for the
internship program should be apparent in respect to adequacy of resources
and the willingness to budget specifically for training activities.
Accreditation of internships involves special problems not typically
encountered in doctoral program approval. Internships are invariably much
smaller than doctoral programs. An internship with a dozen trainees is con-
sidered a large program and somewhere between two and four interns is
about average. Having a critical mass of trainees is always a problem for
such small programs. Likewise, the staffs of many internship agencies are
quite small and often are comprised primarily of part-time psychologists.
Further, whereas the main function of universities is education and train-
ing, service agencies offering internship training often do so as a low prior-
ity activity. This low priority is reflected in minimally adequate training
budgets, pressure on staff to spend their time in service rather than training
activities, and exploitation of interns as low-paid staff members rather than
treatment of them as trainees. Since internships are usually one-year expe-
riences, shifts in administrative attitudes toward the program, turnover
among small staffs, reduction in funding, or interpersonal strife within an
agency can have major effects on the quality of training.
Programs in smaller hospitals and clinics sometimes solve the problems
associated with small staffs, lack of diversity, and low levels of funding by
entering into consortium arrangements with several local agencies. Taken
individually, each member of the consortium may not have sufficient vari-
ety of clinical material or diversity of staff and role models to achieve accre-
214 RONALD B. KURZ AND ALFRED M. WELLNER
ditation, but if interns are rotated among all or most of them an adequately
varied program can be arranged. Most consortia involve only three or four
agencies, as for example, the psychology department of a medical school, a
Veteran's Administration General Medical and Surgical Hospital, and a
community mental health center. As with other rotational programs, the
intern may spend three or four months working at each agency. A few have
recently developed that are very complex, involving 10 or 12 community
agencies. Although consortia allow for great variety in training experiences,
they present problems for the accreditation system because they also tend
to suffer from lack of central control, non uniformity of policies and stan-
dards for admission and evaluation of interns, and poorly articulated train-
ing goals and models. Nevertheless, consortium arrangements seem to be
appealing to an increasing number of programs, and with financial prob-
lems of training agencies becoming more serious, the number of consortia
seeking accreditation in the future will probably increase.
Professional autonomy is another matter of serious concern in the
accreditation of internships. Doctoral training programs in universities and
professional schools of psychology are under the direct control of psychol-
ogists. Except for some programs in university counseling centers, intern-
ships, on the other hand, are typically in settings run by other professions.
This is nowhere more evident and perhaps more serious than programs in
medical schools and teaching hospitals. There has been a sharp increase in
the number of psychologists employed in these settings in the past 25 years
(Lubin, 1979), with medical schools being a favorite place for psychology
internship training (Cohen, Lubin, & Nathan, 1979). Whereas such settings
give training high priority, are usually stable, and have large faculty and
intern groups, they are often lacking in autonomy for psychologists. Most
psychologists in medical schools are in departments of psychiatry where
their roles tend to be limited or fixed by other professions (Nathan, Mill-
ham, & Lubin, 1979), and where there has been large-scale exclusion of psy-
chologists from full voting privileges (Matarazzo, Lubin, & Nathan, 1978).
Although to this date APA's Accreditation Committee has not questioned
the approval of programs in medical settings where full voting medical staff
membership has not been afforded psychologists, certainly any programs
in which psychology has been placed in a narrow or subservient role, or in
which psychologists do not have essential control over their own training
activities would not be accreditable.
Finally, another set of concerns with internship training is being
addressed by the Association of Psychology Internship Centers (APIC).
Since 1968 APIC has been the primary source of information concerning
internship training for various professional groups, training programs, and
governmental agencies. The APA relies on APIC for advice and guidance
regarding accreditation of internship training activities. In addition to pub-
lishing a directory of internship training opportunities and settings, and
monitoring the timing of internship offers to students, APIC is presently
working on several issues that will have an impact on the accreditation cri-
ACCREDITATION OF PROFESSIONAL TRAINING PROGRAMS 215
teria. For example, aside from the general dictum that students accepted for
internship training should have adequate practicum level preparation, the
Criteria for Accreditation provide little guidance to training programs
regarding the quality and quantity of the pre-internship training. APIC is,
therefore, attempting to develop a set of standards for students at the begin-
ning of internship training. This will not only aid the internships in orga-
nizing their selection processes and help the Committee on Accreditation
to specify its own criteria, but also will eventually have an impact on the
doctoral programs by providing some clear goals for their training to pre-
pare students for internships. Similarly, APIC is in the process of defining
the skills and competencies interns ought to have on completion of intern-
ship training and the techniques for evaluating intern performance.
APIC also has under discussion whether unpaid internships should be
accredited. There are strong arguments on both sides of this issue. Some
believe that the internship, as the first foray of graduate students into the
real professional job situation, should provide financial remuneration as a
way of signifying the appropriate professional status and the role of the
intern. The stipend thus becomes another factor in establishing the auton-
omy and worth of psychology and its training programs. Others believe
that were we to eliminate unpaid training positions, we would deny many
good students the opportunity for internship training and would frustrate
the desires of many psychology staff members who ascribe high value and
status to their roles as psychology trainers.
field. Thus in the late 1960s school psychology, recognizing its responsibil-
ity to the public and its needs for standards and self-regulation, began to
urge APA to include it in the scope of the APA accreditation system. As
APA began to develop suitable criteria and other details necessary to
accredit this area, it became involved in a jurisdictional dispute with the
National Council for Accreditation of Teacher Education (NCATE) which
also accredits school psychology programs through its accreditational pro-
grams for the preparation of school service personnel, and with the
National Association of School Psychologists (NASP). The early history and
temporary resolution of this conflict which permitted APA to begin its
school psychology accreditation has been described elsewhere (Kurz, 1974).
Active discussions among the three organizations regarding the accredita-
tion of school psychology programs are continuing. A special task force has
also been convened to find common ground for resolution of matters per-
taining to the roles and responsibilities of each organization in accredita-
tion and other issues concerning titling and credentialing and the entry
level for the practice of school psychology (American Psychological Asso-
ciation, 1979c).
The entry of APA into the accreditation of school psychology programs
in 1970 was, and still is, confined to doctoral training programs. This is con-
sistent with the principle of the Council of Postsecondary Accreditation to
encourage accreditation activities at only one entry level of each profes-
sional field, with APA's accreditation of clinical and counseling psychology
programs at the doctoral level, and with current membership in APA set at
the doctoral level. It is not consistent with the large number of applied prac-
ticing psychological specialists who are practicing their specialties with
master's as the highest degree. For this reason, several conferences in the
early 1970s (Southern Regional Education Board, 1971; Western Interstate
Commission for Higher Education, 1971; Korman, 1976) have called on APA
for the development of accreditation at the master's level. The complica-
tions of taking such a step include the conflict with NCATE and NASP, the
requirements of COPA and the U.S. Office of Education, the enormous
increase in cost and administrative difficulties, the doctoral requirement for
the practice of psychology as established by the standards for providers of
psychological services, the very significant issue of admitting master's level
psychologists to full membership in the APA, and the state legislative
requirements for licensure and/or certification. It also is complicated by the
attempts to establish a consistent set of education and credentialing stan-
dards for psychologists in all specialty fields and the desire of psychologists
to be included in any national health insurance that might develop since
both of these goals are predicated on the Ph.D. as the minimum level.
Although a proposal for a cost-saving master's accreditation system (Kurz,
1971) had been approved by two training conferences (Western Interstate
Commission for Higher Education, 1971; Korman, 1976) the concept was too
controversial and unpopular with the general membership of APA to be
adopted.
218 RONALD B. KURZ AND ALFRED M. WELLNER
ate such a process. In addition to the APA concerns, the AASPB and the
individual state boards of examiners also are exploring the nature of spe-
cialty designation for licensure or certification of practitioners. Efforts are
currently under way to identify the nature of specialties, criteria which
relate to the training and practice of anyone specialty which will then have
impact on how these are developed for standards for providers as well as
standards or criteria for accreditation.
CONCLUSIONS
REFERENCES
223
224 GEORGE STRICKER
physicians (HCPOP). They also are responsible for the review of some men-
tal health services. This approach to quality assurance for medical services
had its origins with area-wide organizations of physicians that were inter-
ested in matters concerning costs and quality of medical care. These orga-
nizations, called Foundations for Medical Care, gave rise to the Experimen-
tal Medical Care Review Organization (EMCRO) program, which in turn
provided the model for the development of PSROs (Brook & Williams,
1976). PSRO is only concerned with patients who are covered by Medicare,
Medicaid, or the Maternal and Child Health and Crippled Children's Ser-
vices programs (Titles XVIII, XIX, and V of the Social Security Act). Whether
or not services offered to these patients will be reimbursable will depend
on the PSRO review decision. Currently, it is being phased in primarily in
short-stay hospitals. Eventually, by statute, it must be extended to other
institutions, including long-term care facilities and specialty hospitals, and
ultimately, it will be applied to ambulatory care patients. The Department
of Health, Education and WelIare (HEW) has funded a series of demonstra-
tion projects in long-term care facilities and ambulatory settings with such
expansion clearly in mind. Further, if federal support should be extended,
such as through a National Health Insurance plan, a preponderance of
patients may fall under the protection of this legislation, assuming that they
are covered by the plan. States and insurance carriers who are experiencing
difficulty with mental health review also might turn to PSROs for review
services, if the PSRO system can demonstrate its effectiveness. Over half the
conditionally designated PSROs are currently performing some private
review in addition to their mandated functions, so that reimbursement deci-
sions are being made for patients who do not come under the federal aegis.
This type of review has been actively encouraged by the Department of
Health, Education and Welfare. Thus, although PSRO is a system that is
currently in a developmental phase, it may provide the basis of insuring
accountability in health care delivery on a widespread basis in the future.
PSRO is a federally mandated system to assure accountability in the
delivery of health services (Goran, Roberts, Kellogg, Fielding, & Jessee,
1975). It was authorized in 1972 as part of the amendments to the Social
Security Act under Public Law 92-603. The task of a PSRO is to determine
whether services are necessary, of proper quality, and appropriately deliv-
ered in the most economical setting. As of October 1978, 195 PSRO areas
had been deSignated and a PSRO was in some stage of operation in all but
two of these (Seidenberg, 1979).
Accountability in the provision of health services is concerned with the
dual components of quality assurance and cost containment. Quality assur-
ance focuses on the provision of at least adequate health services, while cost
containment assures that this is achieved through the provision of neces-
sary services at a reasonable cost and through the elimination of unneces-
sary or ineffective services.
There are three separate tasks assigned to a PSRO: concurrent review,
medical care evaluation studies, and profile analysis. The overall intention
PEER REVIEW SYSTEMS IN PSYCHOLOGY 225
great many services that are currently subject to PSRO review, it is critical
that they know about PSROs and be involved in PSRO developments, both
for pragmatic reasons and out of principle. The pragmatic reasons concern
the probable future expansion of PSROs into widespread review activities.
The principle is one that holds that only psychologists should review the
work of psychologists. It is pursuant to this principle that the American
Psychological Association (APA) has been active in the encouragement of
the development of Professional Standards Review Committees (PSRC).
ate. HIAA, in turn, agreed to act as a liaison between the FIs and the PSRCs,
and publicize the review mechanism to its member carriers (Rosenberg &
Theaman, 1982).
The first guidelines for the PSRCs were promulgated in 1968 and com-
mittees were established in a few states that had immediate needs for
review activity. By 1971, when the Aetna Insurance Company agreed to
include psychologists as providers under the Federal Employees Health
Benefits Plan, a policy covering federal employees that was administered
by Aetna, 10 regional review committees were established, covering the
entire United States.
At this time COHI, which had taken the initial leadership role in the
establishment of PSRCs, felt that it would be more appropriate if they with-
drew from the review picture. Since COHI was quite openly an advocacy
group, and review activities were clearly intended to be impartial and non-
adversarial, the danger of at least the suggestion of a conflict of interest
loomed. This led to a recommendation to the Board of Professional Affairs
of APA that they establish a Task Force on Peer Review Committees. This
task force, which consisted of five psychologists and two public members,
was established and charged with formulating plans for a network of inde-
pendent PSRCs and drafting new guidelines that would reflect the experi-
ence accumulated by the existing review groups. In 1973 these guidelines
were issued and in 1974 APA established a standing Committee on Profes-
sional Standards Review (COPSR). The function of COPSR was
(1) to monitor and evaluate all matters pertaining to professional standards
review, specifically including government systems of professional standards
review, (2) recommend policies and actions for the maintenance and operation
of state Professional Standards Review Committees, (3) maintain informational
and educational liaison with other groups within the Association that share an
interest in matters relevant to its mission. (Conger, 1976)
Each state and the District of Columbia now maintain PSRCs under the
auspices of the State Psychological Association, although the degree of
activity varies widely among them. The PSRC is composed of a varying
number of psychologists, depending on the size of the state, and it is rec-
ommended (American Psychological Association, 1975) that they also
include public members, which many of them do. While some PSRCs have
been involved in insurance review and have, by arrangement with a PSRO,
even extended their activities to the conduct of PSRO review, others have
never reviewed a case. These discrepancies are a result of factors such as the
number of active service providers in the state, the existence of direct rec-
ognition statutes, the willingness of the FI to make referrals, and the extent
of active effort by the PSRC in seeking referrals.
A case may be submitted for review by the therapist, the patient, or the
FI and may concern the activities of any of the other parties. When a case
is brought to review by the therapist it usually concerns an action taken by
the FI, with the PSRC asked to render a contrary judgment. A patient may
bring a similar case to review or may question some activities by the ther-
230 GEORGE STRICKER
apist, such as a charge for a missed session. The great majority of cases, how-
ever, are brought by the FIs and concern the practice of the provider. In any
of these situations, the decision of the PSRC is purely advisory and is not
binding on any of the parties, although it is usually accepted.
When the practice of a provider is under review, the decision of the
PSRC will concern whether that aspect of the practice was usual, customary,
or reasonable. These are terms that compare the practice to norms estab-
lished by the provider himself, the community of providers, and the situ-
ation. Thus, usual refers to the typical activity of the provider in question,
customary to the typical activity of all providers in the geographic area, and
reasonable to situations in which the practice may be neither usual nor cus-
tomary, but is justified by the particular needs of the case.
While many referrals to PSRCs from FIs involve decisions about fees,
this does not seem to be a good use of the review mechanism, since FIs
maintain excellent normative records and are in the best position to know
whether a fee is usual or customary. Perhaps they are asking whether an
unusual fee is reasonable for a particular case, but the question frequently
only asks whether a fee is customary.
When referral questions do not concern fees, they very often concern
the amount of service, either in terms of time per session, sessions per week,
or length of the therapeutic episode. Except in the case of innovative ther-
apeutic procedures, the quality of the service is rarely questioned. In any
case, the PSRC will try to determine whether the service was necessary,
efficient, economic, and rendered in a manner in keeping with profession-
ally recognized standards.
There are a clear set of procedural steps that the PSRC follows after
receipt of a case to review (American Psychological Association, 1975). The
provider will be informed that a case is under review and will be told of
the procedures. These vary, depending upon the complexity of the case. If
it is relatively straightforward, the chair of the PSRC may reach a prelimi-
nary subjective judgment, inform the other PSRC members by telephone
and, if they concur, forward that opinion to the FI. In more complex cases,
additional information may be sought from the provider, consultation may
occur among the PSRC members, either by telephone or in person and, in
some instances, the psychologist may be asked to appear before the PSRC.
If a physical meeting is required it usually involves the provider alone
although, on some occasions, the patient also may be asked to appear. The
purpose of the meeting is to elicit additional information and to exchange
opinions so that the nature and circumstances of the service might be clar-
ified. The meeting is considered to be one of fact-finding rather than an
adversary procedure with disciplinary consequences.
Whether the decision-making procedure is document-based or supple-
mented by interview, the notification of opinion is by mail, to the party
initiating the action. Any objection to the opinion by any of the parties
involved may be registered in the form of an appeal to the board of direc-
tors of the state psychological association. Much as with an appellate court,
PEER REVIEW SYSTEMS IN PSYCHOLOGY 231
the appeal only can be on procedural grounds, such as failure to follow the
committee's guidelines. The board does not wish to be placed in a position
of second-guessing one of its committees or repeating procedures that have
been properly conducted.
Protection of confidentiality is built into the procedures of the PSRC.
All names of providers and patients are deleted from materials that are cir-
culated and these materials are destroyed after the appeals period has
elapsed. The providers are asked in the original notification letter to obtain
the signed consent of the patient before supplying any information. The
patient is only asked to appear in person if absolutely necessary and, in the
event that occurs, the PSRC is particularly cognizant of the need to restrict
questions to the particular area of concern of the case.
There has been confusion in the minds of some about the scope of
responsibility of the PSRC, and how it differs from other review committees
of a more disciplinary nature. The PSRC is not an ethics committee or a
licensing board and it will not render judgments in these areas. If a case
brought to the PSRC has clear implications concerning ethics or licensing,
however, it is the responsibility of the PSRC to forward the case to the
appropriate committee for further action.
Aside from the rendering of review judgments, education is seen as an
integral part of the activities of the PSRC. The educational process begins
with the activity of the PSRC in the community as it makes providers, con-
sumers, and FIs aware of its existence so that its services may be utilized.
This is one area where PSRCs have been differentially proactive. Education
is also seen as part and parcel of the review process. For the provider, the
review decision offers a guideline concerning the view of peers as to what
constitutes usual, customary, and reasonable service and this knowledge
may help to shape future practice. For the patient, the decision is informa-
tive as to the boundaries of appropriate psychological services. For the FI,
the parameters of practice are drawn with increasing clarity and this should
serve to guide the selection of subsequent cases for review. Apart from the
review process, the PSRC also seeks to inform FIs as to the nature of sound
psychological practice and to inform providers about the procedures of FIs.
The PSRC is an outgrowth of organized psychology, yet it owes its alle-
giance to the principles of sound practice, rather than to the Psychological
Association that sponsored it. It provides an opportunity to see whether
psychologists will allow a sense of professionalism and public responsibil-
ity to govern their judgment. To the extent that this occurs, the PSRC will
be successful and psychology will be in a position to be proud of its place
in the community of professionals.
1 The
discrepancy between the two contracts reflects the preponderance of physician involve-
ment in inpatient care.
PEER REVIEW SYSTEMS IN PSYCHOLOGY 233
2The original members of the National Advisory Panel were George Stricker (Chair, 1977-
1981); Russell Bent (Vice-Chair, 1977-1981; Chair, 1982-current), Melvin Gravitz, Anna
Rosenberg, Lee Sechrest, Joan Willens, and Harl Young. Gravitz resigned after one year and
was replaced by Roderick Pugh in 1980. In 1981, Rosenberg and Sechrest were replaced by
Diane Follingstad and Milton Theaman (Vice-Chair, 1982-current). In 1982, Willens and
Young were replaced by J. Benedict and Maurice Zemlick. William Claiborn was Project
Director from October 1977 to September 1981, and Sharon Shueman has served in that role
since then.
3People who work in the office of a fiscal intermediary, review claims on substantive rather
than administrative grounds and determine whether they should be paid, denied, or for-
warded for peer review.
234 GEORGE STRICKER
the same time, to gather no more information than was necessary, in order
to protect the privacy of the patient. The document that was constructed
asks the provider to submit a description of the past and current conditions,
therapeutic interventions, progress, and goals of treatment. A copy of this
document is included in the Appendix. It does not request detailed histor-
ical material, elaborate psychodynamic formulations, or detailed progress
notes. It must, however, supply sufficient information, stated in explicit
behavioral terms, to allow for a professionally informed review decision.
The burden for providing information is on the psychologist, and a failure
to provide necessary data might result in the denial of a claim.
This treatment report form is filed at each of the mandated review
points. The information is examined by utilization reviewers in the office
of the FI, usually Blue Cross/Blue Shield or Mutual of Omaha. These
reviewers, frequently nurses, then decide whether or not the case should
be referred to psychologist peer reviewers. The criteria that were con-
structed by the panel (Stricker, 1978, 1979) were to be applied by these uti-
lization reviewers, who determine on the basis of professionally con-
structed criteria whether or not a case requires peer review. In the event
that it does, all identifying information is removed before it is sent to the
three reviewers. The peer reviewers are not given any specific criteria but
are asked to use their best professional judgment in arriving at decisions
about the quality and appropriateness of service. Thus, the system is one in
which preliminary screening is done by non psychologists on the basis of
explicit, professionally constructed criteria, and further recommendations
are arrived at by psychologists on the basis of implicit clinical criteria.
It must be noted that the treatment report form, although it does
require a diagnosis for insurance purposes, does not rely on the diagnosis
for review purposes, representing a sharp break from a medical model of
review. In order for a diagnostic system to be of value, it must be applied
in a reliable way by practitioners and be discriminating in terms of treat-
ment expectations. The current psychiatric nomenclature, despite the fact
that it has the potential for reliable application (Matarazzo, 1978), is not
used in a reliable way by practitioners submitting insurance claims. The
usual experience with outpatient mental health services is that four diag-
nostic categories (anxiety, depression, situational reaction, behavioral dis-
order) account for almost 90% of the claims received. In part, this is due to
a conscious decision on the part of the therapist to circumvent the system
and protect the patient from possible future embarrassment or discrimina-
tion by submitting the most benign diagnosis conceivable. Whether the
motivation is in the interests of the provider or the patient, the effect of this
action is to render the diagnosis a meaningless point of entry into a review
system. Even if diagnosis was used in a reliable fashion, however, there is
considerable doubt as to whether different diagnoses indicate different
courses of treatment, especially when psychotherapeutic, rather than psy-
chopharmacological, treatments are involved. For example, the PSRO cri-
teria, which are diagnosis based, are virtually identical for each of the diag-
PEER REVIEW SYSTEMS IN PSYCHOLOGY 235
noses, indicating that diagnosis does not provide a differential basis for
treatment planning (American Medical Association, 1975).
The explicit review criteria that were constructed represented an
attempt to define adequate practice in order to select cases that exceed these
limits for peer review. The peer reviewer would then have the option of
allowing a particular practice to be reimbursed because it was reasonable
under the special circumstances of the case. It is important to recognize that
the criteria do not intend to be a straitjacket restricting practice to a spe-
cific set of procedures. Justification for practice outside the criteria may be
provided and will be reimbursable if approved by peer reviewers.
In order to clarify the nature of the review criteria, a representative
selection will be summarized. A portion of the treatment review form asks
for a statement of progress since the last review point. This progress must
relate to specific treatment goals and it must explain the reasons that under-
lie a lack of progress, if such is the case. The therapist is asked to make a
judgment of the progl'ess since the last review point.
The statement of the problem must be in sufficient detail to allow
determinations about the necessity of care. It should include information
about the circumstances, frequency, degree of disruption, and point of onset
of the problem. It must include evidence of either significant functional
impairment or significant personal distress. It must make clear that the
patient is unable to function effectively in at least one of the following
areas; home or family, job or school, interpersonal relationships, bodily
function, protection of self and/ or others, and personal comfort. This
emphasis on impairment stems from CHAMPUS regulations, which require
that mental health services be restorative, rather than for growth and devel-
opment, in order to qualify for reimbursement. This restriction should
make clear that services may fall outside of the criteria and still be profes-
sionally appropriate.
Since the statement of the problem is of more value than diagnosis and
defines the necessity for service, it is important that it be stated clearly and
behaviorally. A presenting problem such as "depression" would not be suf-
ficient, whereas a statement such as "the patient feels continuing sadness
associated with the loss of role clarity due to the growing independence of
children" would make the need for services far more clear.
Along this same line, a goal such as "the patient will feel better" would
not allow for informed review, while a statement such as "the patient will
have reported substantial relief from personal distress, including feeling
calmer, less tense, better able to handle stress, and eating and sleeping reg-
ularly" easily could,be used as a criterion for progress. This last example
illustrates the need for goals to be stated in specific and concrete terms. The
goals also must be related to the problems and must be stated in terms of
change expected by the next review point. The changes also must be ones
that are reasonably obtainable through psychotherapeutic processes.
There are a number of limitations upon service that are based on
CHAMPUS regulations, rather than on panel judgments as to clinical effi-
236 GEORGE STRICKER
cacy. Thus, interventions such as sex therapy or training analysis fall out-
side of the regulations and would not be reimbursable. Whatever interven-
tions are indicated must be related to the goals and problems that are stated
elsewhere in the treatment report form.
There are a number of time limitations, some of which are contained
in regulations and others that were devised by the panel. Individuai ther-
apy sessions must have a duration of 60 minutes or less, must total two
hours a week or less, and must occur at least once every two months. Marital
and family sessions must be between 45 and 90 minutes. Group therapy
must occur in a group of enrolled membership between 4 and 10, with
patients 8 years of age or older, and must have a duration of 60 to 120 min-
utes. In order to treat a child, the patient must be 4 years of age or older
and the treatment plan must show collateral involvement with a Significant
person in the patient's life.
Some of the limitations that have been mentioned can be waived in
either of two circumstances. The first is a therapeutic emergency. An emer-
gency is an abrupt and substantial change in behavior, usually associated
with a clear precipitating situation, and is in the direction of severe impair-
ment of functioning or marked increase in personal distress. During such a
clinical emergency the frequency and duration of treatment may be
increased, but there is a limit of eight emergency sessions within each epi-
sode of care.
The criteria might also be waived in circumstances where there are
clear and appropriate clinical reasons for doing so. The determination of
the appropriateness will be made by the peer reviewers, and thus the bur-
den will be on the psychologist to present reasons for deviation in a clear
and explicit manner. The general approach of the review system is to estab-
lish a framework for customary treatment and allow deviations to be
approved by peers wherever it is appropriate to do so.
Because of the request that is made for explicit information about
patients, it also was necessary to devise procedures that would insure the
confidentiality of the material and protect the privacy of the patients. An
initial step in this direction was the involvement of the patient in the con-
struction of the treatment report form. It is important to note that no doc-
ument will leave the office of the FI with any information identifying either
the therapist or the patient. The treatment report forms will be separated
from the claims documents and will not be microfilmed or copied in any
way except for review purposes. All documents will be destroyed as soon
as the episode of care is concluded and the period allowable for appeal of
review decisions has elapsed. These precautions should serve to protect the
privacy of the patient and minimize the potential for any abuse of confi-
dential information.
The system that has been described is one that was specifically con-
structed for one health plan, and which was tailored to the regulations of
that plan. The panel was aware of the limitations this created, and thus
developed two sets of criteria, a CHAMPUS-specific set and an ideal set of
PEER REVIEW SYSTEMS IN PSYCHOLOGY 237
Locus of Review
PSRO has been concerned with care provided in short-stay hospitals.
There is an unspecified provision for future movement into the ambulatory
238 GEORGE STRICKER
sector, but this has not yet been initiated on other than a demonstration
basis. The PSRC has been concerned almost exclusively with ambulatory
care, although it is possible for it to address itself to a hospital case if one
should be referred. The CHAMPUS program is exclusively concerned with
ambulatory care, although the parallel contract with the American Psychi-
atric Association does cover inpatient care. Along this line, it should be
noted that the CHAMPUS panel has developed a set of recommendations
and an approach to the review of care provided in alternative settings such
as day hospitals and crisis centers.
Staffing
PSROs are composed exclusively of physicians. There is a possibility
for the input of psychologists and the involvement of psychologists in the
review process. This involvement, however, is subject to the ultimate
responsibility of physicians and psychologists clearly serve at their request.
The PSRC is composed of psychologists and public members. It has the
clearest and most active involvement of the potential consumer of mental
health services. The CHAMPUS program consists exclUSively of
psychologists.
Scope of Effort
Aside from its review functions, the PSRO is also mandated to perform
medical care evaluation studies and profile analyses. The PSRC is concerned
entirely with the review of individual cases upon referral by a party to the
therapeutic transaction. CHAMPUS is concerned with the screening of all
cases that are submitted and the review of selected cases.
Perspective
PSRO review is prospective and concurrent in nature.' Both admission
certification and continued-stay review involve the monitoring of ongoing
cases, with decisions involving the immediate disposition of the health care
process. PSRC is concerned with retrospective review. It makes judgments
about services that already have been rendered and recommends reim-
bursement policies for these services. Its decisions also can have prospective
implications since one recommendation that is possible is the termination
of services. CHAMPUS operates in a similar manner. By regulation, the
review system must be retrospective and judgments must be made about
care already offered, although these judgments often have concurrent and
prospective implications. However, in the ideal review system that has been
constructed by the panel, review is prospective. Treatment plans are sub-
'PSROs also engage in retrospective reviews when doing MCEs and profile analyses, but
active case review is prospective and concurrent.
PEER REVIEW SYSTEMS IN PSYCHOLOGY 239
mitted and approved in advance. This assures both the provider and the
patient that ongoing services will be reimbursable.
Case Selection
Both PSRO and CHAMPUS are engaged in exceptiorts review. Rather
than making judgments about every case, which would be virtually impos-
sible because of the magnitude of work involved, certain cases are selected
for the careful attention of peer reviewers. The PSRC operates after this
selection and performs a total review on all cases that are submitted. PSRO
has the capacity, through profile analysis, to identify outliers. This is a
group of providers whose care is remarkably deviant from the customary.
The identification of outliers, if they represent a significant group, can lead
to a major cost savings and a sharp increase of quality of care by eliminating
or modifying the behavior of a group of practitioners whose care is beyortd
acceptable limits (Brook & Williams, 1976). In CHAMPUS's ideal system,
profile analysis also is indicated as a very valuable procedure for the pur-
pose of identifying outliers.
Criteria
Both PSRO and CHAMPUS have explicit screening criteria and
implicit peer review cirteria. Since PSRC does not do any screening, its cri-
teria are entirely implicit. In fact, peer review decisions in all three systems
are currently based on implicit criteria. One of the goals of the CHAMPUS
panel is to develop explicit criteria to aid peer reviewers in the judgment
process.
Decision Making
In the PSRO system the initial reviewer selects cases, but decisions are
made by peers. In the PSRC system all decisions are made by peers. In
CHAMPUS the explicit criteria that have been constructed include a num-
ber of decision alternatives that are placed in the hands of the initial utili-
zation reviewer. In some instances these decisions can be made without fur-
ther review, while other cases are designated for submission to peer
reviewers for a judgment. Although the actual decisions are not always
made directly by a peer in the CHAMPUS program, the panel considers the
utilization reviewer as implementing a set of professional standards and
thus acting as peer surrogates.
Definition of Quality
The classic foci for quality are the structure, the process, and the out-
come of treatment (Donabedian, 1966). Structural definitions are oriented
toward characteristics of the institution providing the care. Process defini-
240 GEORGE STRICKER
tions are oriented toward the provider and represent a judgment about the
nature of the services that are being provided. Outcome criteria are oriented
toward the patient and look at the effects of the service. Unfortunately, the
relationships among structure, process, and outcome are not clear and the
satisfaction of quality standards in one arena does not guarantee quality in
the others (Brook & Appel, 1973).
The only use of structural criteria is by the PSRO system. It will dele-
gate the review function to hospitals assuming, among other things, that
the hospital has met JCAH standards and these standards are largely struc-
tural in nature. The only aspect of PSRC or CHAMPUS review that approx-
imates the structural is the designation of who might be a qualified
provider.
All of the three systems are primarily process-based review systems.
They attend to the nature of the care that is offered and compare this with
explicit or implicit standards of professionally acceptable care. It must be
noted that each of these systems is more concerned with technical aspects
of care than with the art of care, a dimension usually overlooked in quality
assurance efforts (Brook, Williams, & Davies-Avery, 1976).
Outcome criteria are not used by PSRO in concurrent review activities,
but may be used retrospectively in medical care evaluation studies. The
PSRC has little opportunity to employ outcome criteria unless the case that
has been submitted has completed an episode of care. The CHAMPUS sys-
tem has attempted to recognize the value of outcome criteria by developing
a progress oriented treatment report form. This calls for an intermediate
statement of outcome and, if progress is not in keeping with goals, the case
may be reviewed unfavorably.
CONCLUSION
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American Psychological Association, Committee on Professional Standards Review. Proce-
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Washington, D.C.: Author, 1975.
242 GEORGE STRICKER
Brook, R. H., & Appel, F. A. Quality of care assessment: Choosing a method for peer review.
New England Journal of Medicine, 1973, 288, 1323-1329.
Brook, R. H., & Davies-Avery, A. Mechanisms for assuring quality of u.s. medical care services:
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Brook, R. H., & Williams, K. N. Evaluation of the New Mexico peer review system. Medical
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Brook, R. H., Williams, K. N.. , & Davies-Avery, A. Quality assurance today and tomorrow:
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Appendix
OUTPATIENT MENTAL HEALTH TREATMENT REPORT
DIAGNOSIS:
Use DSM-III Codes and Nomenclature:
Axis 1_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
Axis 11 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Axis 111 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Axis IV (optional) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
243
244 GEORGE STRICKER
Axis V (optional) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
I. State patient's initial reason for seeking treatment. Describe how and when the
condition or impairment of function was first manifested. Summarize prior treat-
ment by you or other therapist, if any.
II. Describe the patient's current condition. Describe the nature, duration, and
severity of functional impairments. Include current mental status or results of
psychological assessment.
III. If applicable, give the date and describe the significant results of physical exam-
inations. Include pertinent laboratory tests, abnormal findings, and dates of
tests. (If diagnosis is alcoholism, provide results of neurological, liver function
and chemical screen.)
B. Components of treatment:
1. Psychotherapy: Specify types, frequency, and length of sessions. (If
group, give number of patients in the group. When applicable, explain
relationship and nature of treatment provided to members of the same
family.)
5. If psychotherapy sessions are more than two (2) per week, provide
rationale:
B. Components of treatment:
1. Psychotherapy: Specify types, frequency, and length of sessions. (If
group, give number of patients in the group. When applicable, explain
relationship and nature of treatment provided to members of the same
family.)
5. If psychotherapy sessions are more than two (2) per week, provide
rationale.
VII. Other remarks or additional detail (such as consultations) that would assist
professional reviewers in understanding this case.
ADDRESS TELEPHONE
v
LAWS AFFECTING PROFESSIONAL
PRACTICE
10
Health Insurance and Third-Party
Reimbursement
HERBERT OORKEN
To illustrate from the start that this is a complex, highly varied, and often
confusing field, let me assert that there is no such thing as health "insur-
ance!" Your health is not being insured against the unlikely event that you
will ever be sick or disabled. Rather, based on the premise that health care
will be needed and is costly, we are simply prepaying expected costs in a
uniform, generally monthly, premium amount. In group health plans/pol-
icies, the prepayment is leveled across a broader group. Expenditures
become more predictable and administration and related costs become less
per each subscriber. For some subscribers the leveled cost actually will be
greater than what they might expend, while for others it will be less. Also,
apart from accidents and "catastrophic" sickness or disorder, the decision to
seek health care, where, from whom, and how often, has a high degree of
electivity.
Subscribers, after obtaining health care from recognized providers/
professionals (e.g., some plans will not cover optometric services) for ser-
vices included in the policy benefits (e.g., routine check-ups are not covered
by many plans), are entitled to be reimbursed for the cost of those services,
minus any deductible or co-payment requirement. Usually, the subscriber
is obliged to pay the first $100 of expenses in a year (the deductible), or say
20% of the first $1,000 or $2,000 of expenses (the co-payment/co-insurance).
The subscriber is of course responsible for paying the provider for services
rendered. To shortcut this process, some providers have a participating
agreement with the carrier whereby they are paid directly (except for the
deductible or co-payment). Essentially, then, they are not paid directly by
the client but by a "third party."
249
250 HERBERT DORKEN
CHAMPUS
Action, 1973). Thus, the decision to recognize biofeedback could expand the
involvement of clinical psychologists in services to CHAMPUS
beneficiaries.
In order to qualify for reimbursement under the CHAMPUS, a service
provider must meet certain qualifications and conditions. First, as noted
above, reimbursement is limited to qualified providers and to services that,
in the language of the law, are "medically or psychologically necessary."
Second, CHAMPUS automatically will recognize those listed in the National
Register of Health Service Providers in Psychology (1978) as "clinical psycholo-
gists." Others must gain provider status by application and credential
review with the fiscal intermediary, an insurance carrier such as Aetna or
Blue Shield, or computer corporation that processes claims and issues pay-
ment for services under federal contract.
Third, in order to improve overall quality assurance of health care and
to effect review and control on the utilization of psychological services, the
American Psychological Association, under contract to the Department of
Defense, developed a peer review system for psychological services that was
implemented in 1980 (see Chapter 9). This system will insure that all claims
will become subject to review. Thus, the peer review system will exert pro-
gressively more scrutiny, the more frequent and extended a beneficiary's
visits. Certain procedures are excluded outright, that is, are not reimbursa-
ble at all. Others are allowed only on authorization. For more than a few
visits, treatment plans, including a statement of the problem to be
addressed and the outcome expected, will have to be filed for peer review
and continued care will have to be rejustified. The system is designed to
promote efficiency, effectiveness, and accountability and to limit utilization
to services that are necessary, are considered beneficial, and are delivered
by qualified providers. It is in the shape of things to come, not just for the
CHAMPUS program.
In effect, then, over a period of time there will have to be a demon-
strable benefit from services to retain them in a plan. Providers also will
have to establish that they meet accepted standards of the profession. The
days of repeated visits without a plan, except for a return visit, are coming
to an end, while greater precision in provider qefinition will limit those
who can be recognized as health practitioners. There will be hard questions
for psychologists to answer. Grinker (1972) put the dilemma well: "Can
anyone answer even one 'what' in the question: What kind of therapist,
using what kind of treatment, in what kind of setting, for which kind of
patient, achieves what kind of result? The answer is 'No.'" But such an
answer is obviously a very insufficient basis on which to provide a health
"benefit package."
In a plan the size of CHAMPUS, any change in benefit, provider rec-
ognition, or the extent of coverage obviously can have major cost implica-
tions. The service volume, however, also makes it feasible to generate
patient and provider profiles by computer for assistance in detecting pat-
terns of fraud and excessive use of diagnostic and/or treatment services.
254 HERBERT DORKEN
below), but CHAMPUS will reimburse for psychological services not cov-
ered by Medicare that are recognized CHAMPUS benefits. On the other
hand, if a person is eligible for Medicaid benefits, CHAMPUS always pays
its benefits first. This avoids having to pick up from where the widely vary-
ing state Medicaid plans leave off or having to transfer CHAMPUS funds
to come under state administration, thereby expediting service access and
reimbursement.
FEHBA
The Federal Employee Health Benefit Act is the law that establishes
conditions and funding of group health plans for federal employees. With
the passage of PL 93-363, which became effective January 1, 1975, this law
was amended so that clinical psychologists (not other psychologists) and
optometrists became recognized as independent providers of health care for
covered benefits in these federal employee health benefit plans that collec-
tively, cover some 10 million lives.
There are about 20 plans, though by far the largest is the Blue Shield
government-wide health service plan. The second largest is the Aetna gov-
ernment-wide indemnity benefit plan. Without any statutory requirement,
Aetna took the "initiative" to recognize psychologists directly for covered
benefits in 1971. This was the initial break in the physician's referral
requirement, later consolidated into law through PL 93-363.
Each of the federal employee health plans differs in its benefits. Some
may not provide coverage for services or conditions that fall within the
practice of psychology. For the others, the provider must look to the plan
benefits for visit limits (e.g., 20 in a year), dollar limits (e.g., $500), location
limits (e.g., only hospital services), disability exclusions (e.g., alcoholism
and drug abuse), and the like.
The Senate did not agree to all provisions of the House bill (H.R. 9440-
Waldie) and the conference report to resolve the differences between the
houses narrowed the House proposal of psychologist to "clinical psychol-
ogist" with the intent language of the report setting limits of expectancy of
a basic standard under state statute of a doctoral degree from a recognized
graduate psychology program and one or more years of supervised experi-
ence. Those grandparented under such laws would also be included.
For its government-wide service benefit plan, Blue Cross/Blue Shield
defines clinical psychologist as a "psychologist who is duly licensed or cer-
tified in the state where the service was rendered and has a doctoral degree
in psychology and has at least two years of clinical experience in a recog-
nized health setting." It also adopted listing in the National Register as
equivalent to its definition and warranting direct recognition.
While no language in PL 93-363 makes any distinction between basic
and supplemental benefits, the Civil Service Commission currently inter-
prets these FEHBA amendments to mean that outpatient psychological ser-
256 HERBERT DORKEN
vices covered by the Blues are supplemental services and thus reimbursed
at 80%. Inpatient services are considered to fall under the basic benefits that
are to be "ordered and billed for by a physician." The recognition of inpa-
tient services are in flux at this time. Referred consultations will be consid-
ered basic services. Moreover, PL 93-363, as passed, not as introduced, con-
tains a loophole, "The provisions of this subsection shall not apply to group
practice prepayment plans," that is, these plans do not have to recognize
psychologists. Thus, this exemption clause eliminates any requirement that
psychologists be available to members of health maintenance organizations,
such as Kaiser, either as staff, on contract, or otherwise directly accessible
to plan members. Consequently, no psychological services need be pro-
vided in such group practice plans. The federal law delineating HMOs, PL
93-222, included Individual Practice Associations (IPAs) within the con-
cept. Rather than being composed of salaried personnel, these are federa-
tions of fee-for-service practitioners. Any IPA that serves federal employees
is not required to have psychologists as participating providers; nor is it
required to recognize psychological services.
For billing purposes there are standard forms, the most common of
which have been developed by the insurance industry, Blue Shield, the
American Medical Association, and certain government programs. Except
for special groups, one of these standard forms usually can be used to bill
a claim. The AMA form is included in Appendix B as an illustration. The
form used by Blue Cross/Blue Shield in California is highly similar. Forms
must be fully and accurately completed. The information supplied must be
sufficient to indicate to whom services were rendered, the charge billed,
and whether the services are a covered benefit of the plan. Failure to supply
sufficient and accurate information will only lead to reimbursement delays
and/or claim denials.
REHABILITATION
MEDICARE
As Title XVIII under the Social Security Act, Medicare is the first fed-
eral involvement in a nationwide health insurance plan. With few excep-
tions, all residents 65 years of age and older have mandatory hospital insur-
ance coverage derived from Social Security revenues. In addition to this
Part A coverage, an optional voluntary Part B coverage for supplementary
medical insurance (Markus & O'Sullivan, 1977), which is nationally avail-
able, can be purchased by all Medicare beneficiaries. Within Medicare cov-
erage, certain costs are not covered (Le., deductibles plus certain services).
The state, however, can meet part or all of the cost of deductibles, cost shar-
ing, or similar charges under Part B of Medicare for Medicaid beneficiaries.
Similarly, persons may privately purchase "Medigap" insurance to supple-
ment or cover what Medicare does not.
An estimated 28.1 million persons held Medicare hospital insurance
protection in 1980, about 11% of an increasing segment of the population.
(In 1978 there were another 2.7 million chronically disabled, including
those with end-stage renal disease.) Total program cost was $35.7 billion, or
an average of $1,270 per person that year.
In sharp contrast to the three previous federal programs, psychologists
are very restricted in the services they can provide Medicare beneficiaries.
As of this time, psychological services are recognized in but two ways under
the Medicare Law. Licensed/certified psychologists as independent practi-
tioners may only bill for evaluative services upon medical referral. Other-
wise, psychological services are recognized only when "incident to" a phy-
sician's services; that is, when provided in the physician's facilities, under
phYSician supervision, and billed by the physician on a paramedical or
"physician extender" role. With the direction and supervision of the phy-
sician, the "extenders" enable a phYSician to increase the volume of services
for which he/she can be responsible. There is no dollar or visit limit on
such services. Further, even under any supplementary Medigap insurance,
psychological services would be recognized only in those states that have
direct recognition laws for psychologists.
By contrast, inpatient psychiatric hospitalization carries a lifetime limit
of 190 days. Physician services are fully recognized during that time and
psychological services are covered to the extent their cost is included within
258 HERBERT DORKEN
the per diem charge; that is, they are hospital employees and no fee is billed
for their services. In further contrast, outpatient psychiatric services require
50% co-payment by the patient and reimbursement is limited to $250 a year
(at $50 a visit, 10 visits; at $60 a visit, 8 visits). The combined effect is alleged
by critics to increase hospitalization unnecessarily. And, of course, without
access to the services of practitioner psychologists and given the more
highly urbanized distribution of psychiatrists, many of the elderly and dis-
abled Medicare beneficiaries are for practical purposes denied appropriate
care that might otherwise be available.
In the Medicare amendments of 1972, psychology sought independent
provider status but was "accepted" in committee for services only under
medical supervision. The amendment was opposed by psychology and
defeated, leaving the situation described above. Meanwhile, various bills
have been advanced seeking direct recognition but none has prevailed.
MEDICAID
per month (less when shared by certain other limited recognition provid-
ers). The state's current (as of August 1980) maximum allowance or fee for
psychologists is $27.05 per hour. Conditions such as these limit the number
of psychologists willing to accept Medi-Cal (California Medicaid) clients. In
1976, only 55% of California's licensed psychologists who were active
health service providers saw any Medicaid beneficiaries. On the average,
they were paid $3,000 over the year. (By contrast, 88% of psychiatrists par-
ticipated and were paid an average>-()f $10,600.)
By survey of licensed psychologists, Darken and Webb (1980) found
that for full-time fee-service practitioners, Medicaid (Medicare also)
accounted for only a small proportion of their claims submitted to third
parties. They also brought the least satisfactory reimbursement experience
and the highest rate of submission to review. Such conditions and the lim-
ited number of states recognizing psychological services severely limit their
involvement in services to the poor.
Total Medicaid expenditures in 1979 were estimated at $20 billion.
Thus, Medicaid and Medicare combined accounted for almost $49.7 billion
of the total national expenditures on health care in 1979, up from $32.4 bil-
lion in 1976 when they were 23.3% of the $139.3 billion total. To place the
extent of the growing government involvement in health care in perspec-
tive, it should be noted that by 1975, the government paid over 42% of the
nation's total medical care bill, including 53% of the hospital costs (Kristein,
1977).
DISABILITY DETERMINATION
Under Title II, Old Age, Survivors and Disability Insurance (OASDI),
the Social Security benefits may be paid before age entitlement if the mem-
ber is disabled. Disability is defined as the
inability ... to engage in any substantial gainful activity by reason of any med-
ically determinable physical or mental impairment which can be expected to
result in death or which has lasted or can be expected to last for a continuous
period of not less than 12 months.
WORKERS' COMPENSATION
VETERANS
TAXES
STATE LAWS
We have seen that federal law is a very major factor in whether and to
what extent psychological services will be reimbursed in various health
"insurance" plans. These laws, however, pertain only to federal programs
and agencies. Traditionally, certain areas of law that bear on practice are
matters of state jurisdiction. With several exceptions, the insurance industry
is regulated by state law. The licensing of health facilities and health prac-
titioners is also a state responsibility. The specifics of such laws will have a
definite effect from preventing, to limiting, to facilitating, to augmenting
the practice of psychology.
LICENSING / CERTIFICATION
By June 1982,36 states and the District of Columbia had passed Direct
Recognition/Freedom of Choice (FOe) legislation, embracing 87% of the
population of the United States. This legislation amends state insurance and
related codes to require that where health plan/insurance policy benefits
fall within the practice of psychology the consumer / patient can have direct
access to qualified psychologists if that is his or her choice. This direct rec-
ognition does not alter the policy benefits, it only broadens the range of
providers who can render the covered service.
When considering whether the covered benefits/services fall within
the practice of psychology, it is prudent to think back on the Licensing/
Certification Act and for states to take action to assure that their law reflects
current psychological practice. Of course, without a law that mandates
access to psychologists, any recognition is voluntary on the part of the car-
rier. Actually, some of the major insurance carriers, such as Occidental and
Massachusetts Mutual, began to recognize psychological services in some of
their group health plans in the early sixties. What is voluntary, however,
rather than statutory, has no certainty. But their experience was favorable
and they so testified for psychology during hearings on PL 93-363 (see
FEHBA above).
Any insurance that is underwritten in or issued for delivery in a state
must meet the laws of that state. Some FOC laws, such as that in New Jersey,
have an extraterritoriality clause. Its constitutionality has not been tested in
court. In effect, that law seeks to require that a beneficiary of a New Jersey
policy wherever located and whether the beneficiary'S state of residence has
an FOC law or not, must recognize psychological practice. Otherwise,
despite a master policy issued in an FOC state, the claim department may
not accept claims from psychologists in non-FOC states. This occurs in large
companies with employees in various parts of the country. If the master
264 HERBERT DORKEN
policy is issued in an FOC state and the service is rendered in another FOC
state by a qualified practitioner, then reimbursement should follow. A pos-
sible exception is due to laws such as Ohio, Illinois, Georgia, or Virginia,
which recognize only psychologists licensed in that state. Conversely, if the
master policy is issued in a non-FOC state but the beneficiary is resident in
an FOC state, the carrier well can contend that there is no obligation to
recognize psychological services.
Thus, quite apart from the importance of an FOC law to psychologists
in the state, passage of such laws in other states reduces the gap in psy-
chologists' access for clients having health insurance plans issued out of
state. Table I shows the states having this direct recognition legislation. The
36 states and the District of Columbia contain 87% of the national popula-
tion plus, of course, federal employees and CHAMPUS beneficiaries in the
other twenty-one states. This table shows the order and data in which states
passed their FOC Laws, the 1976 population census estimate in thousands,
APA members by state, the unduplicated number of psychologists by state
recognized for independent practice, the ratio of these psychologists per
10,000 of population, and other details.
In order to assure greater consistency in the recognition of psycholo-
gists in state health insurance laws, a committee of the American Psycho-
logical Association undertook to negotiate a model law proposal with the
Health Insurance Association of American (HlAA) which represents several
hundred and more than 80% of the insurance carriers licensed to under-
write health insurance. The Model Psychologist Direct Recognition Bill was
approved by HlAA in May 1976 and by the APA Council of Representatives
as APA policy in September 1976. It is comparable to the National Register'S
minimum standard for listing. The Model Bill's definition of psychologist
is at once broader than graduation from an APA-approved doctoral pro-
gram in clinical psychology and narrower than state licensure / certification.
How much narrower? First the psychologist provider must be licensed/cer-
tified in the state where the service is rendered, not in some other state.
Second, the doctoral degree could be a Ph.D. or Psy.D., or possibly, an Ed.
D. or D.Sc. Third, the degree must be in psychology, not necessarily
awarded through a department of psychology, but in psychology, not in
education, counseling, theology, human engineering, sociology, or some
other related field. An earned, as opposed to an honorary degree is
assumed, and nothing is inferred as equivalent to a doctoral degree. Fourth,
two years of experience would be defined on a full-time equivalent basis
(FTE) in accord with state or federal practice. Depending upon the jurisdic-
tion, a year is usually considered to be 1,500 or 1,800 hours. Fifth, clinical
experience means direct patient care experience for health or disability, not
teaching, applied research, program evaluation, or administration. Sixth,
recognized health setting means that the place is in the business of health, not
social welfare or other endeavor. It might be the distinction between a stu-
dent health service and a student counseling center. Recognized infers a for-
mal basis, such as a state licensed health facility (hospital, skilled nursing
HEALTH INSURANCE AND THIRD-PARTY REIMBURSEMENT 265
TABLE 1
Freedom of Choice Legislation Recognizing Psychology
Lic./
cert.
7/76 1978 No. Lic./ psycho.
Census APA cert.Q 10,000
No. State Passed (1,000) members psycho. popn. Explanatory note b
tv
'I
'"
268 HERBERT DORKEN
STATE PLANS
COMMERCIAL CARRIERS
THE BLUES
conditions such as that for UAW. In 1978, 50 of the 69 Blue Shield plans
provided reimbursement for psychologists; it was mandated by law in 32
states (37 by 1982). As for physician involvement, 28 plans have no such
requirement, 11 require M.D. referral, 8 require M.D. supervision, and 3
require both referral and supervision. Fourteen of the plans have partici-
pating provider agreements with psychologists. The details are available
only by direct inquiry to each plan. It becomes essential to know the broad
plan policies regarding psychologists and then the specifics of subscriber /
member group or individual policy coverage.
Some of the Blue Shield policies provide a different rate of reimburse-
ment depending upon the profession of the provider; others make no dis-
tinction between psychiatrist or psychologist and simply aggregate the fee
screen data by procedure rather than by profession. In large states, it is com-
mon to find that usual fees vary among the PSRO areas of the state and
among procedures. Plans that offer participating provider agreements can
insist upon standards that are higher than simply licensure. Blue Shield of
California, for example, requires in addition to licensure that the
psychologist
hold an earned doctoral degree in psychology from an accredited university or
professional school and have had at least two years of clinical experience in a
recognized health setting, or [is] listed in the National Register of Health Service
Providers in Psychology.
As defined in federal law (PL 93-222) an HMO provides basic and sup-
plemental health services to its members for which they prepay a fixed,
community rated, payment. The services, within defined benefits, are pro-
vided through members of the staff as needed and unrelated to the prepay-
ment. The organization assumes full financial risk on a prospective basis.
HEALTH INSURANCE AND THIRD-PARTY REIMBURSEMENT 271
SELF-INSUREDS
Large companies not in high risk work may well find it attractive to be
self-insured. They can purchase administrative services only (ASO) from
insurance companies and/or "stop-loss" or high-deductible policies, for
example, where the insurance plan pays only when an individual's health
care expenses have exceeded or cost the company more than $5,000 in the
year. The Employee Retirement Income Security Act (ERISA, PL 93-406),
passed in 1974, preempts state law regarding employee welfare benefit
plans. Thus, state regulation no longer prevails and since there is little in
the way of federal regulation to· date regarding health insurance, group
health plans that are employer "established or maintained" or by an
employee organization are for practical purposes deregulated.
This federal law is focused largely on pension plans and possible
abuses, but both management and labor generally appear to support the
deregulation of group health insurance. Recent court decisions in New
Hampshire and Massachusetts suggest that mandatory mental health insur-
ance laws may have some immunity to ERISA's state preemption. On the
other hand, court decisions in California won by Standard Oil and Hewlett-
HEALTH INSURANCE AND THIRD-PARTY REIMBURSEMENT 273
WORKER'S COMPENSATION
HOSPITAL PRACTICE
PRACTICE TRENDS
such as biofeedback and the behavior therapies, have clearly proven effec-
tive with specific health problems.
It is also becoming clear not only from the HMO law but from the man-
dated adoption of the Professional Standards Review Organization amend-
ments to the Social Security Act and the oversight provided in the National
Health Planning and Resources Development Act of 1974 (PL 93-641) that
we are moving increasingly toward organized models of health services. In
effect, health care is becoming industrialized in the full sense of the
analogy.
Incidentally, since the psychologist's fee was approximately $5 less, the con-
sumer could have about two more visits before the fiscal maximum was
reached. Those seeing only a psychiatrist or psychologist, however, aver-
aged only 7.3 visits. Again, though the data are rare, the economic compe-
tition is everyday reality and can dramatically affect a practitioner's reim-
bursement experiece. The development of working collegial relations with
general medicine and certain non psychiatric specialties seems the most
effective way in which to increase referrals.
With advancing age, use of health care resources increases. In 1975,
while those aged 65 and over were 10% of the population (now almost
11%), they consumed 29.4% of health expenditures. Stated otherwise, while
the national per capita health expenditure was $476, for those 65 and over
it was $1,360 per person (Mueller & Gibson, 1976). While Medicare alone
paid 72% of their hospital bill, there are mounting indications of over-hos-
pitalization and remarkably little use of community mental health and
other ambulatory mental health services. This is a practice area in clear need
of greater attention from the profession to assure inclusion under Medicare
(see above).
CHANGING PRACTICE
REFERENCES
Dorken, H., &: Webb, J. 1976 Third-party reimbursement experience: An interstate compari-
son by carrier. American Psychologist, 1980, 35, 355- 363.
Dorken, H., &: Webb, J. Licensed psychologists on the increase: 1974-79. American Psychologist,
1981,36,1419-1426.
Egdahl, R, et al. Fee for service health maintenance organizations. Journal of the American
Medical Association, 1979, 241, 588-591.
Follette, W., &: Cummings, N. Psychiatric services and medical utilization in a prepaid health
plan setting. Medical Care, 1967,5,25-35.
GLS Associates. Analysis of state programs which mandate mental health benefits under pri-
vate health insurance. Final Report, June 29, 1979. NIMH #278-78-0040 (MH).
Gottfredson, G., &: Dyer, S. Health service providers in psychology. American Psychologist,
1978,33,314-338.
Grinker, R. Foreword. In B. Garger, Follow-up study of hospitalized adolescents. New York: Brun-
ner/Mazel,1972.
Hannings, R, et al. Forensic psychology in disability adjudication: A decade of experience.
HEW Publication No. 72-10284, Washington, D.C.
Harsham, P. What, me incorporate? Money, 1973, 2, 55-58.
Hochberg, R, &: Stunden, A. Psychology and compensation: A reimbursement handbook for
California licensed psychologists. Los Angeles: Division of Clinical and Professional
Psychology, California State Psychological Association, 1979.
Jones, K., &: Vischi, T. Impact of alcohol, drug abuse, and mental health treatment on medical
utilization: A review of the research literature. Medical Care, December 1979, 17, Supple-
ment, pp. 1-82.
Kristein, M., et al. Health economics and preventative care. Science, 1977, 195,457-461.
Levine, D., &: Willner, S. The cost of mental illness, 1974 Mental Health Statistical Note No.
125, February 1976. DHEW Publication No. (ADM) 76-158.
Markus, G., &: O'Sullivan, J. Medicare-Medicaid. Congressional Research Service, Library of
Congress, September 28,1977.
Moore v. Metropolitan. New York State Psychologist, 1974, 26,4. Also published as Insurance
Law upheld, New York State Psychologist, 1973, 25, 1 and 11.
Mueller, M., &: Gibson, R Age differences in health care spending. Fiscal year 1975. Social
Security Administration, DHEW Publication No. (SSA) 76-11700.
National Register of Health Service Providers in Psychology. Washington, D.C.: Council for the
National Register of Health Service Providers in Psychology, 1978.
U.S. Department of Health, Education &: Welfare, Rehabilitation Services Administration,
Final report on characteristics of clients rehabilitated during fiscal year 1974. Informa-
tion memo No. RSA-IM-76-87. Washington, D.C., 1976.(a)
u.s. Department of Health, Education &: Welfare, Social Security Administration Staff Paper
No. 21, Health Insurance Administrative Costs, DHEW Publication No. (SSA) 76-11856,
1976.(b)
Virginia Academy of Clinical Psychologists v. Blue Shield of Virginia, U.s. Court of Appeals, 4th
Circuit, No. 79-1345, Brief of American Psychological Association as Amicus Curiae,
1979.
Von Korff, M., &: Kramer, M. Mental and nervous disorders utilization and cost survey.
National Institute of Mental Health, 1979, Mimeograph.
Wiggins, J. Disability and rehabilitation services. In H. Dorken and Associates, The profes-
sional psychologist today. San Francisco: Jossey-Bass, 1976.
Appendix A
f.:-"'""'."rr"''!=:S:'''::''=·~==~':''"'1lON;c.I''CARIl=~---------I BAOOF'TrOCHILD
~rURALOf 8 =~1lD
CARD NO OTHER (Specify)
RELATIONSHIP
SIGNED DATE TOPATIENJ
_ 1 _ _ ( _ 18 1I>rougIISS ... 10 be comploled blithe phyIIclOn ., _ _ _.)
1. NAME.~&PHONENO OFFEFEMINOPHYSCIAN 20 NAME .. ADDRESS Of FACILITY Wl-£RE SEftVICES ~ lOIher tt.I home Of ofIIce)
o PI'I.....ATE PRACTICE or
0 UNIFOAMEO SERVICES
g~:ING
21 .~O~~S 122 HOSPfTAUZATIONINRlAMATION 123 L.A8WOAKOOTSIDEYOUROFFCE?
PHYSICIAN 1AOMITfED Me I DAY I YEAR DISCHARGED MO I DAY IYEAR I 0 YES D NO CHARGES
24 ~IAGNOSIS, SYMPTOM OR NATURE OF ILLNESS OR INJURY, Fl:LATE OIAGNOSlS TO IIROCEOURE IN COLUMN ·'0"" BY FEFERENCE TO NUMBERS 1.2. 3 or Ox CODE
a-
Z
25 A OATfSOFSERVICE C
PROCeDURE COOE F
MOOAYfY!AR ODENTIFY 'CHAIIGES
21 PATIENTS N:COUNT NO 29 PHYSICIANS OR OTHER PRQ\IIOER·S NAME ADDRESS. ZIP G TOTAL CHARGES
r;cOE .. PHONE NO (INCLUDING AREA CODE)
279
280 HERBERT DORKEN
ThiS claim form IS to be used when submmlng a claim WHERE TO FILE CLAIM
requesting payment for Inpallent or outpatient medical
Send the claim 10 the approprtate CHAMPUS contractor
services or supplies provided to eligible beneficiaries processmg claims for the state or country where the
under the CHAMPUS and CHAMPVA programs, when
services/supplies were prOVided Contact your CHAMPUS
provided by CIVIlian sources of medical care Those In-
AdVisor or OCHAMPUS for the name and address of the
clude physIcians. pharmaCies. medical suppliers, medical appropflate contractor (Exception - When entitled tq.....
equipment suppliers, ambulance companies, laboratOries,
other medical benefits coverage See Item 14 below)
or other authonzed non-Inslltutlonal providers
Important: All mformatlon m Items 1 through 18 IS reqUIred
WHO FILLS OUT CLAIM FORM to process the claim Double check Ihe form. especially
The beneflclary/pallent, sponsor (or other parent) at a Item 8 on SOCial Secuflly number or VA file number, Item 5
child under 18, or the guardian for the individual patient. IS on Idenhflcatlon card number, and Item 18. your signature
reqUIred to complete the Patient/Sponsor InformatIOn Sec- Be~eflclary/patJent's name, sponsor's name, and spon-
lIOn, Items 1 through 18 at the top of the form The sor S SOCial Securtty number or VA ftle number must also
beneficiary/patient (or sponsor) fills out that section re- be on all auachmenls Incomplete forms Will be returned
gardless of who submits the claim - the beneflclaryl for mlssmg InformatIon Retam a copy of the claim form
patient (or sponsor) or the prOVider of medical serVlceSI and alf attachments for your records
supplies Speclollnotructlon.:
When the claim IS submItted by a phySICian or other pro- • Submit a separate claim form for each beneflclaryl
vlder, the lower part of the form (Physlclan/Other PrOVIder pallen!
InformatIOn, Items 19 through 33) must be completed by • FIle no later than December 31 of the year follOWing
the prOVider Item 32, Agreement to PartiCipate. must be the year In which the services were prOVided If a
checked "Yes or No " If a prOVider does not choose to claim IS returned for addlltOnallnformatJon, It must be
partiCipate but completes the form. an authonzed resubmitted by the regular flhng deadhne, or WithIn 90
sIgnature must stili appear In Item 33 days of the notIce of the retumed form - whichever
date IS tater
When the claIm IS submItted by the beneflclarylpatlent or
sponsor for direct reimbursement. an Itemized statement PAnENT/SPONSOR INFORMATION
listing the servIces/supplies must be attached The lower REQUIRED
sectIon of the form for PhYSICian/Other ProVider Informa-
tIOn may be left blank FollOWing are explanations of some of the Items reqUired
on the claim form For a more detailed explanation of all
ITEMIZED STATEMENTS the Items, refer to the special booklet, "How to Complete
CHAMPUSICHAMPVA Claim Form 500," available from
If Items 19 through 33 of the claim form have not been
your nearest Untformed Services medIcal facility, your
completed by the phYSICian or other prOVider, an Itemized
CHAMPUS contractor, or from OCHAMPUS, Denver, Col·
statement must be attached An Itemized statement must
orado 80240
contam
a the benefiCiary/patient's name Item 5: Identification CercI Inform.don. Enter card
b date the services/supplies were prOVided number from space 1 of the IdentIfIcation card (DD
c descnplton of each service/supply Form 1173) If an actIve duty member uses his/her card for
d charge for each seNtce/supply dependents under age 10, use Card Number of DO Form
2A, WIth letters "AD" Indicating Active Duty, after the card
The Itemized statement must be on the prOVider's billing
number
letterhead, contaIning the provlder's name and address
For prescription drugs, the Itemized statement must con-
"om 8: SponIor'. Social Slcurrty Number. Enter spon·
sor's SoCial Securt!y number. Enter sponsor's former Serv-
tain Ice number only If the sponsor does not have a Social
a name of the benefiCiary/patient Secuflly number
b name, strength and quantity of each drug If CHAMPVA benefICiary, enter veteran's VA file number
c prescnptlon number of the drug
If a NATO benefiCiary, enter "NATO" In this space.
d name and address of the pharmacy
If a sponsor IS an active duty secUrtty agent, enter "Se-
e name and address of the prescnblng phYSICian
curtly "
Not acceptable as Itemized statements are billing state-
ments shOWIng only total charges, cancelled checks, cash
register receipts (or Similar type receipts).
282 HERBERT DORKEN
n.m.: VA Statton Number (CHAMPVA only). Enter the • Beyond 4O-mlle rildlul. A Nonavailabihty Statement
three digit number of the VA Station which issued the iden- IS not requlfed for admission to a Civilian hospital
tificatIOn card. when the beneficiary/panent lives more than 40 miles
_14: Do You Hove Other Hoot'" Inauranee? It you from a Military or Public Health Services hospital.
are covered under another medical benefits plan or health • Coll.lnflrmllry. A Nonavallabdlty Statement IS not
Insurance coverage, check "yes" and supply the name reqUIred for inpatient care In a cottege infirmary,
and address of the other health insurer, and what plan or
• Other exception•• A Nonavallablhty Statement IS not
program you have from that insurer required for admission to an approved Skilled Nurs-
CHAMPUS will not duphcate benefits of any olher health Ing FaCIlity, ReSidential Treatment Center, Speclahzed
Insurance plan or program. Treatment FaCIlity, or a ChnslJan SCience Sanatonum.
• Act{ve Duty Dependent. entitled to other medical
benefits or health Insurance coverage must fill out Item 18: Signuure. Every CHAMPUS/CHAMPVA claim
Ilems 1 through 18 on this form and file In the usual mljst be signed by the beneficiary'patient whE"n that bene-
manner. The CHAMPUS contractor Will coordinate I,(",ar,· ,S 18 or oller It It",e tenel'Clary'patrent,s una ole 10
benefits with the other medical care Insurer Sign on his/her own behalf, refer to the special booklet,
• R.t'...... Dependents of Retirees, Dependents of "How to complete CHAMPUS/CHAMPVA Claim Form
Deceaoed Spon ...... and CHAMPVA aeneflclarl•• 500 ,. The sponsor may sign for any benefiClary/palient
must first submit a claim for reimbursement to the under 18: or in the absence of the sponsor, the bene-
other medical care Insurer, except II the other cover- fiCiary/patient's parent or guardian may Sign For reasons
age IS Medicaid II Medicaid, first submit to CHAM- of privacy, a beneflciary/patJent under 18 may choose to
PUS After receiving an Explanation of Benefits (EOB) Sign and personally submit the claim.
or a work sheet from the other health Insurer, fill out
and file the CHAMPUSfCHAMPVA claim form, attach- PHYSICIAN/OTHER PROVIDER INFORMATION
mg a copy of the EOB or work sheet, being sure to FollOWing are explanaliOns of some 01 the Items reqUired
complete Items 1 through 18 of the CHAMPUSI when the phYSICian/other provider completes the claim
CHAMPVA claim form form For a more detailed explanation of all Items, refer to
Item 16: Inpatient/Outpatient care. Check appropriate the special booklet. "How to Complete CHAMPUS,
space according to the followmg explanallOns CHAMPVA Claim Form 500," available from your nearest
• OUlpatlont. All eligible CHAMPUSICHAMPVA Uniformed Services medical facility, your CHAMPUS
benefiCiaries may choose Outpatient care from contractor, or from OCHAMPUS, Denver, Colorado
either cIvIlian, Military or Public Health Services 80240
facllllles. A Nonavallablhty Statement (DO Form 1251)
IS not required for outpatient care
Item 28: Provider Number. Enter the provider number
assigned by the appropriate CHAMPUS contractor
• Inpatient For admiSSion to a cIvIlian hospital, a
Nonavadablhty Statement (DO Form 1251) IS reqUired hem 32: CHAMPUS Participation. If a provider chooses
by all beneficiaries (except CHAMPVA) who live to participate, check "Yes" In this box, Each provider
Within a 40-mlle radiUS of a Military or PubliC Health should carefully read the back of the claim form regarding
Services hospital A copy of the Nonavailability participation, and understand the agreement With the
Statement must be attached to each claim relating to Government, and the consequences for falSifYing any part
the Inpatient stay; i.e , attach a copy to the surgeon's of the claim form.
claim, to the anesthesiologist's claim, etc A
Item 33: Signature. Enter the signature of the phYSician
Nonavallabihty Statement IS Issued by the MIlitary or
or other provider, or his/her authOrized representative If
Public Health Services Hospital Commander before
the phYSICian or other provider completes the claim form,
medical care IS provided
the form must be signed regardless of whether or not
• Emergency Adml.llon. In the case of a bona fide
he/she agrees to partiCipate as a CHAMPUS provider
medical emergency, a Nonavallablhty Statement IS
See ftem 32 on CHAMPUS partiCipatIOn.
not reqUIred for an mpa!lent admiSSion
IMPORTANT REMINDER
All information In Items 1 through 18 IS reqUired to process the CHAMPUS/CHAMPVA claim form. Carefully check
\tem 8, Social Secunty number or VA file number: Item 5, Identification card, and 1Iem 18, signature identification
Information must also be on all attachments Incomplete forms will be returned for completion. Keep a copy of the
claim form and all attachments for your records
Appendix B
THIS FORM TO BE USED TO BI...L aWE CHOU O' SOUTHERN CAUFORNIA OR aWE SHIElD Of CAUFORNIA ONLY.
Pl.£ASE VEIIIFY VJlTH YOUR PATIENT THE CORRECT ORGANIZATION TO BILL
o o o
R£AO INSTRUCTJONS BEFORE COMPLfTING OR SGNING THIS FORM
4 PATIENT'S ADDRESS lSu",. CIIr• .,.,.. ZIP codtIJ 5 PATIENt'S SEX 15 INSURED'S 10 NO. MEDICARE NO ANDIOR MEDICAID NO
(1tICIuW MY 1MI",.6j
~~~
9 OTHER HEALTH INSURANCE COVERAGE· Enlel' Nam. of 11 INSUREO'S ADDRESS (Str.". city. $1"1#,. ZIP CQt/eJ
Pohcyholderand Plan Name.ndAddfHIIand PohcyrwMechcaI
A PATIENrs EMPLOYMENT
YE'I I INO
B AN AUTO ACCIDENT
Si,gn'ngJ
,o"""__ A..... A.lOifnmOt!'.__""U,.,"-'"
17 PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE IRetKIlMd b«tue 13IAUTHOiIJZEPA'1MfN101'MlDICALBENE"'S10UNDCRSIGNED
IAlAllorw""'R~..~ot ... ~M~ _ _ _ NftaU'1U>"'f1<:"plht. C,."" PHYSKI14NORSUl'l'LIERfORSEIIVlCEDESCRlBEOBlWW
MEDlCAREB."ot".'_"~I/ ..
18
YOU FOR THIS CONDITION
PREGNANCY (lMPI YES~NO
17 DATE PATIENT ABU; TO DATES OF TOTAl DISABIt.ITV OATES OF PARTIAL DISABILITY
RETURN TO WORK FROM ITHROUGH
FROM I
THROUGH
18 NAME AND ADDRESS OF REFERRING PHYSICIAN OR OTHER SOURCE 20 FOR SERVICES RELATED TO HOSPITALIZATION
A~~:OSPlTALIlATION DATErDISCHAAGED
21 NAME .. ADDRESS OF FACILITY WHERE SERVICES RENDERED {II OIhcr /hllll ~ til' Q/f"'~1 22 WAS LABORATORY WORK PERFORMED OUTSIDE VOUII OFFICEl
VES~ NO CHARGES
D~NOSIS OR NATURE OF ILLNESS OR INJURV RELATE DIAGNOSIS TO PROCEDURE IN COlUMN 0 BY REFERENCE TO NUMBERS I, 2 3, ETC OR OX CODE
, DFAMILVPlANNINGSERVICE
------=:":~~f~~==l=- :=:=1 , II
--- ---------,.------- ------------------------------------------- ------ --------------i--- --- -- ------- -- ------- -- ----------i----
i ! !
~==~==t=== ===r~~=-=r
-----l-- -- - ------ - - - - - - - --------
1
"1""----- -------------------------------- - ---
i I
r---
25 SIGNATURf OF PHYSICIAN OR SUPPLIER
l ..rtllyunde,penal,yol""IIIIY_'IMIfI;wwgo_
,ngos ...... ndcorrectlr_boo ...... ,Dt....
III"'''I.I
28 ACCEPT ASSIGNMENT
~lfllA~fNJIrI
27 TOTAL CHARGE I 28 AMOUNT PAID 129 BAlANCE DUE
PHD 38 P DO OOPL26520 11
32 YOUR PATIENT S ACCOUNT NO 33 YOUR EMPLOYER I 0 NO
DORKEN HERBERT 0 PHD
2q12 21ST AVENUE
• PLACE OF SERVICE CODES
1 _(.HI _ INPATIENT HOSPITAL 7 _ {ICFJ - INTERMEDIATE CAR£ FACILITY SAN FRANCISCO CA 941'2
2 - (CHI - OUTPAnENT HOSPITAl • - iSNFi - SKILLEDNURSING FACIUTY
3 _ (0) - DOCTOR'S OFFICE
• - - AMBULANCE
4 - (HI - PATIENTS HOME 0- (0lJ - OTHER LOCAnONS
• - - DAY CAllE FACILITY lPSY) A -(Ill - IM)EPENDENT lABORATORY
• - ,NIGHT CARE FACIUTY (PSVI • - - OTHER MfDICAVSURGICAL FACIUTY
C 4359 '11-78)
283
284 HERBERT DORKEN
MEDICARE PAYMENTS: If the patient cannot write, have him sign by mark (X) and
have a witness sign in item 12. If the patient cannot sign by mark, another person may
sign, showing his relationship and indicating on the reverse of the form why the patient
could not sign. A patient's signature requests that payment be made and authorizes
release of medical information necessary to pay the claim. If item 9 is completed, the
patient's signature authorizes releasing of the information to the insurer or agency
shown. In assigned cases, the physician agrees to accept the charge determination of
the Medicare carrier as the full charge, and the patient is responsible only for the deduct-
ible, COinsurance, and noncovered services. Coinsurance and the deductible are based
upon the charge determination of the carrier, if this is less than the charge submitted.
MEDI-CAL PAYMENTS:
I hereby agree to keep such records as are necessary to disclose fully the extent of
services provided to individuals under the state's Title XIX plan and to furnish information
regarding any payments claimed for providing such services as the state agency may
request. I further agree to accept, as payment in full, the amount paid by the Medi-cal
program for those claims submitted for payment under that program, with the exception
of authorized deductibles and coinsurance.
This is to certify that all information entered on this form is true, accurate and complete.
I understand that payment and satisfaction of this claim will be from Federal and State
funds, and that any false claims, statements, or documents, or concealment of a material
fact, may be prosecuted under applicable Federal or State laws.
11
Licensing and Certification
TOMMY T. STIGALL
IEffective July 1, 1979, the Florida and South Dakota laws were repealed as a result of legis-
lative sunset review. New regulatory statutes were enacted in both states during 1981.
TOMMY T. STIGALL. State Office of Mental Health and Substance Abuse, Louisiana
Department of Health and Human Resources, Baton Rouge, Louisiana 70821.
285
286 TOMMY T. STIGALL
The enactment and form of licensure and certification laws has been
influenced heavily by various policy statements and recommendations con-
cerning state legislation issued by the American Psychological Association
(APA). In particular, the report of the American Psychological Association
Committee on Legislation (1967) has served as a model for states to enact
new laws or to amend existing statutes. Recommendations for legislation
contained in the 1967 model were based, in part, upon an earlier joint report
of the APA and Conference of State. Psychological Associations Committee
on Legislation (Joint, 1955).
While acknowledging that "it has never been possible to prepare a
'model bill'" (p. 1097), the 1967 guidelines nevertheless contained specific
legislative recommendations covering 13 major areas of concern. This
model for state legislation was adopted as official policy at the September
1967 meeting of the APA Council of Representatives.
At the time these recommendations were published, there was already
serious concern about accommodating differing roles and legitimate aspi-
LICENSING AND CERTIFICATION 287
The practice of psychology within the meaning of this act is defined as render-
ing to individuals, groups, organizations, or the public any psychological ser-
vice involving the application of principles, methods, and procedures of under-
standing, predicting, and influencing behavior, such as the principles
pertaining to learning, perception, motivation, thinking, emotions, and inter-
personal relationships; the methods and procedures of interviewing, counsel-
ing, and psychotherapy; of constructing, administering, and interpreting tests
of mental abilities, aptitudes, interests, attitudes, personality characteristics,
emotion and motivation; and of assessing public opinion.
The application of said principles and methods includes, but is not
restricted to: diagnosis, prevention, and amelioration of adjustment problems
and emotional and mental disorders of individuals and groups; hypnosis; edu-
288 TOMMY T. STIGALL
logical and no less than 2 years of supervised experience" (p. 1099). The
unfortunate choice of language referring to a doctorate "primarily psycho-
logical" in nature has continued to plague regulatory boards who must
interpret the educational credentials of candidates in light of such statutory
provisions. Frequently statutes allow for candidates to possess doctoral
training in a closely related field or that which is deemed to be "substan-
tially equivalent" to a doctoral degree in psychology. A review of board
actions in this area has led one observer to conclude that "primarily psy-
chological in nature" has become in practice a euphemism for "not psy-
chology" (Berger, 1976).
Reaffirming the 1955 policy, statutory definition and regulation of spe-
cialties within psychology was not recommended by the committee in 1967.
It chose instead to rely upon a code of ethics (American Psychological Asso-
ciation, 1981) and professional self-regulation to achieve conformance of
practice with specialty competence. Subsequent experience and public
opinion have not supported this approach, and there has been increasing
awareness of the need for standards of practice and credentialing within
recognized specialties in addition to generic licensure or certification
(American Psychological Association Committee on Professional Standards,
1981; American Psychological Association Committee on State Legislation,
1978).
Other recommendations of the 1967 model were intended to facilitate
geographic mobility for psychologists by encouraging reciprocal endorse-
ment of credentials among states and by allowing for time-limited practice
by out-of-state consultants. An explicit provision for privileged communi-
cation between psychologist and client was recommended. The composi-
tion of boards was to be representative of the different areas in psychology
so as to include especially psychologists concerned with education and
training as well as those engaged in practice. There was no mention of pub-
lic-member appointments to boards, a practice that now has become more
commonplace. Nor was there any recognition of continuing education as a
requirement for renewal of licensure or certification.
It is common for laws regulating the various professions to empower
boards to approve schools or professional training programs, as well as to
credential individuals (U.S. Department of Health, Education, and Welfare,
1977b). In some instances, boards make use of approved listings of programs
or schools meeting national standards of accreditation. The 1967 legislative
model for psychology specified only that candidates for licensure or certi-
fication should be graduates of accredited institutions and noted in addition
that "nothing in the law should require the registration of departments of
psychology or doctoral programs in psychology" (p. 1102). In discharging
their statutory responsibility to evaluate the educational qualifications of
individual applicants, boards nevertheless are required to make judgments
as to the adequacy of education and professional preparation offered in spe-
cific training programs. In this sense at least, on a case-by-case basis, boards
do undertake an implicit evaluation and approval of training programs as
well as individuals.
290 TOMMY T. STIGALL
QLaw, as amended, establishing the regulatory authority for psychology; there may be other laws which affect the practice of psychologists or the function of the board.
bLaw specifies that nominations to the board shall be made by the psychological association; in other jurisdictions, nomination is unrestricted.
cComposed of two psychologists and two social workers.
dComposed of two certified psychologists, one associate psychologist, one teacher of psychology, and one certified pastoral counselor.
eInciudes two public members and one government member.
fInciudes one member nominated by the Office of Mental Health and Mental Retardation, one member nominated by mental health and mental retardation advocacy groups. Commissioner of Professional and
Occupational Affairs ex officio.
8Public members appointed by Lt. Governor in Council.
h Includes Registrar as nonvoting member.
ipublic members appOinted by Quebec Office of Professions.
TABLE 2
Requirements for Credential
Experience Examination
Jurisdiction Title Education Total Post Written Oral EPPP pass point'
Jurisdiction Title Education Total Post Written Oral EPPP pass point'
Jurisdiction Title Education Total Post Written Oral EPPP pass point'
Ontario Psychologist Doctoral 1 x X n
Quebec PsychologistW Postgraduate r o X· X· 50% correct
Saskatchewan Psychologist Doctoral o X N/A
Note: All jurisdictions have general requirements such as age, citizenship or residency, and character. Some jurisdictions may require continuing education for renewal of the
credential, including Arkansas, California, Colorado, Florida, Georgia, Iowa, Louisiana, Maryland, Michigan, Minnesota, Nevada, New Mexico, Nova Scotia, Oregon, South Dakota,
Utah, Vermont, Washington, West Virginia.
• All values relative to national norms on the Examination for Professional Practice in Psychology (EPPP).
b Must function under supervision in accordance with statutory limitations and board regulations.
C Licensed by Board of Behavioral Science Examiners under provisions of Calif. Bus. & Prof. Code §§ 17860-17870 (Supp. 1982).
t In accordance with requirements for highest level of certification as a school psychologist established by Department of Public Instruction
• Until December 17, 1984, will register without examination applicant with doctorate and two years experience acceptable to board.
• Until December 17, 1984, will register without examination applicant with master's degree and four years of experience acceptable to the board. Thereafter, registration may be
available at discretion of board.
wWorking knowledge of French language required.
x Doctorate, licentiate, or master's.
LICENSING AND CERTIFICATION 303
Definition Diagnosis
of and Psycho- Biofeed- School! Counseling! Behavior Physician
Jurisdiction practice Research Teaching treatment therapy back education guidance modification Hypnosis collaboration
Alabama X X X X psychotherapy
Alaska X X X X X X X X
Arizona X
Arkansas X X X X X psychotherapy
California X X X X X X X
Colorado X X X X X X X X psychotherapy
Connecticut X X X X X X
Delaware
District of Columbia X X X X X X medical
problem
Florida X
Georgia X X X X
Hawaii X X
Idaho X X X X X
Illinois X X X X X mental illness
Indiana X X X X X X mental or
physical
illness
Iowa X X X X X X
Kansas X X X X X X
Kentucky X X X
Louisiana X X X X X X X X
Maine X X X X
Maryland X X X X X X X
Massachusetts X X X X X X X X
Michigan X X X X X X X
Minnesota X X X X X
Mississippi X X X X X
Missouri X X X X X X X X
Montana X X X X X
Nebraska X X X X organic or
psychiatric
disease
Nevada X X X X psychotherapy
New Hampshire
New Jersey X X X
New Mexico X X X X X X
New York X X X X X
North Carolina X X X X X X
North Dakota X X X X
Ohio X X X X X X X psychotherapy
Oklahoma X X X X
Oregon X X X X X X X
Pennsylvania X X X X
Rhode Island X X
South Carolina X X extended
psychotherapy
South Dakota X X X X X X X
Tennessee X X X X psychotherapy
Texas
Utah X X X X X X X X
Vermont X X X
Virginia X X X X X X
Washington X X X X
West Virginia X X X
Wisconsin X X X X X X X
Wyoming X X X X X
Alberta
British Columbia X X X X X X X
Manitoba X X X X X X treatment of
mental
disorder
Continued
TABLE 3
Provisions Related to Scope of Practice (continued)
Definition Diagnosis
of and Psycho- Biofeed- School! Counseling! Behavior Physician
Jurisdiction practice Research Teaching treatment therapy back education guidance modification Hypnosis collaboration
New Brunswick
Nova Scotia
Ontario treatment of
mental
disorder
Quebec x x
Saskatchewan
Note: All definitions recognize psychological testing, evaluation, or assessment as being within the scope of practice of a psychologist.
aNo definition of practice in statute; law authorizes certified psychologist to diagnose, treat, and correct human conditions ordinarily within the scope of practice of a psychologist.
~Limited definition of practice for school psychologist only.
'Nonstatutory definition of practice has been adopted by regulatory body.
dNo definition of practice in statute; provisions specified are found in definition of psychology or psychologist.
'Psychological diagnosis only.
LICENSING AND CERTIFICATION 309
Certified Out of
Social school state Visiting Supervised Student Other
Jurisdiction psychologist psychologist psychologist' lecturers assistants intern / trainee professionsb
Alabama X X X
Alaska X X
Arizona Xd X X
Arkansas X X X
California X"d X X' X Xf
Colorado Xd X X X X
Connecticut X' X X
Delaware X X X X
District of Columbia X X X X
Florida Xd,h X X X
Georgia X X
Hawaii X X xj
Idaho X X X
Illinois X Xd X X X Xk
Indiana X X'" X X X,
Iowa X X X X'"
Kansas X Xd X X X Xk
Kentucky d,n X X
Louisiana X X X X
Maine X X X XO
Maryland XP X X
Massachusetts X X X X
Michigan Xd X X X X X
Minnesota X X X X X
Mississippi X X X X
Missouri X X X X
Montana X X X X X
Continued
TABLE 4
Exemptions by Title (continued)
Certified Out of
Social school state Visiting Supervised Student Other
Jurisdiction psychologist psychologist psychologist' lecturers assistants intern I trainee professionsb
Nebraska X X X X X
Nevada X X' X Xf
New Hampshire X
New Jersey Xd X X X
New Mexico X X X
New York X X Xk,/
North Carolina X X X xm
North Dakota Xd X X X
Ohio X Xd,h X X X X
Oklahoma X X X X X
Oregon X Xd X Xf
Pennsylvania X Xd X X X X
Rhode Island Xd X X
South Carolina X Xd X X X X
South Dakota X· xd,g X X X
Tennessee xd,t X X X
Texas X X
Utah X X
Vermont X X X X
Virginia X' X X·
Washington X Xd X XW
West Virginia Xd X X X X
Wisconsin X Xd,h X X X X Xk
Wyoming d,x X X X
Alberta
British Columbia Xl
Manitoba
New Brunswick X
Nova Scotia X
Ontario Xi
Quebec X'
y,d
Saskatchewan
Q Exemption applies for limited time period to psychologist credentialed in another jurisdiction.
b Except as noted, may not be represented as a psychologist.
, Or psychometrist.
d Exemption limited to school employment only.
e Registration required.
I Exemption limited to other professions recognized by law.
g Or school psychological examiner.
h Statutory licensure for independent practice of school psychology available.
i Temporary permit available.
j Only medical practitioner specified.
k Any person exempted, not using title of psychologist.
I May not describe services as psychological.
m Any person may use title without engaging in practice.
R Exemption for certified psychometrician.
otherwise exempted.
I Or school psychological services worker.
U Exemption for any person employed as a psychologist by a public school district.
v Any person exempted, not charging a fee and not represented as licensed,
W Only counseling and gUidance specified.
Alabama X X X X X· X '"'....."
X' X' X' X'
:;;
Alaska i'i
Arizona Xd Xd Xd X',f :>-
.....
Arkansas X X X X' X X (5
xg xg xg Z
California X
Colorado X',f X·"
Connecticut X X X X X
Delaware X X X
District of Columbia Xi Xi Xi Xi x· X'
Florida X X X X X· X X, Xi
Georgia X X X X X· X·
Hawaii X X X X'
Idaho X X X X
Illinois X X X X X
Indiana X·" X·
Iowa X X X X X X
Kansas X X X X X
Kentucky X X' X
Louisiana X, X, X,
Maine X X X' X
Maryland X X X X X
Massach usetts X X X X X X
Michigan X, X' xm X"
Minnesota X X X X' X X
Mississippi X X X X
Missouri X X X X X X w
Montana X X X X X X X ( JI
Continued
-
V>
.....
'"
TABLE 5
Exemptions by Setting (continued)
w
"'-l
-
318 TOMMY T. STIGALL
7Traweek v. Alabama Board of Examiners in Psychology cir. c/o Jefferson Co., AI., Equity No.
198-073 (1976).
LICENSING AND CERTIFICATION 321
8State Board of Psychological Examiners v. Coxe, Miss., 355 So.2d 669 (1978).
9Berger v. Board of Psychologist Examiners, 521 F.2d 1056 (D.C. Cir. 1975).
322 TOMMY T. STIGALL
SPECIALTY CREDENTIALING
IOTex. Rev. Civ. Stat. Ann. art. 4512c, § 8(b) (Vernon 1976 & Supp. 1982).
llMiss. Code Ann. § 41-21-61(f) (Supp. 1980).
LICENSING AND CERTIFICATION 325
has sought support from APA for its efforts to secure recognition from the
U.S. Office of Education as the accrediting body for graduate training of
marriage and family counselors. Yet, in some states where marriage and
family counseling laws have been enacted, psychologists and other mental
health professionals have been prosecuted for practicing without a license
issued by the board of marriage and family counseling (Williams, 1978).
Fragmentation of psychology as a profession can also occur on the basis
of multiple levels of training and credentialing, as well as across specialty
areas. An alternative to the model of generic licensure followed by specialty
certification is embodied in master's degree training programs for individ-
uals to function as school psychologists with credentials issued by state
departments of education or public instruction. Such persons usually are
exempt from the requirement for statutory licensure or certification, either
because of a general institutional exemption or a specific exemption for cer-
tified school psychologists. While APA accreditation of school psychology
training is limited to doctoral programs, the National Commission on
Accreditation of Teacher Education (NCATE) accredits master's programs in
school psychology. In most jurisdictions, individuals practicing school psy-
chology on the basis of an educational certificate are limited to employment
within the school setting and are prohibited from engaging in the practice
of psychology in any other context. Thus, there are doctoral level school
psychologists who meet all requirements for licensure or certification by
statute. There also are individuals with master's training in school psychol-
ogy who are ineligible for statutory licensure or certification but who con-
tinue to represent themselves as psychologists and function within the pub-
lic or private schools on the strength of a specialty credential that has been
issued in lieu of generic licensure or certification. In an address to the
National Association of School Psychologists (NASP), Bardon (1979) raises
the question whether school psychology is an independent profession or a
specialty of psychology.
I have been unable to find any basis for believing that school psychology is, in
and of itself, a profession. School psychology has no special body of knowledge.
It relies on the science and practice of psychology in all its aspects for its prac-
tice. Its ethics are adaptations of psychology's ethical code to a specific social
institution. It relies for its power and prestige and its public image on how
professional psychology is perceived, these perceptions determined in very
large part by what is said and written about other professional specialties, espe-
cially clinical psychology. It is not viewed by the public or even by the schools
as a profession. One can call it a profession, but, in fact, it simply is not one.
(pp. 164-165)
sonnel" and work with APA to implement the Standards for Providers of Psy-
chological Services, including supervision of unlicensed school psychological
service workers. Bardon concludes by asserting that
there cannot be professional psychology at the doctoral level and school psy-
chology at the non-doctoral level without some recognition of the meaning of
the difference. APA will not back down. It seems to me that at the very least
American psychology would have to do what has been done with cigarettes.
When professional psychology is mentioned, a disclaimer will have to be made
to the effect that "School Psychology is not psychology. Please take heed." If
this happens, who will win what? (pp. 166-167)
in the right direction (Fish, 1977; Jones, 1975). By the end of 1981, at least
19 states have enacted legislation authorizing boards to require documen-
tation of continuing education credits as a condition of the psychologist's
licensure or certification renewal (see Table 2, Note).
The American Psychological Association Committee on State Legisla-
tion (1978) has recommended that psychology regulatory boards be empow-
ered by law to issue regulations specifying the continuing education
requirements that must be met by each licensee. This recommendation is
based upon appreciation of the complexities involved in defining and
administering continuing education requirements and the inappropriate-
ness of attempting to incorporate these details in the law itself. The legal
responsibility of boards of examiners has been distinguished from the
profession's responsibility for continuing education in the AASPB Guide-
lines for Accrediting Continuing Education in Psychology (Fish, 1977). Regulatory
boards would assume the responsibility for approval of continuing educa-
tion offerings, set the number of credits that may be earned in various cat-
egories of participation, and verify compliance on the part of individual
psychologists. Professional organizations and educational institutions
would be responsible for developing and promoting continuing education
offerings. Formal training experiences in the form of workshops, seminars,
or postgraduate course work would be expected to constitute the bulk of
creditable activities. However, a significant proportion of credits might also
be earned through informal activities approved by the board. These could
include self-study programs or individual, creative professional activities.
The AASPB Guidelines make it clear that "credit for continuing education
should not be applicable to advanced standing in specialty educational pro-
grams. Career changes should be preceded by formal, accredited academic
or professional educational programs" (p. 257).
Continuing education offerings endorsed by the APA (American Psy-
chological Association, 1982) or other recognized accrediting bodies could
be accepted by psychology examining boards without further evaluation.
Other continuing education programs and offerings would need to be eval-
uated on the basis of criteria adopted by the state or provincial regulatory
authority. The AASPB Guidelines recommend that boards establish criteria
for evaluation of programs on the basis of the following general consider-
ations: sponsorship, administration, faculty, program content, evaluation
and documentation of participation, and facilities. Approved offerings
would be expected to include a procedure for evaluating the benefit of par-
ticipation in terms of the announced goals and objectives of the training
program.
Beyond continuing education there are other mechanisms that have
been advanced for promoting continued professional competence. The 1977
Public Health Service report on Credentialing Health Manpower recom-
mended further study of alternative means for competency assurance on a
priority basis.
LICENSING AND CERTIFICATION 329
14See, for example, Tarasoff v. Regents of the University of California, 33 Cal. 3d 275,108 Cal.
Rep. 878 (1973); aff'd 529 P.2d 553, 118 Cal. Rep. 129 (1974); vacated after rehearing, 551
P.2d 334, 131 Cal. Rep. 14 (1976).
LICENSING AND CERTIFICATION 331
Only Florida and South Dakota have had psychology licensing laws
terminated as a result of legislative sunset review, and both subsequently
have enacted new legislation. In other states where this process has taken
place, laws have been continued, reenacted, or have been modified based
on recommendations arising from the legislative study committee.
Experience in states undergoing the sunset review process indicates
that this can become an occasion for great divisiveness within the profes-
sion, since all the statutory provisions regulating practice are open to chal-
lenge (Cohen & Goldman, 1980). The most hotly contested issue is likely to
be that of minimum educational requirements for credentialing as a psy-
chologist, with groups ineligible for licensure under the existing statute
lobbying for more liberal standards or alternative "equivalency" provi-
sions. For example, it may be argued that an applicant need not have been
trained in an accredited graduate department or school of professional psy-
chology so long as the content of training can be shown to be "substan-
tially" or "primarily" psychological in nature. Others may seek to substitute
years of supervised work experience or "competency-based" examinations
for formal graduate education and training. Still other special interest
groups may seize upon sunset review as an opportunity to institute new
grandfathering provisions for a time-limited period. With an increasingly
firm national consensus on the definition of professional psychology and
the necessary qualifications of service providers, these pressures can be
resisted more successfully.
Although the goal of sunset legislation has been to promote efficiency
and accountability in state government and to minimize unnecessary gov-
ernment regulation in the private sector, the practical consequence has
been negligible in terms of significant bureaucratic reform or government
cost savings. For the profession of psychology, however, legislative sunset
review poses a clear and present challenge as licensing boards are faced
with the prospect of public hearings and legislative audits concerning their
credentialing, disciplinary, and fiscal activities. The essential question that
boards of examiners of psychologists and, indeed, the community of psy-
chologists as a whole must answer is: "How does statutory regulation of the
practice of psychology benefit and protect the public at large?"
The profeSSion has long held that statutory credentialing and regula-
tion of practice is to be preferred over nonstatutory credentiaiing, such as
self-certification by the state psychological association, which existed prior
to the enactment of laws in most jurisdictions. One effect of legislative sun-
set review is to bring about a confrontation of this issue and to force a care-
ful reconsideration of the merits of both approaches. Although it is difficult
to document fully the effect that loss of statutory credentialing may have
on either the profession or the public, a number of consequences have been
anticipated and described by various groups concerned with credentialing
issues and the regulation of practice. The American Psychological Associa-
tion Committee on State Legislation (1979) has enumerated the following
hazards for the consumer that may follow from the absence of professional
recognition in state law:
LICENSING AND CERTIFICATION 333
RECIPROCITY
CONCLUSION
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12
Mental Health Law
GOVERNMENTAL REGULATION OF DISORDERED PERSONS
AND THE ROLE OF THE PROFESSIONAL PSYCHOLOGIST
STEPHEN J. MORSE
For hundreds of years the Anglo-American legal system has been devel-
oping special rules for dealing with problems caused by the inherently per-
plexing phenomenon of mentally disordered behavior. In almost every area
of civil and criminal law, from rules concerning preventive detention to
rules concerning criminal responsibility, mentally disordered persons are
treated differently from nonmentally disordered persons.
This chapter will first discuss the nature and assumptions of mental
health law, analyzing why special legal treatment of disordered persons is
authorized. It then describes the following substantive mental health laws:
civil commitment, guardianship and conservatorship, competence to stand
trial, the insanity defense, mentally disordered sex offender provisions, the
rights of patients (including the right to treatment and the right to refuse
treatment), and civil competence in general. The aim is to provide the
professional psychologist with an understanding of the major legal doc-
trines that treat mentally disordered persons specially.! Finally, it will ana-
Sections of this chapter are taken or adapted from prior articles (Morse, 1978a, 1978b).
IThis chapter does not aim to make its readers experts in mental health law; rather, as noted,
it aims to provide a general familiarity with doctrines and the important issues. The prac-
ticing professional psychologist who is faced with a forensic issue or who participates in
forensic mental health cases should of course consult the statutes, regulations, and judicial
decisions of his or her state to determine what the specifically applicable law is. (Indeed,
some states treat issues quite differently from the dominant approach outlined in the chap-
ter.) Another extended general treatment of many of the issues covered in this chapter is
R. L. Schwitzgebel and Schwitzgebel (1980).
STEPHEN J. MORSE. Law Center, University of Southern California, Los Angeles, Cali-
fornia 90007.
339
340 STEPHEN J. MORSE
The legal system and mental health science are both concerned with
understanding and controlling human behavior. In polar terms, the legal
system approaches human behavior from the standpoint of moral evalua-
tion and the imposition of values, whereas mental health science
approaches it in terms of scientific, value-neutral, empirical investigation.
Further, the legal model of behavior holds that persons have free will: they
choose their behavior and thus are morally and legally responsible for it.
By contrast, the scientific model is deterministic: behavior, like all phenom-
ena, is caused by its antecedents and questions of moral and legal respon-
sibility are supposedly irrelevant. 2
In most instances, the different approaches of the legal system and
mental health science cause few difficulties. It is generally believed that the
fundamental assumptions of the legal system adequately interpret and deal
with the problems of normal behavior. The problems associated with men-
tal disorder, however, cause a very different reaction. Society and the legal
system have always been confused and often frightened by mental disorder
(Rabkin, 1972; Sarbin & Mancuso, 1970).
Special legal rules seem compelled in response to problems created by
disordered behavior because it intuitively appears that disordered persons
are significantly different from most persons in fundamental ways.
Although society assumes that most persons have free choice concerning
their behavior, disordered persons are viewed as having little or no choice
(Chodoff, 1976). Observers believe that persons who are normal would not
freely choose to behave in a mentally disordered-inexplicably irrational
or crazy-fashion. Consequently, when disordered persons engage in
legally relevant behavior, the legal system must decide if it can properly
apply to them generally applicable legal rules. They, after all, appear to be
fundamentally different and to lack normal ability to control their behavior
within reasonable limits. The explanations for disordered behavior have
changed over the centuries, but special legal treatment of disordered indi-
viduals always has been bottomed upon the assumption that such persons
are fundamentally different from normal persons.
Applying special rules to adjudicate the problems created by mental
disorder raises fundamental moral, social, and political issues. For example,
2Readers with philosophical training will recognize that many philosophers deny that there
is an antinomy between free will and determinism (Ayer, 1954; Griinbaum, 1972; Schlick,
1939/1962). Nevertheless, the description in the text is an accurate depiction of the general
view, in polar terms, of most participants in both systems.
MENTAL HEALTH LAW 341
tal disorder and the behavioral component (at least in principle) (e.g., Cal-
ifornia Welfare & Institutions Code, § 5250, 1972; Weihofen, 1960). For
instance, civil commitment usually is based on findings that the person is
(1) mentally ill; (2) dangerous to self or to others, or gravely disabled; and
(3) that the dangerousness or grave disablement is a product or result of the
mental disorder or defect (Note, 1974). A criminal defendant is incompetent
to stand trial if he or she is mentally ill and therefore unable to understand
the charges, assist counsel, or understand the consequences of the proceed-
ings (Stilten & Tullis, 1977). Guardianship or conservatorship may be
imposed upon an individual who is mentally ill and therefore unable to
care for his or her property or self (e.g., California Probate Code § 1460,
1977; Horst"man, 1975).
As discussed (pp. 340-42), mentally disordered persons have been sin-
gled out for special legal treatment because it is believed that it is morally
and socially inappropriate to treat them as everyone else. The moral and
legal basis for this special treatment depends on three factual assumptions
concerning mentally disordered persons: (1) they are significantly different
from most persons because they are ill; (2) their legally relevant behavior
is the product of their illness and not of their free, rational choice; and (3)
their future behavior is particularly predictable. The validity of these
assumptions, especially the first two, is the foundation of mental health law.
Only if a person is abnormal, nonresponsible, and in some cases predictable
should he or she be accorded special legal treatment.
Mental illness alone does not warrant special legal intervention. A per-
son who is simply mentally ill is left alone unless the actor behaves in one
of the legally relevant ways described by the behavioral components. But
when mentally disordered persons behave in legally relevant ways, such as
dangerously or incompetently, special rules apply to them that do not apply
to "normal" dangerous or incompetent persons. For example, extremely
dangerous but nonmentally disordered persons, even those who might be
"reformed," are not preventively confinable by civil commitment upon the
basis of dangerousness alone.
Two points concerning the behavioral component of mental health
laws must be noted. First, in all cases the behavioral component is the pri-
mary impetus for legal regulation. What disturbs society, for example, is an
individual's dangerousness, grave disablement, inability to assist counsel,
or inability to manage financial affairs. In other words, society believes that
it must protect itself from dangerous persons, that it must protect disabled
persons from themselves, that a criminal trial is unfair unless certain con-
ditions are met, and that it is inhumane to let an incompetent person mis-
manage his or her property. Second, behaviors described by the behavioral
standards, such as dangerousness or various incompetencies, also appear in
the conduct of normal persons. The behavior is neither necessarily related
to mental health problems nor is it exclusively or especially within the
province of mental health science and professionals.
It is noteworthy that the special legal treatment of disordered persons
344 STEPHEN J. MORSE
CIVIL COMMITMENT
only under the explicit or implicit threat that otherwise they will be
involuntarily committed or sent to jail (Gilboy & Schmidt, 1971). Thus an
unknown percentage of voluntarily committed patients are not truly vol-
untary. Nonetheless, it is undoubtedly true that the percentage of truly vol-
untary patients has increased for many reasons. First and most important,
on both ideological and scientific grounds, most mental health profession-
als now favor voluntary commitment because it restricts liberty less and,
allegedly, consensual hospitalization and treatment is believed to be far
more conducive to improvement in a patient's condition (Wexler, 1974). In
addition, hospitals tend to be more humane and better equipped than they
previously were and most try to limit the length of stay as much as possible.
Thus, current patients have less reason to fear that they are committing
themselves to a ghastly institution that might keep them hospitalized for
inordinately long periods, and even for life (but see Los Angeles Times, 1979).
Involuntary civil commitment laws permit the state to incarcerate a
person against his or her will in order to protect the person or to protect
society (Note, 1974). Although the person is not accused or convicted of a
crime, he or she thus may be deprived of physical freedom, the right to free
association, the right to travel, and often the right to free speech, and may
be subject to involuntary treatment of various sorts. Each day there are
between 100,000 and 200,000 citizens in hospitals who have been involun-
tarily hospitalized, and the average patient in a state or county hospital is
incarcerated for 42 days (Stone, 1975). This massive intrusion on liberty is
an extraordinary exercise of the state's power, and the constitutionality and
propriety of involuntary commitment has therefore engendered enormous
debate in the last two decades (Dershowitz, 1969; K. S. Miller, 1976; Morse,
1982a; Peszke, 1975; Szasz, 1963; Stone, 1975; Zusman, 1982).
The standards for involuntary commitment vary from state to state, but
all require that the person is mentally disordered and has behaved or is
predicted to behave in a legally relevant fashion (i.e., meets the behavioral
component of the law). The most usual behaviors included in the various
statutes, expressed in varying language, are that the person is dangerous to
self, dangerous to others, or in need of care and treatment (Livermore,
Malmquist, & Meehl, 1968). It should be noted, as will be discussed further
below, that "in need of care and treatment" type criteria are now becoming
quite rare; indeed, courts faced with the question of the constitutionality of
such criteria have held them unconstitutional (e.g., Lessard v. Schmidt, 1973).
Of course, many persons without serious mental disorder are dangerous to
themselves or others or are in need of care and treatment, yet the state does
not authorize intervention in the lives of such nonmentally disordered per-
sons in order to protect, care for, or treat them. The reason that state inter-
vention is authorized for mentally disordered persons is that it is believed
that such individuals cannot exercise ordinary and rational self-control over
the behavior that is dangerous or creates the need for treatment. The justi-
fication for involuntary hospitalization and treatment is thus supposedly
benign. It aims to prevent a group of people who are allegedly incapable of
346 STEPHEN J. MORSE
parents' near absolute control over the care, custody, and upbringing of
their children. Indeed, the United States Supreme Court has recently held
in a celebrated case, J. R. v. Parham (1979), that such power is traditional and
that the child's due process rights are adequately safeguarded by the par-
ents' concern and the admitting physician's independent, medical, expert
decision to admit the child to the hospital. Some jurisidictions, such as Cal-
ifornia (In re Roger 5.,1977), have held on state constitutional grounds that
due process requires counsel, some sort of hearing, and certain other rights
before a minor of 14 years of age or older may be "involuntarily" admitted
to a hospital. But no jurisdiction is compelled by the federal Constitution to
provide more due process than the Parham case requires. In the vast major-
ity of jurisdictions, then, almost no process is due before minors can be
involuntarily "voluntarily" admitted by their parents, and, in effect, the
substantive standard for the commitment of a minor is that the parent and
hospital agree that the minor is mentally disordered and needs or could
benefit from hospitalization (see also, In re Roger S., 1977). Because the
implicit substantive standard is undefined, enormous and extraordinary
discretion is left in the hands of the parents and the hospital.
"Voluntarily" admitted minors are released from hospitals upon the
request of their parents, at the discretion of the hospital, or at the age when
adult civil commitment standards first apply, that is, unless they are recom-
mitted according to the usual procedures applied to adults (Melville v. Sab-
batina, 1973). If the hospital or some other responsible person (e.g., social
service worker) believes that the child desperately needs to be hospitalized
or needs continued hospitalization, but the parents refuse to sign the child
in or insist on signing the child out, the only solution is to have the child
declared a ward of the court on the grounds of parental neglect (California
Welfare & Institutions Code § 300, 1980). Then a guardian may be appointed
who will be granted the power to admit the minor to the hospital or to
retain him or her therein. Appointment of a guardian in order to insure
mental hospitalization of a child is a rare event, however. Finally, when a
hospitalized minor reaches the age at which adult procedures apply the
state must initiate ordinary civil commitment in order to retain the individ-
ual in the hospital.
The commitment of minors to mental hospitals poses vexing problems
of law and social policy. When the commitment of an adult is in question
only the rights of the state and the adult need to be considered and bal-
anced, but in decisions concerning the commitment of minors, the right of
the parents also must be weighed. On the one hand, as noted, parents tra-
ditionally have near absolute authority over the care and upbringing of
their minor children, including decisions about medical care (see also, J.
Goldstein, Freud, & Solnit, 1979). Providing the minor with independent
due process rights clearly interferes with parental rights. On the other
hand, involuntary hospitalization is an extraordinary loss of liberty for the
minor and also may result in serious stigma. Being incarcerated in a strange
institution may be terrifying and disruptive (see Lindsey, 1977) and, in
MENTAL HEALTH LAW 351
tives" (LRA) doctrine (also known as the "less drastic means" or "reasonable
alternatives" doctrine [see Chambers, 1972]). The rights of patients in gen-
eral, including the right to treatment, will be discussed later in this chapter
(see p. 372). LRA is discussed here because it is a right that prevents a person
from being hospitalized and in the mental health law context it is applied
to date primarily to civil commitment and not to other forms of
commitment.
The LRA doctrine has been announced by the United States Supreme
Court in a number of cases in varying contexts (e.g., Shelton v. Tucker, 1960).
Simplistically and briefly, LRA holds that when state regulations infringe
on constitutionally protected rights and interests (e.g., liberty) in order to
fulfill legitimate state purposes, they should do so using the means least
restrictive of those rights and interests. The LRA doctrine is eminently sen-
sible in a free society; it is desirable that the state should seek to promote
its purposes by those means that least restrict important rights. Assuming,
as many persons do, that the state has legitimate purposes in providing for
involuntary hospitalization (e.g., protecting society from dangerous men-
tally disordered people, protecting mentally disordered persons who are
dangerous to themselves, caring for and treating disordered persons who
are incapable of doing so for themselves), it is nonetheless true that invol-
untary hospitalization trenches on important rights including the right to
physical liberty, to travel, to free association, and others. If hospitalization
is not needed for protection or care, it should not be used because the state's
intrusion on individual rights is thereby minimized.
Although at one point the United States Supreme Court appeared to
have denied the applicability of the doctrine to the civil commitment con-
text (State v. Sanchez, 1969), in O'Connor v. Donaldson (1975, citing Shelton v.
Tucker) the Court later appeared implicitly to approve its applicability in
civil commitment cases. In any case, the question is not settled as a matter
of constitutuionallaw, but many lower courts (e.g., Lessard v. Schmidt, 1973;
Lynch v. Baxley, 1974) have applied the doctrine to civil commitment. For
instance, in the landmark case of Lessard v. Schmidt (1973), a federal district
court held, inter alia, that before a person could be hospitalized involuntar-
ily the party recommending confinement had to prove to the court: (1) what
alternatives were available, (2) "what alternatives were investigated," and
(3) "why the investigated alternatives were not deemed suitable." Hospi-
talization could be ordered only if other, less freedom-infringing, alterna-
tives would not do.
In addition to judicial decisions that have applied the LRA doctrine to
civil commitment on constitutional grounds, a large number of jurisdictions
have passed legislation adopting the doctrine. For instance, by an act of
Congress the District of Columbia has had such legislation for many years
(D.C. Code § 21-54S(b), 1967).
As is often the case, the law in the books or as expressed in judicial
opinions has not been carried out to the letter or in spirit (Hoffman & Foust,
1977). Effectuating LRA is time-consuming and expensive-rather than
MENTAL HEALTH LAW 353
eventually be closed and all its residents would be placed in the community
where they would receive services based on individualized plans; (2) every
retarded inmate or another person speaking for him or her would partici-
pate in the formulation of the plans; (3) the state had to submit plans for
placement of the residents in community programs that were individual-
ized and set up in the least restrictive manner; and (4) the state was enjoined
from recommending or placing further persons at Pennhurst (Halderman v.
Pennhurst, 1979).
The defendants appealed to the federal Third Circuit Court of Appeals
which affirmed much of the district court's opinion but did so on a different
basis (Halderman v. Pennhurst, 1979). By this point, it was universally agreed
that conditions at Pennhurst were abominable; the court therefore concen-
trated on the merits. It affirmed that the retarded have a right to habilitation
in the least restrictive environment, but these rights were founded on fed-
eral and state statutory grounds (the federal Developmentally Disabled
Assistance and Bill of Rights Act and Pennsylvania's Mental Health/Mental
Retardation Act of 1976) rather than on constitutional grounds. But, said the
court, a legal preference for deinstitutionalization did not mean that no one
should be hospitalized; for some patients, institutionalization might be jus-
tified as appropriate so long as the states did not rely solely on such insti-
tutions and provided alternative facilities for those patients who did not
require institutionalization to be habilitated. The right to habilitation in the
least restrictive setting, including a preference for deinstitutionalization,
was therefore upheld, but the appellate court did so on statutory grounds
and held that some institutionalization was allowable.
The Supreme Court reversed the Court of Appeals decision, Pennhurst
v. Halderman (1981), and held that the federal Developmentally Disabled
Assistance and Bill of Rights Act did not grant the mentally retarded the
right to habilitation in the least restrictive environment. Because the statute
does not expressly condition the right to receive federal funds on state com-
pliance with providing patients with treatment in the least restrictive set-
ting, the Court construed the statute as merely expressing a congressional
preference for deinstitutionalization (or LRA). The Court decided the case
on narrow grounds, strictly interpreting the federal statutory language,
without considering the federal constitutional or state statutory grounds
that were the basis for relief in the district court.
Most recently, in Youngberg v. Romeo (1982), another patients' rights
class action suit originating in the Pennhurst institution, the United States
Supreme Court held that institutionalized retarded patients have a consti-
tutionalliberty interest in safety and freedom from bodily restraint. To pro-
tect these rights, the Court held further that permanently institutionalized
retarded inmates have a right to the training that "an appropriate profes-
sional would consider reasonable to ensure his safety and to facilitate his
ability to function free from bodily restraints." Although Youngberg is pri-
marily a patients' rights case and does not grant the right to deinstitution-
alization, it does hold that retarded persons are entitled to treatment that
MENTAL HEALTH LAW 355
ing from the vague (e.g., incompetent by reason of mental illness and
senility) (Annotated Missouri Statutes § 475.060(9), 1956) to the amusing
(e.g., likely to be prevailed upon by artful and designing persons) (Califor-
nia Probate Code § 1460, 1956/77), but the essential thrust of all such laws
is that the person is unable within reason to look after oneself or one's
financial resources.
Guardianship or conservatorship proceedings are usually initiated by
family members or sometimes by the state and they are accomplished in
most jurisdictions by a judicial proceeding (see Alexander & Lewin, 1972;
Horstman, 1975). The alleged incompetent will appear unable to manage
food, shelter, clothing or medical needs, or will seem to manage finances
foolishly. A guardian of the person is given the power to care for the phys-
ical needs of the person, to consent to medical care, and even to authorize
inpatient hospitalization for the person. In many states guardianship may
be strictly limited and tailored to the specific incompetency displayed by
the ward. In a sense, the guardian stands in relationship to the ward as a
parent does to a child. A guardian or conservator of the estate is given the
power completely to manage the finances of the ward to whom the guard-
ian or conservator has a fiduciary duty. In some cases, guardianship may be
ordered over both the person and the estate of an incompetent.
Although the need for the various forms of guardianship is readily
apparent in some cases, guardianship, like involuntary commitment, is a
fundamental intrusion on the liberty, autonomy, and dignity of a person.
There is less public and professional concern with the civil liberties aspects
of guardianship than with those of involuntary commitment, but courts and
psychologists should exercise caution in this area as well. It is most impor-
tant here to separate distaste for the behavior of an actor based on value
differences from a judgment that the actor is truly incapable of managing
his or her person or finances. For instance, is an elderly widower who
spends his money lavishly on a young woman, to the disadvantage of his
children who expected to inherit a sizeable estate, behaving incompetently
(see In re Oakes, 1845)? The answers to such questions are rarely clear, but
if the widower is competent, his right to behave in ways others perceive as
foolish should be preserved.
It is difficult to give the concept of competence a precise meaning and
courts and commentators have rarely explicated this vague concept (but ct.
Fingarette, 1972; Murphy, 1974). In my opinion, competence should refer
to a combination of the abilities, within reasonable limits, to attend to and
weigh the data relevant to a particular decision (Morse, 1978). It does not
mean that the person always attends to or weighs such data or that the per-
son always reaches sensible decisions. It means only that the individual has
the abilities necessary to be deemed competent. Focusing on ability rather
than on outcome is much more protective of the person's dignity and auton-
omy. A person may choose to disregard data that most other persons would
find dispositive of action in a particular context, but so long as the actor is
MENTAL HEALTH LAW 357
capable of considering and weighing the data, his or her right to choose
"wrong" should be respected.
Even if a reasonable definition that focuses on competence capacity can
be formulated and justified, how is a decisionmaker to determine if such
capacity exists? The best course of action, albeit an imperfect one, is to exam-
ine the person's behavior in as much detail as possible (Morse, 1978). If he
or she demonstrates a capacity for rational action in a wide variety of cir-
cumstances, or does so consistently in a particular context, it is reasonable
to conclude that the person is generally competent or competent in the par-
ticular context, and that a given "irrational" action is a matter of choice
based on differing values. Of course, if a person always appears to behave
unreasonably, even with a broad, tolerant definition of "reasonable," then
perhaps a judgment that the person is incapable of behaving reasonably is
warranted. But in most cases, it is probably wiser to have a presumption
against a finding of incompetence because of the deprivation of rights occa-
sioned by such a finding.
As one would expect, guardianship may be terminated, again most
often by a judicial proceeding, at any time that the ward's competence is
restored.
The Supreme Court of the United States has held that due process of
law is violated when an incompetent criminal defendant is tried. In other
words, a criminal trial can be fundamentally fair only if the accused is com-
petent to stand trial (Drope v. Missouri, 1975; Pate v. Robinson, 1966). Again,
the standards for competence to stand trial vary somewhat from state to
state, but a relatively standard formulation is this: the defendant must be
able (I) to understand the nature of the charges against him or her and the
proceedings; and (2) assist his or her counsel (Dusky v. U.S., 1960; Note,
1966). Unless the accused meets them, he or she will be unable to participate
effectively in the defense, thereby negating the defendant's ability to main-
tain his or her innocence and defeat the state's allegation of guilt. More-
over, trying an incompetent defendant compromises the dignity of the pro-
ceedings. Indeed, competence to stand trial is so important that the
Supreme Court has held that a judge must raise the issue sua sponte if he or
she has reason to believe a defendant is incompetent (Drope v. Missouri,
1975). Unlike the insanity defense (which will be discussed on p. 360), the
competence to stand trial issue is raised frequently (Steadman, 1979).
Although incompetence to stand trial theoretically may be produced
by any cause that affects mental functioning, almost all persons found
incompetent are so found because of mental disorder (Stilten & Tullis,
1977). Nevertheless, not all mentally disordered defendants are incompe-
358 STEPHEN J. MORSE
tent; the mental disorder also must produce the legally relevant behavior:
inability to understand the charges and proceedings or the inability to assist
counsel. Moreover, if a disordered incompetent defendant is competent
when taking psychotropic medication (so-called synthetic sanity), most
courts have held that such a defendant should be deemed competent and
may be tried although the competence is produced by medication (e.g., State
v. Rand, 1969; see generally, Haddox, Gross, & Pollack, 1974).
The legal standards for competence to stand trial are readily compre-
hensible; yet, like most such standards, they present problems of vagueness
in their application. How much comprehension of the charges and pro-
ceedings is enough? How much assistance to one's counsel is sufficient?
Extreme cases are, of course, easy to decide, but, as always, the majority of
cases will fall in the "gray" area. Still, the competence to stand trial stan-
dards reflect an important social, ethical, and legal concern, and courts must
do their best to apply the standards on a case-by-case basis. There has been
at least one notable research attempt to ope rationalize carefully the com-
petence standards (Harvard Laboratory of Community Psychiatry, 1973),
but it was not completely satisfactory and competence adjudication still pro-
ceeds almost entirely without the benefit of such operationalized standards.
If the district attorney, defense counsel, or judge believes that a defen-
dant is incompetent at any stage in the criminal proceedings, an order for
a competence evaluation will be sought and typically will be granted. The
evaluation is done by a mental health professional and then the court deter-
mines after a hearing if the defendant is incompetent. In the majority of
states the decision is made by the judge, but a few states provide for a jury
determination of the competence issue. In nearly all cases, the judge will
agree with the mental health professional's finding (Steadman, 1979). If the
defendant is found incompetent, he or she generally is committed to a state
hospital (often for the criminally insane) for treatment designed to restore
him or her to competence. Some states, such as California, allow some
incompetent defendants to be treated on an outpatient basis (California
Penal Code § 1370, 1980), but hospitalization is the usual rule. When the
hospital believes that the accused is competent, he or she is returned to
court to determine if this is the case. Furthermore, some states provide for
formal, periodic reexamination of the defendant's competence and it is
highly likely that such periodic reexamination is constitutionally required
in light of Jackson v. Indiana (1972; [discussed infra]) and Addington v. Texas
(1979). If the defendant is found competent, and typically he or she is so
found if the hospital certifies it, the criminal process proceeds to its final
resolution.
In view of the immense deference given to mental health professionals
in this context, an interesting question to note here is whether mental
health professionals are really experts on the questions of the defendant's
ability to understand the charges or to assist counsel. Although mental
health professionals may be expert at providing data about mental disorder,
might not an experienced criminal attorney be better able to provide data
MENTAL HEALTH LAW 359
on the legally relevant behavior in this area? (See also p. 406 infra; Morse,
1978a).
Until 1972, when the U.S. Supreme Court decided the important case
of Jackson v. Indiana, defendants hospitalized as incompetent to stand trial
could be hospitalized as long as necessary in order to restore them to com-
petence. In effect, incompetence commitments were for a term of one day
to life, irrespective of the nature of the charge against the defendant.
Indeed, many defendants remained hospitalized for periods of time vastly
in excess of the maximum terms of imprisonment for the crimes charged
against them. Although never convicted of a crime, many incompetent
defendants, including a large number accused only of minor crimes, lan-
guished in hospitals for decades (Group for the Advancement of Psychiatry,
1974). In Jackson v. Indiana, the Supreme Court recognized the injustice of
indefinite incompetence to stand trial commitments and held that they
were unconstitutional. The Court held that incompetent defendants could
be committed only for a reasonable time necessary to restore them to com-
petence. If competence could not be restored within a reasonable time, the
accused had to be released. If the state believed the accused still required
hospitalization, civil commitment was the appropriate procedure.
The Court did not set a particular time limit on the length of permis-
sible commitment and states therefore have dealt with the question of "rea-
sonableness" in different ways. At a minimum, it seems clear that commit-
ment cannot be longer than the maximum prison term possible for the
charges against the defendant, and probably it should be shorter. Further-
more, the commitment period should cease at any time that the treating
professionals determine that restoring the defendant to competence is
beyond their present capacities. California's new commitment scheme (Cal-
ifornia Penal Code § 1370, 1980) is worthy of mention because California is
often a national leader in legislative and judicial reform. There the com-
mitment period runs only as long as treatment is provided and a "substan-
tiallikelikhood" exists that the defendant will regain his or her competence
in the foreseeable future. Moreover, the maximum term possible is three
years or the maximum term of imprisonment for the most serious charge
against the defendant, whichever is shorter. Thus California has set a rela-
tively brief maximum commitment period and requires evidence of treat-
ment and a substantial likelihood of improvement in order to justify con-
tinued incompetence to stand trial commitments. This is as it should be.
Incompetence commitments are based on the need to treat the defendant
so as to restore his or her competence. If treatment is not available or is
unlikely to be effective, the commitment should not be ordered or should
cease. Moreover, since most cases involve actively psychotic persons who
can be stabilized relatively qufckly on appropriate medication and since
incompetent defendants have not been convicted of a crime, incompetence
commitments, which deprive the defendant of liberty, should be relatively
brief. Indeed, even the relatively brief three-year maximum in California is
probably much longer than is necessary.
360 STEPHEN J. MORSE
THE INSANITY DEFENSE, DIMINISHED CAPACITY, AND GUILTY BUT MENTALLY ILL
dant was legally insane at the time of the act, but the crucial question is the
accused's mental state when the violation of criminal law occurred.
The most famous and still most widely used test is that formulated by
the British House of Lords in 1843 in M'Naghten's case. In response to a
series of questions put to it for an advisory opinion, the Lords formulated
the following test for the insanity defense:
To establish a defense on the ground of insanity it must be clearly proved that,
at the time of the committing of the act, the party accused was labouring under
such a defect of reason, from disease of the mind, as not to know the nature and
quality of the act he was doing; or, if he did know it, that he did not know he
was doing what was wrong. (M'Naghten's Case, 1843, p. 931)
Note that the M'Naghten test, colloquially called the "right/wrong" test, in
principle focuses entirely on cognitive capacity; affective and volitional
incapacity is ignored. Some states, however, have revised M'Naghten, appar-
ently to include an affective component whereby the defendant must be
unable to know and "comprehend" the nature and quality of his or her act
(see People v. Wolff, 1964 [now supplanted by People v. Drew, 1978]).
The M'Naghten rule makes perfectly good sense: defendants who do
not know what they are doing or who do not know society's moral or legal
rules because of disorder are consequently incapable of conforming their
behavior to law and should be excused. Nevertheless, criticisms of M'Nagh-
ten are numerous (see People v. Drew, 1978). It is said to be a psychologically
unrealistic test because it ignores the full range of human psychological
functioning, treating persons as if they were simply cognitive beings.
M'Naghten also allegedly unduly restricts the scope of expert testimony
because experts are limited to testifying only about cognitive incapacity.
Moreover, it is asserted that the M'Naghten rule is unrealistic because it is
an "all-or-nothing" test, whereas the relationship of disorder to responsi-
bility is one of degree and subtle shadings. On the other hand, M'Naghten
has staunch defenders (Livermore & Meehl, 1967) who believe this hoary
test sensibly delineates the minimal legal preconditions for responsibility
(M'Naghten is not a test of psychological disorder) while avoiding meta-
physical questions about volition. Also, many of the criticisms that seem apt
in theory are not problematic in practice. In M'Naghten jurisdictions, for
example, experts are not prevented from offering broad testimony about a
defendant's mental state.
Another prominent test is what may be called the "control" test, pop-
ularly known as the "irresistible impulse" test. A classic formulation of this
test is,
If, by reason of the duress of such mental disease he [the accused] had so far
lost the power to choose between the right and the wrong, and to avoid doing
the act in question, as that his free agency was at the time destroyed. (Parsons
v. State, 1887, p. 597)
This test was an outgrowth of the so-called wild beast test, wherein an
insane criminal defendant was analogized to a wild beast, that is, a creature
362 STEPHEN J. MORSE
The United States Court of Appeals for the District of Columbia later char-
acterized the Durham rule as a "more fruitful, accurate and considered
reflection of the sensibilities of the community as revised and expanded in
the light of the continued study of abnormal human behavior" (Brawner, p.
976). The new test was broader than M'Naghten or the "control" test or a
combination of the two. No mediating incapacity between mental disorder
and criminal behavior was required. Moreover, the rule seemed to give
mental health professionals free reign to provide a complete picture of the
defendant's mental health and the relationship of the accused's disorder or
defect to the criminal behavior.
The Durham test did not succeed in practice as its proponents hoped it
would. Many of the terms, such as disease and product, needed to be defined,
a task the same court, the United States Court of Appeals for the District of
Columbia, undertook with great difficulty in a series of cases after 1954 (e.g.,
McDonald v. U.S., 1962 ). Furthermore and most importantly, the Durham
test led to expert domination of trial proceedings in insanity defense cases
(Washington v. U.S., 1967.) There was no generally accepted understanding
of the "product" requirement, a requirement that basically expressed an
ethical and legal conclusion. Experts would offer conclusions on the "prod-
uct" issue, thus offering opinions on the ultimate legal issue as if it were a
scientific question. Durham had been adopted to give the experts freer reign,
but, ironically, the rule allowed experts to usurp the function of the judge
or jury. In 1967, in Washington v. United States, the Court of Appeals dealt
with expert domination by prohibiting experts from using conclusory diag-
MENTAL HEALTH LAW 363
longer than the maximum term of imprisonment allowed for the offense
charged. Thus, as the death penalty fell into disuse, the insanity defense
was raised more sparingly. In the future, however, one may safely predict
a revival of the use of the insanity plea. First, and perhaps foremost, the
United States Supreme Court has declared that under certain conditions the
death penalty may be imposed consonant with the Constitution (Gregg v.
Georgia, 1976). Second, as we shall discuss below, the procedures following
an insanity acquittal have changed. Defendants acquitted by reason of
insanity no longer face the near certainty of lifelong commitment to a hos-
pital for the criminally insane. Statutory and judicial developments have
now made it far easier for insanity acquittees to demonstrate that they are
no longer mentally ill and dangerous and therefore far easier for them to
secure their release from commitment (see Matter of Torsney, 1979). In Cal-
ifornia, for another example, an insanity acquittee can be committed ini-
tially for a term not longer than the maximum term of imprisonment
allowed for the crime with which he or she was charged (In re Moye, 1978).
Let us turn now to an examination of insanity defense procedures.
Almost always the defense is raised by the defendant, but in some jurisdic-
tions the judge may raise the issue sua sponte if the case seems clearly to call
for an adjudication of the defendant's sanity (U.S. v. Robertson, 1974). In
many jurisdictions the defense must notify the prosecution in advance of
the former's intention to raise the insanity defense at trial (e.g., Fed. R.
Crim. Pro., 12.2). The requirement of such advance notification of a defense
is unusual in our highly adversary criminal justice system, but it is believed
that the assistance of mental health experts is necessary for both sides prop-
erly to prepare insanity defense cases. The prosecution is therefore able to
have experts examine the defendant in advance of trial in order to make its
own trial preparations. There are many who believe that it is a violation of
the Fifth Amendment self-incrimination privilege to force the defendant to
speak to a mental health professional who is working for the prosecution
(Lefelt, 1972; Note, 1970; Rollerson v. U.S., 1964), but the majority rule
appears to be to the contrary (Rollerson v. U.S., 1964).
A plea of not guilty by reason of insanity may be combined with a plea
of not guilty. In other words, the defendant may claim that he or she had
another justification or excuse, such as self-defense or duress, and, if those
fail, that he or she was insane in any case. Some jurisdictions try all defenses
at once whereas others have adopted what are known as bifurcated pro-
ceedings. In the latter situation, the first phase of the trial ajudicates
whether the defendant is guilty of the charged offense without regard to
his or her possible legal insanity. (In some jurisdictions, evidence of mental
disorder short of legal insanity may be introduced at the first phase simply
to negate a mental state that is a necessary element of the offense charged.
This is known as diminished capacity, a topic to which this chapter will
turn on p. 368.) If the defendant is acquitted at the first phase of a bifurcated
trial, he or she is discharged from custody. If the accused is convicted at the
first phase, the question of the defendant's legal sanity is adjudicated at the
366 STEPHEN J. MORSE
second phase of the bifurcated trial. If, on the other hand, the defendant
has pled only "not guilty by reason of insanity," there is no bifurcated trial,
but only a hearing on the sanity issue. If the judge or jury rejects the insan-
ity plea, the accused is treated like any other convicted criminal and is sen-
tenced according to the usual procedures. But if the defendant is acquitted
by reason of insanity, he or she is then subject to a special set of procedures.
Successful defenses to criminal charges lead to acquittal and freedom
for the defendant. The insanity defense is the major exception to this rule,
for it usually leads to onerous confinement in a state hospital for the crim-
inally insane which is typically akin to a maximum security prison (Cali-
fornia Penal Code § 1026, 1976). The reason for this atypical response to an
"acquittal" is readily comprehensible. Most acquitted defendants are not
considered dangerous to society because a reasonable doubt has been cast
on whether they committed the act charged or because a reasonable justi-
fication or excuse, such as self-defense, was demonstrated. By contrast, an
insane defendant has an excuse that negates criminal responsibility but not
his or her dangerousness. Although the defendant may not be blameworthy
for antisocial behavior caused by legal insanity, he or she will be considered
a threat to society until the insanity is ameliorated or cured and the conse-
quent dangerousness is reduced (see J. Goldstein & Katz, 1963; see also, Fin-
garette & Hasse, 1979). Confinement in a custodial mental health setting
therefore seems appropriate.
There are three main types of procedures whereby commitment of
insanity acquittees is accomplished: (1) automatic commitment; (2) commit-
ment according to procedures similar to, but different from, civil commit-
ment procedures; and (3) ordinary civil commitment (German & Singer,
1976). Of these, the first seems least desirable, unless it is for a short term
of evaluation, because it is assumed that a defendant who was insane at the
time of the criminal act is still insane and dangerous at the much later time
when he or she is tried. As any clinical psychologist would recognize, a
person who is clearly mentally disordered at one time may behave quite
normally at another. Thus, the justification for automatic commitment
seems relatively weak.
Some type of civil commitment procedure that freshly decides whether
hospitalization is imminently necessary is justifiable because, in the some-
what recent past, the defendant has committed an antisocial act caused, at
least in substantial part, by mental disorder. The only question, then, is
whether standards and procedures different from those applicable in ordi-
nary civil commitment cases are warranted. Proponents of different stan-
dards argue that there should be at least some presumption of continuing
disorder and insanity (see In re Franklin, 1972) leading to a commitment pro-
cess whereby it is more easily accomplished. On the other hand, it is argued
that an insanity acquittee is theoretically no different from any other citizen
who is potentially committable on dangerousness grounds and should
therefore be subject to ordinary civil commitment standards. The United
States Supreme Court has not decided this issue, thus leaving the state leg-
MENTAL HEALTH LAW 367
islatures and courts to fashion their own standards and procedures. Some
form of nonautomatic commitment is the trend among those states that
have recently faced this issue (State ex rei. Kovach v. Schubert, 1974; Wilson v.
State, 1972).
Once an insanity acquittee is committed to a hospital, the next impor-
tant issue concerns the standards and procedures by which he or she may
secure release from custody. Again, the states vary widely regarding their
approach to the release of insanity acquittees. Basically, all require that the
defendant is no longer disordered and/or dangerous. As a matter of logic,
the criteria for release ought to be disjunctive rather than conjunctive. If the
person becomes either mentally normal or nondangerous, involuntary
incarceration in a hospital on the ground of dangerousness caused by men-
tal disorder is unnecessary. Other procedural issues that are currently under
consideration by courts and legislatures are the necessity for periodic
review, which is now probably required constitutionally in light of Adding-
ton v. Texas, and whether the acquittee or the state bears the burden of per-
suasion at a release hearing. There is good evidence that insanity acquittees
are not a significant threat to society after release (Thornberry & Jacoby,
1979) and the trend is clear: Insanity acquittees are being provided with
reasonable opportunities to secure their release and courts are willing to
accept the propriety of release in a growing number of cases.
The increasing ease of release from postinsanity acquittal commitments
has caused a great deal of concern in some quarters and has strengthened
calls for the abolition of the insanity defense. It is believed that it is too easy
to feign insanity (Yochelson & Samenow, 1975). When insanity acquittals
resulted in lifelong commitments, this possibility was not troublesome
because "acquitted" defendants were ultimately "punished" anyway by
imprisonment in a state hospital for the criminally insane. Now, however,
with restrictions on release easing, there is fear that persons who deserve
punishment may be escaping their just deserts. Both positions are quite
illogical, but they do evince societal ambivalence about the insanity
defense. If a jury decides a defendant is truly not criminally responsible
because of mental disorder, a punitive response is not appropriate. The per-
son should be treated and allowed to return to society as soon as his or her
psychological condition permits. Still, society feels punitive toward crazy
offenders and cheated if they are not punished in one way or another. Thus
the dilemma: Society is discomforted by punishing those who seem irre-
sponsible because they are clearly crazy, but we are equally discomforted
by lenient treatment of persons who commit antisocial acts even if they are
crazy. This ambivalence, coupled with growing skepticism about the non-
responsibility of many defendants who plead not guilty by reason of insan-
ity, is one of the reasons for the continued disenchantment with the insan-
ity defense. Although some states have abolished the defense in response
to such disenchantment, it is safe to predict that few states will follow suit.
Substantial narrowing and reform of the defense may be expected,
however.
368 STEPHEN J. MORSE
Diminished Capacity
In addition to the insanity defense, a slight majority of American juris-
dictions also allow a partial defense to criminal responsibility based on
mental disorder or defect that is termed "diminished responsibility,"
"diminished capacity," or "partial responsibility" (Note, 1977). One form of
this defense allows the defendant to demonstrate that because of mental
abnormality he or she did not form, or was incapable of forming, a specific
mental state required for the commission of a particular offense (Common-
wealth v. Walzack, 1976). For instance, a conviction for first degree murder
may be predicated upon an intentional killing that is committed, to use
common statutory language, "willfully, deliberately and premeditatedly."
A murder defendant who is mentally disordered but not legally insane may
try to demonstrate that his or her abnormality was sufficient to prevent him
or her from killing "willfully, deliberately and premeditatedly" even if the
killing was intentional. If the jury is convinced that the defendant did not
have the required mental element of the crime, premeditation, the defen-
dant cannot be convicted of first degree murder. The defendant still may be
convicted of second degree murder, an intentional killing without preme-
ditation. Thus, a defendant who successfully asserts a diminished respon-
sibility defense is convicted of a lower degree of crime than the one origi-
nally charged and consequently receives a lesser punishment. Although
this form of the diminished capacity defense should in principle apply to
all crimes, in some jurisdictions various illogical restrictions have limited
its use to prosecutions of only some (Morse, 1979).
Another approach to diminished capacity, primarily developed in
Great Britain (and applied there only to prosecutions for murder), is simply
to reduce the degree of crime for which a mentally abnormal defendant
may be convicted even if his or her conduct fully satisfied all the defini-
tional elements of the higher, originally charged crime (English Homicide
Act, 1957; J. c. Smith & Hogan, 1978). This approach does not ask a "for-
mal," definitional question: Were the statutory elements of the crime
negated by mental abnormality? Rather, it poses the moral question of
whether the defendant is less responsible because he or she was not fully
normal when the crime was committed.
A defendant who successfully asserts a diminished capacity defense is
not committed to a hospital. As noted, he or she is simply convicted of a
lower degree of crime and in most cases is sentenced like any other defen-
dant convicted of the same lower offense.
Much confusion and illogic has attended the development of the law
of diminished capacity (Morse, 1979). Some jurisdictions have taken the
position that, for legal purposes, insanity is an all or none issue; if the
defendant does not plead not guilty by reason of insanity, evidence of
insanity is rendered irrelevant. Such a position is illogical and probably
unconstitutional. One may decide to take this position as a matter of social
policy, but evidence of mental disorder hardly seems irrelevant to criminal
MENTAL HEALTH LAW 369
QUASI-CRIMINAL COMMITMENT
In a small and decreasing fraction of the states there are special statu-
tory schemes to deal with a small class of legally sane but mentally abnor-
mal criminal offenders who are not necessarily able to assert the diminished
capacity defense but who are considered especially dangerous because of
their mental abnormality (see Wexler, 1976). Today these laws are limited
primarily to persons whose sexual behavior is considered dangerous and
the product of mental disorder. Such laws are called "mentally disordered
sex offender" laws, "sexually dangerous persons" laws, or the like (e.g.,
Massachusetts General Laws Annotated chap. 123A, §§ I-II, 1969; see gen-
erally Note, 1964). (Hereafter, we shall refer to all these laws and the people
they apply to by their Massachusetts shorthand, "SDP.") Another outstand-
ing example of quasi-criminal commitment was Maryland's infamous defec-
tive delinquent law which provided for indefinite confinement in an insti-
tution known as Patuxent (Maryland Annotated Code art. 31B, 1971, 1977).
Recently, a small number of states has adopted enhanced sentencing pro-
visions which apply to mentally abnormal offenders generally, but quasi-
criminal commitment to secure hospitals has historically been used for sex-
ual dangerousness.
The purpose of SDP commitments appears clear. The SDP is viewed as
a special type of offender because he is dangerous in a particularly unset-
tling way and that dangerousness is caused by mental abnormality.
Although most SDPs are not psychotic, it is believed that they suffer from
a refractory form of mental disorder and that they therefore need extensive
treatment and should be incarcerated in order to protect society. These com-
mitments usually are triggered by the person's accusation or conviction of
a criminal offense, which must be of a sexual nature in many states (Brakel
& Rock, 1971). SDPs are considered both "mad" and "bad." Their commit-
ments, which are triggered by the criminal process, but which are based in
MENTAL HEALTH LAW 371
large part on a finding of mental disorder and the need for treatment, are
therefore termed "quasi-criminal" (see generally, Stone, 1975, Chap. 11).
After the necessary triggering part of the criminal justice system, e.g.,
accusation, conviction, has occurred, if the prosecutor believes the defen-
dant is an SDP, he or she may petition the court of appropriate jurisdiction
for the commencement of SDP proceedings. The court will order that the
defendant be examined and then a hearing is held to determine if the
defendant is in fact an SDP. As always, the criteria for SDP commitment
vary from jurisdiction to jurisdiction, but the Massachusetts code is typical:
The words "sexually dangerous person" as used in this chapter have the follow-
ing meaning:-any person whose misconduct in sexual matters indicates a gen-
erallack of power to control his sexual impulses, as evidenced by repetitive or
compulsive behavior and either violence, or aggression by an adult against a
victim under the age of sixteen years, and who as a result is likely to attack or
otherwise inflict injury on the objects of his uncontrolled or uncontrollable
desires. (Massachusetts General Laws Annotated chap. 123 § 1, 1958)
The United States Supreme Court has held that in SDP type hearings,
the state must grant SDP defendants many, but not all, of the due process
protections accorded in criminal trials (Specht v. Patterson, 1967). Thus SDP
hearings tend to be rather formal, and the trend today is to provide by stat-
ute or judicial decision increasing due process protections at such hearings.
SDP defendants are accorded extensive due process protections because the
results of an SDP findings are similar to those of a criminal conviction: sig-
nificant loss of liberty and the imposition of stigma. These are such severe
costs to citizens (In re Winship, 1970), that the state must provide substantial
safeguards to the defendant before they may be imposed (In re Burnick, 1975;
People v. Feagley, 1975). If a defendant is ultimately found to be an SDP, the
court has the authority to commit the person to a hospital for custody and
treatment.
In recent years there has been much reform of the SDP commitment
process because its theoretical and practical bases are increasingly in ques-
tion (see generally, Wexler, 1976). First, most SDPs are not psychotic and,
as most clinical psychologists recognize, there is doubt about whether much
"deviant" sexual behavior should be conceptualized as mental disorder.
Second, it is difficult to determine whether or not a sex offender's behavior
is the product of mental disorder: There is little good evidence or concep-
tual reason for finding a causal relationship between an "independent"
mental disorder and sexual misconduct which is the "symptom" of the dis-
order (see Morse, 1978). It is therefore easy for nonmental health factors
(e.g., a desire to achieve an unlimited term of commitment on pure social
danger grounds) to influence the finding. Third, the ability of mental
health professionals to predict the future dangerousness of SDPs (or any-
body else) is very limited (see Note, 1976). Fourth, evidence does not bear
out the fear that most sexual offenders are recidivists who "graduate" to
increasingly serious and dangerous aberrational behavior unless they are
372 STEPHEN J. MORSE
incarcerated and cured (Tappan, 1955). Fifth, clinical evidence and growing
social tolerance have together led to a decrease in the belief that minor
types of sexual offenses, such as indecent exposure, are terribly dangerous
either to the mental health of individuals or to the society as a whole (Cross
v. Harris, 1969). Sixth and last, there is little evidence that reasonably non-
intrusive and consensual treatments for sexual deviation are efficacious (see
Meyer, 1975).
In addition to the disenchantment with the theoretical and practical
bases for SOP commitments, a related motivation for reform in this area has
been the view that SOP commitments are often violative of the civil liber-
ties of the committees (Note, 1976). An SOP commitment is commonly used
to incarcerate a defendant for a far longer time period than the term of
imprisonment authorized for his criminal offense. In the past, the term of
an SOP commitment was unlimited because, allegedly, the defendant could
not be safely released until he was "cured" and therefore no longer "sex-
ually dangerous." Consequently, commitments often became life terms
even wh~n the offense that triggered the SOP proceeding may have been
relatively minor, say, indecent exposure. This outcome seems especially
unjust in light of four factors: (I) the questionable reliability and validity of
the SOP status; (2) the questionable dangerousness of many SOPs; (3) the
lack of effective treatment for the alleged disorder; and (4) the often inhu-
mane conditions in the "hospitals" in which SOPs are housed. In sum, an
SOP defendant might receive what was in fact a life term of imprisonment
in an institution not essentially different from a prison, where no adequate
treatment was, or could be, provided (People v. Feagley, 1975), and all of this
was done on the basis of a judgment that was conceptually doubtful and
scientifically unreliable.
In response to these critical concerns, many states have at least
reformed SOP laws, but sexual offenses and offenders produce highly emo-
tional reactions and a consequent perceived need to "do something" about
sex offenders. Thus, SOP laws remain on the books, albeit statutorily or judi-
cially reformed in most states that retain them. Defendants are given
increased due process protections, such as raising the state's burden of per-
suasion to "beyond a reasonable doubt" (Stachulak v. Coughlin, 1975), to help
the defendant guard against a wrongful finding of SOP status. Furthermore,
the term of commitment has been limited and the right to treatment where
appropriate has been granted in various jurisdictions. Unfortunately, how-
ever, SOP laws still pose a very substantial threat to scientific integrity and
civil liberties, while failing to provide humane benefits to SOPs or substan-
tial benefit to society at large.
This subsection of the chapter will discuss the rights of patients com-
mitted under various types of commitment, but especially civil commit-
MENTAL HEALTH LAW 373
announcing the basis of the right in the federal Constitution. Patients had
no right to treatment and, in the absence of such an enforceable right, ade-
quate treatment and care was rarely provided. One associates the abuses in
mental hospitals with an age long past, but they existed without serious
challenge until the last decade and they continue to exist in too many insti-
tutions despite such challenges.
The first, epochal case to recognize a constitutional right to treatment
was Wyatt v. Stickney (1971). In Wyatt, Federal District Judge Frank M. John-
son held that involuntarily committed mental patients "unquestionably
have a constitutional right to receive such individual treatment as will give
each of them a realistic opportunity to be cured or to improve his or her
mental condition" (p. 784). Wyatt had begun as a suit by Alabama mental
hospital employees who were challenging layoffs. As the state hospital sys-
tem was explored, however, the suit was transformed into a right to treat-
ment suit. Conditions in the hospitals under consideration were shocking:
overcrowding, ghastly sanitation, lack of privacy, and inadequate medical
care were the norm, and mental health treatment was in effect nonexistent.
The decision announcing the right to treatment followed and included a
requirement that the state should report to the court its progress in imple-
menting a hospital reorganization plan. The court considered the report
and in a second opinion (Wyatt v. Stickney, 1971b) held that there were three
"fundamental conditions for adequate and effective treatment" (p. 1343): a
"humane psychological and physical environment"; qualified staff "in
numbers sufficient to administer adequate treatment" (p. 1343); and indi-
vidualized treatment plans. In a further opinion (1972), the court ordered
the state, inter alia, to implement an elaborate set of standards imposed by the
court that covered every aspect of the functioning of the hospitals, to estab-
lish human rights committees for the hospitals, and to prepare and file
progress reports on the implementation of the standards.
In addition to establishing an important precedent, the Wyatt cases also
instituted in the mental health area the massive intrusion of the federal
courts into the running of state mental institutions. Many persons object to
such intrusion on the grounds that it exceeds the proper powers of a federal
court and that courts lack the competence to oversee the details of the
administration of mental hospitals. Nonetheless, the federal district court
did not back down from its position and Wyatt was upheld on appeal (Wyatt
v. Aderholt, 1974). The Wyatt litigation continued, however, and the Ala-
bama hospitals were finally placed in receivership in 1979 by Judge
Johnson.
The next major right to treatment case, Donaldson v. O'Connor, also was
decided by the Court of Appeals for the Fifth Circuit (1974; see also Don-
aldson, 1976). Kenneth Donaldson had been involuntarily hospitalized in
Florida for over a decade although he was dangerous neither to himself nor
to others. After numerous unsuccessful attempts to obtain his release, he
brought suit once again, raising a consititutional claim based on the depri-
vation of the right to treatment and suing individual doctors under the fed-
376 STEPHEN J. MORSE
eral Civil Rights Act (42 U.S.c. § 1983) on the ground that they had
deprived him of a constitutional right. The trial court found for Donaldson
and on appeal the United States Court of Appeal for the Fifth Circuit
affirmed, holding again that a constitutional right to treatment did exist
(Donaldson v. O'Connor, 1974).
The case was appealed to the United States Supreme Court, which was
expected finally to decide whether there was a constitutionally based right
to treatment. Those interested in a definitive decision on this issue were
disappointed, however, because the Court's decision, O'Connor v. Donaldson
(1975), did not address the right to treatment issue except peripherally and
by implication. Rather, the Court opined that the case should be decided on
the narrower issue of the right to liberty, and held that a nondangerous
person who was able to live in the community alone or with the help of
family and friends could not simply be custodially confined. Donaldson
was therefore freed at last. The Court explicitly noted that it was not decid-
ing the right to treatment issue and vacated the Fifth Circuit's opinion on
this issue; but, in dictum, it also noted that whether adequate treatment had
been provided in a particular case was clearly a justiciable issue. In a sepa-
rate concurrence, however, Mr. Chief Justice Burger wrote that he believed
that there was no constitutional right to treatment. Finally, on the issue of
whether the individual doctors were liable for depriving Donaldson of his
right to liberty, the Court remanded the case for reconsideration in light of
another case (Wood v. Strickland, 1975) which granted public servants qual-
ified immunity. (The individual cause of action was ultimately settled when
the defendant doctors agreed to pay Donaldson $20,000.)
In a recent case, Youngberg v. Romeo (1982), discussed briefly supra, the
Supreme Court made a hesitant beginning in setting forth the rights of
institutionalized mental patients to reasonable hospital conditions and
treatment. Romeo (respondent) was a profoundly retarded adult male who
could not talk and lacked the most basic self-care skills. In 1974 he was com-
mitted to the Pennhurst State School and Hospital after involuntary com-
mitment proceedings initiated by his mother. While at Pennhurst, he was
injured on numerous occasions, both by his own violence and by the reac-
tions of other residents to him. In 1976 his mother filed suit in district court
against the superintendent of Pennhurst and others on her son's behalf.
The complaint alleged that Pennhurst officials knew, or should have
known, (1) that Romeo was suffering injuries and that they had failed to
institute appropriate preventive procedures, thus violating his Eighth and
Fourteenth Amendment rights; (2) that Romeo was being restrained for
prolonged periods on a routine basis; and (3) that defendants had failed to
provide him with appropriate treatment or programs for his mental retar-
dation. The issue as ultimately presented to the Supreme Court was
whether Romeo had substantive rights under the Due Process Clause of the
Fourteenth Amendment to safe conditions of confinement, freedom from
bodily restraints, and training or "habilitation."
MENTAL HEALTH LAW 377
The majority stated initially that "the mere fact that Romeo has been
committed under proper procedures does not deprive him of all substantive
liberty interests under the Fourteenth Amendment." Referring to cases in
which the right to personal security and the right to freedom from bodily
restraint had been held to survive criminal conviction, it quickly found that
these were among the liberty interests retained by a person involuntarily
committed as well. The Court also noted, with evident approval, that the
petitioner, the superintendent of the institution, conceded that the state had
a duty to provide adequate food, shelter, clothing, and medical care.
The Court found respondent's claim to a "constitutional right to min-
imally adequate habilitation" more troubling. It avoided as not clearly
before it resolution of "the difficult question whether a mentally retarded
person, involuntarily committed to a state institution, has some general
constitutional right to training per se." It did hold, however, that such a
person's "liberty interests require the State to provide minimally adequate
or reasonable training to ensure safety and freedom from undue restraint."
Thus "the state is under a duty to provide respondent with such training as
an appropriate professional would consider reasonable to ensure his safety
and to facilitate his ability to function free from bodily restraints." (The
Court described an appropriate professional in a footnote as a "person com-
petent, whether by education, training, or experience, to make the partic-
ular decision at issue. Long-term treatment decisions normally should be
made by persons with degrees in medicine or nursing, or with appropriate
training in areas such as psychology, physical therapy, or the care and train-
ing of the retarded.") A failure by the state to provide such "minimally ade-
quate or reasonable training to ensure safety and freedom from undue
restraints" is an unconstitutional infringement of those rights.
The Court acknowledged that respondent's liberty interests in safety
and freedom of movement were not absolute and could be in conflict with
state interests. It thus confronted the question of how to determine whether
the extent or nature of the restraint or lack of absolute safety is such as to
violate due process. Such a determination, the Court held, requires a bal-
ancing of the liberty of the individual and the demands of an organized
society. Responsibility for balancing these interests lies primarily with the
treating professionals. The Court agreed with Chief Justice Seitz of the
court of appeals who had written that, "the Constitution only requires that
the courts make certain that professional judgment in fact was exercised. It
is not appropriate for the courts to specify which of several professionally
acceptable choices should have been made." The courts also must show def-
erence to the judgments of qualified professionals on the issue of treatment,
their decisions as to what is reasonable in light of a patient's liberty interests
being presumptively valid.
The Court concluded by noting that this presumption may be over-
come, and liability imposed, "only when the decision by the professional is
such a substantial departure from accepted professional judgment, practices
378 STEPHEN J. MORSE
their participation simply will not do, even if it is partially true. No mental
health professional should have condoned and indeed perpetuated the
standard of care at many of our public mental hospitals by his or her
employment at such poor institutions. An inadequate hospital system can-
not be justified and maintained if professionals refuse to work there unless
conditions are vastly improved. Moreover, professional organizations
should have devoted far more of their resources to efforts to improve the
state hospitals. The point of this accusation is simple: Psychologists should
recognize their ethical responsibilities when they are involved as care pro-
viders to involuntarily committed patients and they should not condone in
any way the operation of an inadequate institution. Furthermore, when
their advice is sought about the standard of care to be provided, they should
strenuously insist on the highest standard possible.
psychotropic medications have caused concern. And, fourth, it has been rec-
ognized that powerful treatments may be improperly used through lack of
knowledge (e.g., perhaps psychosurgery) or through calculated abuse such
as using a treatment primarily for ward control or for punishment of the
patient (Plotkin, 1977; R. K. Schwitzgebel, 1973; Symposium, 1969).
Most of the early important cases were of limited importance, however,
because they involved unusual circumstances and were therefore of argu-
ably restricted generalizability as precedents. For instance, Winters v. Miller
(1971) concerned a patient who refused medication on the ground that she
was a Christian Scientist. The court held that the state's interest in treating
the patient had to yield to the patient's reasonably raised First Amendment
right to the free exercise of her religion. In another case, Knecht v. Gillman
(1973), the United States Court of Appeals for the Eighth Circuit recognized
that an aversive conditioning program used with mentally disordered crim-
inals could be used for cruel and unusual punishment rather than treat-
ment. Therefore, held the court, before certain treatments could be used,
the institution needed the written informed consent of the inmate, which
consent was revocable at the will of the inmate. Other cases, too (e.g., Price
v. Sheppard, 1976), recognized a nascent right to refuse treatment and the
necessity of considering factors such as the intrusiveness of the treatment
before involuntary treatment could be authorized. Until 1978, however,
there was no judicial opinion of broad applicability that recognized a wide
right to refuse treatment.
Prior to the major judicial decisions, which we shall discuss presently,
some protection of the right to refuse treatment, usually of limited scope,
was provided statutorily. California, for instance, imposed a stringent set of
limitations on the use of the most intrusive therapies, psychosurgery and
electroconvulsive therapy, on involuntary and voluntary patients (Califor-
nia Welfare & Institutions Code § 5325, 1980). Although some of the pro-
visions were held unconstitutional because they violated a patient's right
to privacy or interfered unduly in the doctor-patient relationship (Aden v.
Younger, 1976), the vast bulk of the regulatory scheme is still in force. Fur-
thermore, California requires informed consent for all treatments if the
patient is competent to provide such consent. Thus, it is exceedingly diffi-
cult for a California state hospital involuntarily to administer ECT and it is
impossible in California to perform psychosurgery involuntarily. Wide
ranging statutory schemes such as California's are rare, however, and the
task of dealing with the right to refuse treatment was primarily taken up
by the courts.
In 1978, the Federal District Court for the District of New Jersey held
in Rennie v. Klein (Rennie 1) that an involuntarily committed mental patient
has the right to refuse psychotropic medication in a non emergency situa-
tion. Plaintiff Rennie appeared to suffer intermittently from severe mental
disorder that rendered him homicidal and suicidal, but he complained of
the side effects of Prolixin and related drugs and sought to avoid taking
them. A number of constitutional arguments to support the right to refuse
382 STEPHEN J. MORSE
medication were offered to the court, but all were rejected except the con-
stitutional right to privacy, upon which the holding was finally based. The
right to refuse medication was not held to be absolute, however, and the
court suggested a numer of factors that should be considered when decid-
ing whether to override the right: (1) whether without medication the
patient endangered other patients or staff; (2) the patient's capacity to
decide on a particular treatment; (3) whether a less restrictive alternative
existed; and (4) the risk of permanent side effects from the proposed treat-
ment. The court also held that for patients committed on a parens patriae
basis, forced medication was allowable only after the patient was found
incompetent at a hearing. Although Rennie [ did not provide an absolute
right to refuse, it was the most generally extensive affirmation of the right
to that date.
In Rennie [ the court refused to issue an injunction because at the time
of the opinion Rennie was not receiving psychotropic medication. Later in
the year, however, the hospital resumed Rennie's drug treatment and he
obtained a preliminary injunction against involuntary treatment on behalf
of himself and the entire class of institutionalized patients in New Jersey.
In its opinion in Rennie II, the court reiterated the factors that Rennie [
ordered to be considered when deciding whether to override a right to
refuse treatment, and it specified in some detail the procedures to be used
before patients could be involuntarily medicated. Consent forms had to be
used unless the patient was legally incompetent (upon court determination)
or functionally incompetent (upon determination by a physician). In case
of either type of incompetence, a patient advocate had to be provided and
independent review by an outside psychiatrist was provided for when the
patient's wishes were overruled or the patient was deemed incompetent.
Attorneys or "adversary" psychiatric consultants did not have to be pro-
vided for the patient, however, and the patient had no right to call or exam-
ine witnesses. Further, decisions generally were not reviewable for 60 days.
Finally an emergency was defined as "a sudden, significant change in the
patient's condition which creates danger to the patient himself or to others
in the hospital" (p. 1313). In such a situation, medication could be admin-
istered for only 72 hours unless a physician certified that the emergency
was continuing. Thus Rennie II reaffirmed and expanded the holding in Ren-
nie [.(See also Rennie III, 1981, which modified Rennie II, but affirmed that
there was a constitutionally based, but qualified, right to refuse treatment.)
In Rogers v. Okin (1979), a federal district court in Massachusetts issued
the most far reaching right to refuse treatment decision to date, holding in
a class action suit that voluntary and involuntary mental patients have an
absolute constitutional right to refuse medication except in emergency sit-
uations (defined as a situation where there is a "substantial likelihood of
physical harm to the patient or others" [po 1365]). The case also held on
statutory grounds that patients had the right to refuse seclusion except in
emergency situations. The court flatly denied that mental patients are
incompetent to make treatment decisions and held that even incompetent
MENTAL HEALTH LAW 383
patients did not need to abide by the hospital treatment decisions, but
instead could be represented by a guardian who would make such decisions
for them. The court held further that the constitutional right to refuse treat-
ment, which could be overriden by compelling state interests only in cases
of emergency, was founded on the right to privacy and the First Amend-
ment right freely to produce thoughts.
The court also found that very few of the patients affected, only 12 of
1,000, refused medication for prolonged periods of time and most of these
patients changed their minds within a few days. Thus, the court found fan-
ciful the fears of wholesale treatment refusal by patients who had the right
to refuse treatment and all the hypothesized problems attendant thereto.
Moreover, even if allowing the patient to choose was more costly and
inconvenient, the court argued that such factors could not override consti-
tutional rights. Finally, the court rejected the claim that courts were acting
improperly when they overrode the decisions of hospital personnel. Profes-
sional judgments, countered the court, always are subject to judicial review
when there is an allegation that such judgments have created a deprivation
of constitutional rights.
As noted, the extensive right to refuse treatment created by Rogers
could be overridden only in emergency situations, and the court defined
these very restrictively. Substantial harm to self and others did not include
bizarre behavior, extreme anxiety, and other conditions that mental health
professionals generally would agree ought to be treated. The need for treat-
ment simpliciter was outweighed only by the constitutional rights to privacy
and free thought, which themselves could be outweighed by the compel-
ling state interest that arose only when there was a "substantial likelihood
of physical harm to that patient, other patients, or staff members of the insti-
tution" (p. 1365 [italics added]). As one would expect, the psychiatric profes-
sion was outraged by Rogers I (Special Section, 1980). They believed that it
unduly restricted the proper provision of care and treatment and the rea-
sonable exercise of their medical authority. Response from professional psy-
chology was comparatively scant, however, because, I hypothesize, psy-
chologists are not in principle directly involved in the prescription of
psychotropic medication.
Rogers I was appealed, and in Rogers v. Okin (1980) (Rogers lI), the Court
of Appeals for the First Circuit affirmed the lower court's ruling that psy-
chotropic drugs could be forcibly administered only in emergencies or after
a determination of incompetency had been made. Thus a competent
patient's right to refuse treatment except in emergencies had to be
respected. But Rogers II granted physicians the authority in potential emer-
gency situations to decide whether the state's interest in preventing vio-
lence outweighed the due process right of the patient to refuse treatment.
The court stressed that such a decision involves a process of balancing
numerous factors unique to particular situations. The lower court's "unitary
standard," which asked only if there was a substantial likelihood of vio-
lence, was found to be too rigid and difficult to apply and the appellate
384 STEPHEN J. MORSE
court held that the decision forcibly to medicate a patient had to be made
on an individualized basis. Rogers II therefore remanded the case to the
lower court to design new procedures to insure that before drugs were forc-
ibly administered in an emergency that, first, the patient's interests in refus-
ing antipsychotic medication were taken into account, and second, that a
qualified physician weighed the competing interests and determined that
the state's interest was paramount and that less restrictive alternatives were
unavailable. Rogers II also broadened the lower court's definition of emer-
gency situations to allow forcible administration of drugs if reasonably
believed to be necessary to prevent further deterioration in the patient's
mental health (italics added). Although Rogers II both extends medical
authority and broadens the definition of an emergency beyond the limits
set in Rogers I, the due process right of a competent patient to refuse treat-
ment was upheld.
Rogers II was appealed to the Supreme Court, which agreed to hear the
case (now entitled Mills v. Rogers), but after the high court accepted the
Rogers II case, the Supreme Judicial Court of Massachusetts decided another
major right to refuse treatment case, In the Matter of Guardianship of Richard
Roe, III (Roe III, 1981). As we shall see, Roe III had a major effect on the
Supreme Court's decision in Mills v. Rogers (Mills, 1982).
Roe ("the ward") had twice been committed to a state hospital for
observation: the first time after becoming violent toward his sister and
another, the second time after being charged with attempted unarmed rob-
bery and assault and battery. He also attacked another patient during his
second stay. He was diagnosed as suffering from schizophrenia, paranoid
type, and antipsychotic medication was recommended. He refused. this and
all other treatment. Upon release he lived with his family. Roe's father was
appointed guardian by the probate court, which determined that Roe was
unable to care for himself by reason of mental illness (thus "incompetent").
The issue before the Supreme Judicial Court of Massachusetts was whether
the probate judge had erred in granting the father, as guardian, authority
to consent to the forcible administration of antipsychotic medication to his
noninstitutionalized ward in the absence of an emergency. Basing its deci-
sion on both federal and state law, the court held that he had.
The court said first that its guidelines were applicable where all of the
following exist:
1. An incompetent individual is not institutionalized.
2. A party with standing actually seeks to administer medication to the
incompetent person in the absence of an emergency (which the
court defined as an unforeseen combination of circumstances or
the resulting state that calls for immediate action) .
3. The proposed medication is an antipsychotic drug.
There appears to have been no dispute that a decision to consent to
such medication over the patient's objections should be made, if at all, pur-
suant to a substituted judgment determination, a determination of what the
MENTAL HEALTH LAW 385
The court was careful to note the limits of its holdings. First, it deals
with a noninstitutionalized individual in a nonemergency situation. What
the proper course of conduct would be in an emergency the court does not
say. Second, it deals with noninstitutionalized individuals. "Specifically, we
decline to rule on the rights of patients confined against their will to state
hospitals to refuse antipsychotic medication" (p. 62). Third, "we wish to
emphasize as well that in this case we treat the ward's right to a determi-
nation only in so far as it concerns antipsychotic medication" (p. 62).
The significance of Roe III for future cases involving right to refuse
treatment is that it is a leading precedent that has strong sympathy for strin-
gently protecting the rights of mental patients, including requiring a high
degree of judicial participation in what many regard as primarily medic~l
decisions. Although the holding is limited to noninstitutionalized individ-
uals, it is reasonably clear the court's sympathies also will extend to insti-
tutionalized patients.
As we shall see next, the Supreme Court's decision in Mills was heavily
influenced by Roe III, and Roe III will probably be the basis for future deci-
sions by the court of appeals on remand in Mills. Therefore, it is useful to
conclude the discussion of Roe III by noting its observance that Rogers II
was mistaken when it held that the guardian should be given the disputed
authority to decide (although Roe III noted also that the decision in Rogers
II was in accord with the law controlling at the time).
It was expected that in Mills v. Rogers the United States Supreme Court
would finally resolve the question of whether institutionalized mental
patients have a federal constitutional right to refuse antipsychotic drug
treatment. Ultimately, however, the Court unanimously refused to decide
the case on the merits. Instead, it vacated the judgment of the court of
appeals and directed that court to det~rmine whether: (1) Roe III required
revision of its holdings, or (2) potentially dispositive state law questions
should be certified to the Supreme Judicial Court of Massachusetts, or (3)
abstention (declining to decide or delaying decision to await state court
action) was appropriate.
Although the failure to decide was disappointing, the Supreme Court's
reasons for doing so were reasonable. The Court noted that state constitu-
tions and state law generally might properly grant an individual greater
substantive and procedural protection than the federal constitution, which
sets only minimum limits. Thus, where state protections were broader, as is
commonly the case, state law would be dispositive of the rights and duties
of the parties. In this particular instance, the Roe III decision, discussed
immediately above, had been decided by the Supreme Judicial Court of
Massachusetts after the federal court of appeals decision in Mills and after
the Supreme Court had agreed to hear Mills. Furthermore, the patients (Ms.
Rogers et al.) clearly had relied on state law in their arguments to the court
of appeals. Because Roe III granted disordered persons very extensive rights,
the Supreme Court concluded that, "we cannot say with confidence that
adjudication based solely on identification of federal constitutional interests
MENTAL HEALTH LAW 387
would determine the actual rights and duties of the parties." In other
words, since it was probable that the Massachusetts law was broader than
federal law in this context and might control the case, the Supreme Court
refused to decide because it adheres to a settled policy of avoiding unnec-
essary decisions of federal constitutional issues.
In the course of reaching its conclusions, the Court did offer a number
of hints about what its views might be were it to decide the issue on the
merits. It observed that both parties in Mills "agree that the Constitution
recognizes a liberty interest in avoiding the unwanted administration of
antipsychotic drugs." The Court was studiously noncommittal, however,
about whether involuntary mental patients retain such liberty interests. For
example, it wrote, "Assuming that [the parties in Mills] are correct in this
respect," and in a later footnote again only assumed, for purposes of dis-
cussion, that involuntarily committed mental patients do retain liberty
interests protected directly by the Constitution and that these interests are
implicated by the involuntary administration of antipsychotic drugs. The
Court wrote finally that, assuming the existence of such interests, it inti-
mated "no view as to the weight of such interests in comparison with coun-
tervailing state interests." Despite this string of disclaimers, it appears clear
in light of Youngberg v. Romeo (discussed above at p. 376) that the Court does
recognize such rights and will so hold if it ever decides this exact issue.
The Court went on to compare the rights granted by Roe III with those
granted in related Supreme Court cases (Addington, discussed at p. 348;
Youngberg, discussed at p. 376, and Parham, discussed at p. 350), observing
thal "it is distinctly possible that Massachusetts recognizes liberty interests
of persons adjudged incompetent that are broader than those protected by
the Constitution of the United States." The Court referred to Roe III's grant
of continuing liberty interests to those judged incompetent and its require-
ment of judicial oversight of decisions in this area as examples. The most
obvious implication is that if the Supreme Court finally decides the ques-
tion of the right of involuntary patients to refuse antipsychotic drug treat-
ment, it will recognize some liberty interest for the committed person, but
neither the substantive rights granted nor the procedures required to pro-
tect those rights will be extensive.
In the absence of a definitive Supreme Court resolution of the right to
refuse treatment issue and in light of the Court's recognition that state law
may be more extensive than federal protections, there is still considerable
opportunity for legislative and judicial lawmaking, and psychologists will
be able to provide information to the legal system as it attempts to resolve
this difficult issue.
Whereas the right to treatment was approved nearly universally, at
least in principle, as a sound social policy, the right to refuse treatment has
generated enormous debate. Supporters of the right weigh heavily the
patient's right to dignity, autonomy, and privacy and they fear equally the
extraordinary intrusion on these rights represented by involuntary mental
treatments, especially the most intrusive such as psychotropic medication,
388 STEPHEN J. MORSE
from doing what they are trained and paid to do-treat patients-but most
patients will not refuse treatment. Mental health professionals will have
more work than they can reasonably manage treating the vast majority of
hospitalized patients who will accept willingly the treatments offered to
them. Fears for the therapeutic milieu, the welfare of patients, and the like
simply seem overwrought.
The rights of patients have expanded enormously in the last decade
and one can only hope that they will continue to do so in the future. Never-
theless, some regression or counterraction in some jurisdictions would not
be surprising (A. E. & R. R. v. Mitchell, 1980). Still, I suspect that the right
to refuse treatment will spread to many if not most jurisdictions and will
become a permanent feature of the mental health law terrain. At the very
least, spurred by cases such as Rogers I and II, Roe III, and Rennie I and II,
patients' rights advocates will certainly press for litigation and legislation
to provide the right in those jurisdictions where it is now lacking. In the
next decade, consequently, mental health professionals across the nation
can expect constantly to confront the appropriate parameters of the right to
refuse treatment.
As behavior change technologies become increasingly powerful (and
perhaps also intrusive and irreversible), as they surely will, the right to
treatment will become an even more salient legal issue. For psychologists,
the major questions will concern the widening repertoire of behavior ther-
apies, especially those such as aversive conditioning, which can be forced
on a patient and which may be highly intrusive. Indeed, behavioral tech-
nologies may come to be seen as more problematic than some somatic treat-
ments such as psychotropic medication, which may in some cases be less
intrusive and no more irreversible. Psychologists cannot afford to lose sight
of the consequences of their technologies; nor, gratifyingly, have they done
so. They can expect, however, legal challenges to their treatments, much as
psychiatrists have faced the initial challenges to medication, psychosurgery,
and ECT. One can only hope that psychologists will react less defensively
and with recognition of the fact that consensual treatment is preferable
because it is more respectful.
This subsection will discuss a group of civil mental health laws that,
unlike the civil commitment and guardianship systems, do not fit under
any particular rubric. Such laws are numerous and diverse, and although
they are less "glamorous" than the laws already discussed, they are impor-
tant. Indeed, although there is no hard evidence to support this contention,
my estimate is that the majority of contacts psychologists have with the
legal system involve these laws.
In general civil law, mental disorder plays two different roles. First, it
is a disability that in some situations negates the usual legal significance of
a person's behavior. For example, disordered persons sometimes may avoid
390 STEPHEN J. MORSE
enforcement of their contracts, have a defense to tort liability, or, post mor-
tem, fail to have their wills admitted to probate. In such cases, the person is
not necessarily deemed generally incompetent and subject to guardianship
or the like. Rather, a particular activity is affected by mental disorder, cre-
ating legal consequences. Second, mental disorder sometimes appears to be
the outcome of the various stresses and serves as a basis for recovery against
the stressors or for receiving transfer payments from the government. For
example, disordered persons may recover money to compensate them for
their disorder if they are disabled by it or if it is the result of work-related
injury or tortious harms. To discuss all possible civil mental health laws
would be a task as gargantuan as it would be tedious, so this section will
simply use illustrative examples to explore the two branches of civil mental
health law.
"Conjuring" over a sick man "to make him well" is not a valid consideration
for a promissory note; and ... no man with a healthy mind would voluntarily
give a note for $250, with interest at two per cent a month, for the services of a
conjurer, who proposes to cure a lingering disease by conjuring or incantations.
(Cooper v. Livingston, 1883, p. 694)
At base, however, the finding of disability rests on the belief that the
worker is not shamming when claiming that he or she feels unable to work
and in fact is somehow prevented from working. This is often a difficult
determination to make and, as always, professional psychologists should
MENTAL HEALTH LAW 393
abstain from offering conclusions as scientific that are based in fact on sim-
ple observation and common sense. Nor should they offer unproven theo-
ries to support conclusions reached primarily by common sense (see p. 406
infra for further discussion of this issue).
The difficulties attending the conceptualization and confirmation of
mental disability claims reach their greatest heights in cases of "compen-
sation neurosis," wherein the worker's neurotic disability is in part influ-
enced by an "unconscious desire to obtain or prolong compensation" or by
"sheer anxiety over the outcome of compensation litigation" (Larson, 1970).
Compensation neurosis, of course, must be distinguised from conscious
malingering, but as honest professional psychologists recognize, it is often
difficult to distinguish malingering from real disorder.
Even if one accepts that mental disorder may be both a result of stress
and a cause of uncontrollable disability, the question of remediation pre-
sents additional difficulties. For example, persons seeking social security
disability benefits or worker's compensation can be compelled to undergo
reasonable treatment that may help remedy their disability (Henry v. Gard-
ner, 1967; see California Labor Code § 4056, 1971). An impairment that can
be remedied by reasonable treatment will not serve as a basis for a finding
of disability. As one court noted:
Although the case involved civil commitment and this part of the decision
is not binding on the states, such a statement by the nation's highest court
reflects a widely held view applicable to all mental health law decision
making and it surely will be influential when the proper role of expertise
is debated. Whether the statement is as broadly valid as the Court seems to
believe will be discussed on pages 405ff infra.
It is also noteworthy that the Court explicitly refers to psychologists as
experts because, for many years, only medically trained persons, whether
or not they had extensive mental health training or experience, were qual-
MENTAL HEALTH LAW 395
a neutral and detached fact finder, the judge or jury, resolves the dispute.
Such noncooperative and unscientific methodology is alien to most psy-
chologists and entering the adversary system places them in an unfamiliar
and often uncomfortable milieu (but see Levine, 1974, who argues for the
use of the adversary method in some instances to resolve scientific dis-
putes). In order to perform most effectively and to avoid undue discomfort,
the psychologist should therefore understand both the types of pressures
and conflicts that will beset him or her as a participant in the adversary
system and the roles expected of him or her (see Brodsky, 1977).
When the psychologist enters a case, he or she almost always will do
so on one side of a dispute. As a consequence, the psychologist will overtly
and covertly be placed in the role of an advocate, even if he or she had
every intention of providing "neutral" scientific information regardless of
which side employed him or her. Because the psychologist is being
employed by that side and is a member of a team, it is hard to resist the
pressures. This is especially true because issues and questions can be
phrased in a fashion that will not ask the psychologist to compromise his
or her professional integrity.
Even without any direct pressure, the psychologist will feel himself or
herself slipping into an adversary role. To use a rather analogous example,
all lawyers quickly learn that they begin to "believe in" the side they are
representing. Indeed, law students experience this even when engaging in
simulated exercises such as "moot court" competitions. This phenomenon
occurs even though the lawyer recognizes that the case may be fairly evenly
balanced and that if chance had placed him or her on the other side, he or
she would have felt the same way about the opponent's case. The pressure
to become an advocate is heightened for the psychologist who is in an unfa-
miliar environment and therefore is especially subject to the role expecta-
tions of that environment. Of course, almost all psychological evaluations
are subject to wide interpretations, and as the psychologist discusses his or
her findings with counsel, the psychologist should not be surprised or
ashamed to discover (if he or she is honestly self-observant) a desire to
please and aid the attorney. Often, the longer one spends with a case, the
stronger it seems. These psychological reactions would be well understood
by psychologists if they were studying them from an outside vantage point.
The legal system expects an expert witness, within the bounds of
professional integrity, to act on behalf of his or her client. Most psycholog-
ical issues in forensic cases are capable of alternative resolutions. There is
therefore nothing inherently unethical or dishonest about allowing oneself
to become an advocate as long as the psychologist behaves in accordance
with scientific and clinical canons. Of course, the psychologist should never
reach a conclusion or offer an opinion unless he or she believes it is reason-
ably supported by clinical and research evidence. In sum, the psychologist
should not deny his or her growing bias, but should acknowledge it and
work with it. Otherwise, skillful opposing counsel will be sure on cross-
MENTAL HEALTH LAW 397
such cases. Let us therefore turn to a general discussion of this issue. (Of
course the specific rules about privilege vary from jurisdiction to jurisdic-
tion and the psychologist should become familiar with the rules of his or
her jurisdiction. Moreover, this brief discussion will not attempt completely
to cover all forensic circumstances in which privilege is an issue.) There are
classes of communication between persons who stand in particular relation-
ship to one another, e.g., attorney and client, doctor and patient, that on
grounds of public policy the law will not allow to be disclosed or inquired
into in a legal proceeding. Such communications are said to be privileged
(see generally, Saltzburg, 1980). Such communications are also confidential,
i.e., the "receiver" has a general duty not to disclose the contents of the
communication to third parties without the "sender's" consent. For
instance, communications between a doctor and patient are both confiden-
tial and privileged in order to encourage patients to consult physicians
freely and to disclose to them all information necessary to receive effective
medical care. Of course, the holder of a privilege, say, a patient, may waive
the privilege if he or she so wishes.
Until relatively recently, communications between nonmedical psy-
chotherapists and patients were not privileged in most jurisdictions. As a
clear matter of logiC, however, the policy that supports the physician-
patient privilege is equally applicable to psychotherapist-patient commu-
nications, even if the therapist does not hold the M.D. degree. This has been
recognized by legislatures and courts and a broad psychotherapist-patient
privilege is now commonly applicable when the patient consults the ther-
apist for the diagnosis or treatment of mental disorder or for the purposes
of scientific research (e.g., California Evidence Code § 1014, 1979). There
are, however, exceptions, when the privilege is not applicable.
If a patient puts his or her mental condition in issue in a legal proceed-
ing, he or she waives the privilege as to any psychotherapist-patient com-
munication concerning that condition. A very common and related situa-
tion occurs when a patient consults an attorney and it appears that the
patient's mental condition will be an issue in the forthcoming litigation.
What an experienced attorney does then is to hire an expert as a "consul-
tant" to examine the patient to help the attorney prepare the case. Because
the examination was primarily for legal purposes, the results of the evalu-
ation will be privileged under the attorney-client privilege (but see People
v. Edney, 1976). If the evaluator later testifies, then the privilege is of course
clearly waived.
Another common occurrence is when a court appoints a mental health
professional to examine a criminal defendant in order to help the defense
counsel decide whether to raise the insanity defense. As long as the profes-
sional never testifies, the results of the examination will be privileged. But
when a criminal defendant gives notice of an intent to raise the insanity
defense or some other defense based on mental condition, or when a party
to a civil action raises an issue of mental condition, then typically the pros-
400 STEPHEN J. MORSE
findings had been used for the "limited, neutral purpose" of establishing
the defendant's competency, since a competency examination by itself is
not part of the adversarial process that determines guilt and imposes sen-
tence. When the psychiatrist testified for the prosecution at the death pen-
alty hearing on the crucial issue of the defendant's future dangerousness,
however, the doctor ceased to act as a neutral agent of the court and became
instead an agent of the state. The court-ordered examination thus became
"a phase of the adversary system," and a critical one at that. Since ~he defen-
dant had not been advised prior to the examination of his right to remain
silent and warned that anything he said could be used against him at trial,
his right to be free of compelled self-incrimination was violated by the
admission of testimony based on that examination.
Second, since a defendant is entitled to have his attorney present at any
interrogation or interview that is or will be made a part of his trial, the
defendant's Sixth Amendment right to the assistance of counsel also was
violated. (This issue, too, would not have arisen if the psychiatrist's finding
had been used only to establish competency.) Only if his attorney had been
present to advise him of his rights-particularly his Fifth Amendment
rights-and when to exercise them, would the psychiatrist's testimony have
been admissible at trial.
The mental health professional, then, can expect that his or her testi-
mony may be subject in various contexts to constitutional and procedural
constraints. This does not mean, however, that he or she is expected to
become an expert in constitutional law and criminal procedure. Responsi-
bility for seeing that the proper restrictions are observed lies primarily with
the attorneys in a case and with the court.
At the trial itself, the psychologist will be subject to two kinds of exam-
ination (questioning by the attorneys): direct (and re-direct) by the attorney
representing his or her side, and cross-examination (and re-cross) by the
opposing attorney. The psychologist will be called to the witness stand
when it is the turn of his or her side to present its case. But the trial is
typically not the first time the psychologist witness will have "gone over"
his or her testimony and the possible objections to it. (An exception to this
rule occurs in certain types of routinized cases, such as civil commitment
hearings in some jurisdictions, where the adversary system is not function-
ing fully and effectively [Morse, 1978a, 1982a].) Each attorney will "prepare"
his or her witnesses for trial; that is, they will discuss and practice the direct
testimony the witness will give and the probable cross-examination that
will ensue. If the case is important enough, they may practice this process
many times, although most attorneys try to avoid having their witnesses
appear as if they were giving their testimony by rote. If all this sounds quite
calculating, it is supposed to be. Attorneys detest surprises in the courtroom.
They want to know well in advance the strengths and weaknesses of the
case and they want to prepare the witness psychologically for the rigors of
the witness stand. Thus, the psychologist usually will come to court quite
well-prepared.
402 STEPHEN J. MORSE
Whether it recognizes this fact or not, the law is not concerned mainly
with whether a person suffers from a mental disorder as categorized in the
Diagnostic and Statistical Manual of Mental Disorders III (American Psycholog-
ical Association, 1980; Fingarette & Hasse, 1979). Surely, as epidemiological
reviews demonstrate (Dohrenwend & Dohrenwend, 1969), the number of
persons who might be diagnosed mentally ill according to present stan-
dards is considerably larger than the number of persons who are so differ-
ent from most people that society believes, on moral grounds, that special
rules ought to be applied to them. What the law requires is the social and
moral determination that the person in question is so fundamentally differ-
ent from others by virtue of his or her craziness that he or she cannot be
considered a normal person to whom the usual rules apply (M. S. Moore,
1975; Roche, 1967; Weihofen, 1960). Thus, professionals are not very helpful
to a court if they simply identify the person as suffering from this or that
mental disorder. In addition, the professional generally is more likely than
the lay person to identify particular behaviors as indicative of mental dis-
order (D'Arcy & Brockman, 1976). Finally, present diagnostic reliability is
still somewhat problematic (Morse, 1982a; Townsend, 1980), albeit improv-
ing significantly (Helzer, Clayton, Pambakian, Reich, Woodruff, & Reiley,
1977; Morse, 1982a). At best, the professional can say that the behavior
exhibited is so crazy that for treatment and other nonlegal reasons the per-
son ought to be considered mentally disordered.
If special legal rules are authorized for crazy people, such rules surely
apply to those people who are clearly crazy. In such cases, laypersons and
experts will agree and the scientific and legal criteria will overlap perfectly,
or almost so. But in cases of less than obvious extreme disorder, even
though experts might agree that the person suffers from this or that mental
disorder, whether he or she is crazy enough for the application of special
legal rules must be decided by the judge or jury because a diagnOSiS of men-
tal disorder does not necessarily imply that the person is crazy for legal
purposes. DSM-III itself appropriately cautions that its validity for legal
purposes is not established. Moreover, again as DSM-IJI recognizes,
although the new diagnostic criteria are more precise than those of DSM-
II, they are still vague enough to permit persons who behave quite differ-
ently to fit properly into the same diagnostic category. Anyone can say who
is crazy (or behaviorally disordered). The determination is nearly always
socioculturally conditioned (Dohrenwend & Dohrenwend, 1974; Soddy,
1967). Experts cannot make a scientific determination for the law in less clear
cases (or in any case) because the legal determination is not scientific. The
question for the law is not whether the actor is psychotic, for example, but
whether the actor is sufficiently disordered to warrant special legal treat-
ment. Thus, the question of whether the person is crazy enough for special
treatment is a question of social, moral, and ultimately, legal choice (Baze-
lon, 1976, 1977; Morse, 1978a; Roche, 1967; Washington v. U.S., 1967).
The second question asked by courts is whether legally relevant behav-
ior, such as dangerousness, is caused by or is the product of mental illness.
408 STEPHEN J. MORSE
If SO, the law reasons that the person is not causally responsible and thus
not morally and legally responsible for the behavior (Developments, 1974;
Hall, 1960, 1968). The situation is analagous to that of a person with an
infection, who is not held responsible for a consequent fever. If the person's
legally relevant behavior is beyond control rather than the product of free
choice, then legal intervention in the person's life seems justified because
such intervention seemingly will not infringe unduly on the actor's liberty,
dignity, and autonomy (Morse, 1978a).
I have argued that mental disorder is really crazy behavior of largely
unknown origin. Thus, when one asks if mental disorder is the cause of
legally relevant behavior, one is really asking when behavior causes behav-
ior. That is, when are crazy thoughts, feelings, or actions the cause of legally
relevant thoughts, feelings, or actions? Put this way, three types of relation-
ships between mental disorder and legally relevant behavior may be
distinguished:
1. No relationship: a paranoid who self-defensively strikes a person
who has attacked the paranoid without provocation. Even paranoids
have real enemies.
2. Clear relationship: a paranoid attacks someone who is not an enemy
but who is part of the paranoid's delusional system.
3. Unapparent but assumed relationship: the legally relevant behavior
itself seems crazy but there is no other independent and significant
evidence of craziness (e.g., cases of impulse disorder such as inex-
plicable violent outbursts).
These three types of relationships can be assessed and identified by
anyone who has the behavioral data, as I assume judges and juries would.
They are commonsense connections and require no special expertise to be
made. In the case of no relationship, special treatment is not warranted
because the mental disorder does not seem to be the cause of the legally
relevant behavior. In the cases of clear relationship or assumed relationship,
attributions of nonresponsibility and special legal treatment are warranted
only if the causal connection between the craziness and the legally relevant
behavior was unbreakable by the choice of the actor. The question for men-
tal health professionals, therefore, is whether behavioral science can deter-
mine scientifically if the relationship between craziness and other behavior
is uncontrollable. Let us examine this question.
The first issue to be analyzed is whether there is a strong positive rela-
tionship between craziness and legally relevant behavior. In other words,
do nearly all crazy persons or nearly all of a particular class of crazy persons
engage in particular legally relevant behavior, such as dangerousness? The
answer is clearly no. Craziness is neither necessary nor sufficient to produce
legally relevant behavior. For example, delusional persons do not invaria-
bly act on the basis of their delusions, nor do persons with powerful anti-
social impulses always act on them. Indeed, mental disorder does not even
seem terribly predisposing to the sorts of behavior, such as dangerousness
MENTAL HEALTH LAW 409
or grave incompetence, that lead to legal intervention (Brakel & Rock, 1971;
Guze, 1976; Monahan, 1981; Rabkin, 1979; Rappeport, 1967; Vecchione v.
Wohlgemuth, 1973). Moreover, for example, there is no significant relation-
ship between any particular mental disorder and criminal behavior. (Mon-
ahan & Steadman, 1983). Indeed, mental disorder is much less disposing
than, for comparison, poverty is to crime. Yet the law does not excuse even
the most disadvantaged offenders on the basis of their deprived back-
grounds (Morse, 1976).
Courts are not faced with aggregated data, however, but must decide
individual cases on a case-by-case basis. Even if, in general, craziness is not
predisposing to legally relevant behavior, how should one assess individual
responsibility in cases of a clear relationship between craziness and legally
relevant behavior (e.g., a paranoid who acts on the basis of a delusion about
hostile powers and harms another who is believed to be a hostile agent)?
Could the paranoid attend to and weigh information contra to the delu-
sional belief, or at least control overt action based on the belief? These ques-
tions may seem strange or even clinically absurd, but their answers are at
the theoretical base of why such persons are treated specially. Further, they
seem strange largely because mental health professionals (and most per-
sons) assume they know the answers despite the lack of what most of us
would accept as scientific proof. When we cannot make sense of a person's
behavior, we often ascribe lack of control to him or her. But there is little
hard evidence to prove lack of control.
Again, there is no underlying abnormality or pathology perceivable
only to the expert; the determination to be made involves a relationship
between behaviors that can be determined by anyone. Given that there is a
clear relationship between craziness and legally relevant behavior in a spe-
cific case, could the person have acted otherwise? I do not know and I sug-
gest that no one does. There is no scientific test for whether a person can
control himself or herself. Behavioral scientists and lay persons both have
intuitive feelings: Observers simply decide whether in their judgment it
was too hard for the crazy person in question to behave normally (Morse,
1976, 1978 a, 1978 b )- for example, to control legally relevant behavior
related to and seemingly caused by craziness.
But where is the line to be drawn in deciding which cases are too hard
to ascribe moral and legal responsibility to the actor? How hard is too hard?
I suggest again that this is a matter for social and moral judgment. It is not
a factual question such as: At what temperature will water boil? Behavioral
scientists cannot tell a court on the basis of special data or methods that a
given individual could or could not have behaved otherwise. If a mental
health professional's judgment is really a moral and intuitive feeling, this
judgment should be made only when, as a layperson, the professional
serves on a jury. It is a moral judgment and should be recognized and
treated as such.
The third and last question asked of mental health professionals is how
the person will behave in the future. Not all mental health and mental
410 STEPHEN J. MORSE
health related laws pose this question, but in many important areas, such
as civil commitment or the best-interests-of-the-child standard in child cus-
tody disputes, predictions are placed firmly in the center of the legal
inquiry. Here the question is not whether mental health professionals have
general prognostic information, as indeed they often do, but whether they
can predict better than laypersons future, specific, legally relevant behavior.
Or, to put the question in more legally congenial form: Can professionals
predict sufficiently better than laypersons to qualify them as experts on the
question of prediction? Although the prediction question is more empirical
than those dealing with normality and responsibility, our expertise is lim-
ited all the same. As is well known, future specific behavior, especially
infrequent behavior over the long term, is very hard for anyone to predict
with accuracy, even with the use of actuarial methods (Livermore, Malm-
quist & Meehl, 1968; Meehl & Rosen, 1955/1973). In a court of law the risks
to the person who is a false positive-the loss of liberty, dignity, reputation,
and autonomy-are very serious. Mental health professionals should and
increasingly do recognize that they are not seers (American Psychological
Association, 1978/1980). For example, the limited ability to predict long-
term violent behavior using clinical methods is well recognized (Monahan,
1981). But even though we know this, too many of us forget it when we
appear in court.
Now let me return to the three questions and suggest what I think
mental health professionals can offer to the courts and how they ought to
offer it. First, let us consider the threshold quesion of normality. For various
reasons, mental health professionals have more experience with crazy per-
sons than do most laypersons. It is fair to argue that professionals know the
right questions to ask to determine if the person behaves crazily enough
perhaps to warrant special legal treatment. Thus, a layperson may not know
to ask if an allegedly mentally disordered person sometimes hears voices or
is hypersomniac or has lost a lot of weight recently. In other words, for legal
purposes, professionals can best act as trained, acute observers. They can tell
the judge or jury better or more efficiently than others that the person in
question hears voices or has thoughts of suicide. Of course, the allegedly
disordered person's family, friends, colleagues, and the like also can pro-
vide such data when they have them. Then using lay and expert testimony,
the judge or jury, as the social, moral, and legal decision maker, can decide
if the person is crazy enough to warrant special legal treatment.
Another major nurmality-related issue is whether the person is faking
crazy symptoms. Are professionals reliably better than others at determin-
ing faking? It is unfortunate, but there are rarely "underlying" signs, such
as the quasidiagnostic criterion of pathological tissue, to help answer the
question whether the observable symptoms are probably real. I am not sure
whether professionals are better but, at the least, David Rosenhan's (1973)
study (despite strong criticism of it [Spitzer, 1975]) and studies of impres-
sion management (e.g., Braginsky, Braginsky, & Ring, 1969; Martin, Hunter,
& Moore, 1977) make me uncomfortable about claiming that psychologists
MENTAL HEALTH LAW 411
defendant felt a certain way, rather than reporting that the killing was the
inexorable or near inexorable product of threatened ego disintegration.
Such cases are not like the patellar reflex. What percentage of people with
disintegration fears kill? Was the fear of disintegration a necessary or suf-
ficient cause of killing? In cases of this type, the judgment that the person
could not have acted otherwise, that the defendant's choice was too hard,
is a moral judgment, and not a scientific one.
In conclusion, it is suggested that psychologists be very careful when
discussing causal questions. We should not present a causal variable as nec-
essary and sufficient when there are no hard data to support this contention.
Nor should we overly inject insuffiCiently tested theory as fact or propound
our commonsense factual judgments as scientific. Mental health profession-
als simply do not often have scientific data to say whether a person could
or could not have acted otherwise. And, finally, questions about legal and
moral responsibility are not scientific questions; consequently, the psychol-
ogist should not draw conclusions about responsibility.
On the question of prediction, the law generally asks professionals
about relatively specific behavior (e.g., the outcomes of various therapeutic
interventions or the prediction of dangerousness) about which we do have
data (Bergin & Lambert, 1978; May, 1976; Monahan, 1981; M. L. Smith &
Glass, 1977). But these questions often are asked in terms of relatively
vague, general criteria of probability. My suggestion here is that we profes-
sionals abandon the crystal ball and simply present to the courts the data
we have in precise form rather than drawing legal conclusions. For
instance, instead of telling the court, "This person is likely to improve if
placed in a token economy," professionals should give courts such infor-
mation in the folJowing type of form: "On the average, X% of persons of
this sort change in y, z specific ways over the time period t." Then the court
can decide if that probability of specific change meets the discretionary legal
standard of "likely to improve" (and thus, perhaps, if involuntary treatment
is warranted for the person). The expert has then offered what professional
expertise can contribute and cannot be accused of playing fortune-teller or
drawing legal conclusions in the guise of scientific data.
The courts should be informed if such data do not exist for a given
prediction and professionals should not offer a guess based on clinical wis-
dom. Sometimes the clinician is better than the computer but, as Paul Meehl
has taught (1973), we cannot yet identify those cases in which this will be
so. The guess of a professional, no matter how well intentioned, is unlikely
to be better than the guess of the average judge or juror and thus is not
really an expert opinion. If there are no data, the law should be forced to
make the hard moral choices by itself and should not be allowed to abdicate
its moral responsibility.
Some psychologists may find my conclusions and assessments of our
expertise unduly harsh or pessimistic. We must be honest with ourselves,
however, recognizing the limitations of our science and clinical acumen.
Psychologists have little to gain from extending themselves beyond their
MENTAL HEALTH LAW 413
Mental health law cases, in all their diversity and interesting perplex-
i.ties, are a primary context in which professional psychologists interact
with the law and lawyers. There are literally millions of such cases each
year in the United States, and psychologists are increasingly asked to pro-
vide their expertise to their resolution. Although there are specialists in
forensic psychology, attested to by the incorporation of the American Board
of Forensic Psychology, probably there never will be sufficient numbers of
board certified forensic specialists to handle the cases that arise. Profes-
sional psychologists in general consequently may expect to play some role
in mental health law cases on at least some occasions. This chapter therefore
has sought to present a broad overview of mental health law that describes
the general state of the law and that considers analytically the most impor-
tant issues. It has also attempted to describe and analyze the role of profes-
sional psychologists in mental health law cases.
In conclusion, the primary message I wish to convey is that lawyers
and psychologists often approach problems with differing conceptual
frameworks and speak very different languages. Psychologists must learn
that mental health law cases involve social, moral, political, and legal issues
and values and they should not become condescending or exasperated
when their "scientific" view of a case is not entirely accepted and indeed is
VOciferously challenged. Moreover, psychologists should recognize their
own values and biases and should avoid conflating those values and biases
with scientific fact or opinion. Finally, psychologists should offer their
expertise and opinions to lawyers with the same degree of caution that is
always warranted when they present their work to psychological col-
414 STEPHEN J. MORSE
ACKNOWLEDGMENTS
CASES
1. A. E. and R. R. v. Mitchell, 5 Mental Disability Law Reporter 154 (D.C. Utah 1980).
2. Addington v. Texas, 441 U.S. 418 (1979).
3. Aden v. Younger, 57 Cal.App.3d 662 (Ct. App. 1976).
4. Bailey v. American Gen. Ins. Co., 154 Tex. 430 (1955).
5. Bartley v. Kremens, 402 F.Supp. 1039 (E.D. Pa. 1975), prob. juris noted, 424 U.S. 964 (1976).
6. Commonwealth v. Gould, 405 N.E.2d 927 (Mass. 1980).
7. Cross v. Harris, 418 F.2d 1095 (D.C. Cir. 1969).
8. Dixon v. Weinberger, 405 F.Supp. 974 (D.D.C. 1975).
9. Doe v. Gallinot, 486 F.Supp. 983 (C.D. Cal. 1979),657 F.2d 1017 (9th Cir. 1981).
10. Drope v. Missouri, 420 U.S. 162 (1975).
11. Durham v. U.S., 214 F.2d 862 (D.C. Cil'. 1954).
12. Dusky v. U.S., 362 U.S. 402 (1960) (per curiam).
13. English Homicide Act of 1957,S&:6 Eliz. II, C.I1.
14. Estelle v. Smith, 451 U.S. 454 (1981).
15. Flakes v. Percy, 511 F.Supp. 1325 (W.O. Wis. 1981).
16. Gregg v. Georgia, 428 U.S. 153 (1976).
17. Halderman v. Pennhurs~ State School and Hospital, 446 F.Supp. 1295 (E.D. Pa. 1977),451
F.Supp. 233 (E.D. Pa. 1978), modified 612 F.2d 84 (3d Cir. 1979).
18. Halderman v. Pennhurst, 451 U.S. 1 (1981).
19. Henry v. Gardner, 381 F.2d 191 (6th Cir.), cert. denied, 389 U.S. 993 (1967).
20. In re Burnick, 14 Cal.3d 306 (1975).
21. In re Franklin, 7 Cal.3d 126 (1972).
22. In re lingenfelter's Estate, 38 Cal.2d 571 (1952).
23. In re Moye, 22 Cal.3d 457 (1978).
24. In re Oakes, 8 Law Reporter 122 (Sup. Jud. Ct. Mass. 1845).
25. In re Roger S., 19 Cal. 3d 921 (1977).
26. In re Winship, 397 U.S. 358 (1970).
27. J. R. v. Parham, 442 U.S. 584 (1979). (412 F.Supp. 112 (M.D. Ga. 1976).)
28. Jackson v. Indiana, 406 U.S. 715 (1972).
29. Knecht v. Gillman, 488 F.2d 1136 (8th Cir. 1973).
30. Lessard v. Schmidt, 349 F.Supp. 1078 (E.D. Wis. 1972), vacated and remanded on procedural
grounds, 414 U.S. 473, new j'mt entered, 379 F.Supp. 1376 (E.D. Wis. 1974), vacated and
remanded, 421 U.S. 957 (1975), prior j'mt reinstated, 413 F.Supp. 1318 (E.D. Wis. 1976).
31. Lynch v. Baxley, 368 F.Supp. 378 (M.D. Ala. 1974).
32. Mathew v. Nelson, 461 F.Supp. 707 (N.D. Ill. 1978).
33. Matter of Guardianship of Richard Roe, III, 421 N.E.2d 40 (Mass. 1981).
34. Matter of Torsney, 47 N.Y.2d 667 (Ct. App. 1979).
35. McDonald v. U.S., 321 F.2d 847,114 U.S.App. D.C. 120 (en bane, 1962).
36. Melville v. Sabbatino, 30 Conn. Supp. 320 (Sup. Ct. 1973).
MENTAL HEALTH LAW 415
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Yochelson, S., &: Samenow, S. The criminal personality (vol. 1). New York: Jason Aronson, 1975.
Zander, T. K. Civil commitment in Wisconsin: The impact of Lessard v. Schmidt. Wisconsin Law
Review, 1976,503-561.
Zitrin, A., Hardesty, A. S., Burdock, E. I., &: Drossman, A. F. Crime and violence among men-
tal patients. American Journal of Psychiatry, 1976, 133, 142-49.
Zusman, J. The reasons for state control of the mentally disordered. In C. A. B. Warren, The
court of last resort: Mental illness and the law. Chicago: University of Chicago Press, 1982.
13
Developmental Disabilities Law and the
Roles of Psychologists
MICHAEL KINDRED
INTRODUCTION
Over the last decade Congress has passed a number of laws affecting devel-
opmentally disabled persons. I Federal and state courts also have articulated
important rights for developmentally disabled persons. 2 State legislatures
have enacted new laws, often in response to congressional or court action. 3
IThe first specific federal assistance to mentally retarded persons occurred in 1935, when the
Social Security Act created the Crippled Children's Bureau. The Vocational Rehabilitation
Act of 1945 also covered the mentally retarded. Funds to support mental retardation teacher
training programs were authorized in 1958. In 1961 President Kennedy established the Pres-
ident's Panel on Mental Retardation, which recommended an increased federal involve-
ment. A more substantial federal role has developed since that time. The details of this
involvement will appear in the discussion of specific topics infra.
20n the American tradition of using the courts to vindicate the rights of politically disfa-
vored groups and the relationship of progress for the handicapped to other aspects of the
civil rights movement (see T. Gilhool, The Right to Community Services, in M. Kindred et
ai., eds., for the President's Committee on Mental Retardation, The Mentally Retarded Citizen
and the Law 173, n. 5 at 174. New York: Free Press, 1976. [hereinafter cited as The Mentally
Retarded CitizenD.
3For example, while the first federal court decisions articulating a constitutional right to
treatment or habilitation were related to Alabama institutions, they induced the director of
the Ohio Department of Mental Health and Mental Retardation to establish a task force to
propose reforms of Ohio laws relating to institutional care. K. Gaver, Reaction Comment, The
Mentally Retarded Citizen, supra note 2 at 411, 413. As a result, the Ohio Legislature enacted
S.B. 336 (1973) establishing, among other things, a statutory right to habilitation for the
mentally retarded. This law is now codified at Ohio Rev. Code Ann. §§ 5123.68-5123.99
(Page Supp. 1978). A statutory right to education for handicapped children in Ohio was not
established until enactment of mandatory federal legislation and the threat of withdrawal
MICHAEL KINDRED. College of Law, Ohio State University Law School, Columbus,
Ohio 43210.
423
424 MICHAEL KINDRED
of federal funds. For current provisions, see Ohio Rev. Code Ann., Chapter 3323 (Page Supp.
1978).
The best source of information on current legal developments in this area is The Mental
Disability Law Reporter, published bimonthly by the American Bar Association Mental Dis-
ability Legal Resource Center (1800 M Street N.W., Washington, D.C. 20036). See also Ami-
cus, published bimonthly by the National Center on Law and the Handicapped (211 W.
Washington Street, South Bend, Indiana 46601).
4Almost all pre-1960 laws affecting the mentally retarded emphasized the limitations of such
persons and provided for the restriction or denial of rights enjoyed by most members of
society. Discussion of these laws and analytical tables are to be found in American Bar Foun-
dation, The Mentally Disabled and the Law (1st ed., 1961 Lindman & McIntyre, eds., Chi-
cago: University of Chicago Press, 1961 [cited hereinafter as Lindman & McIntyre]). Special
restrictive laws also were enacted that dealt with epileptics. See R. Barrow & H. Fabing,
Epilepsy and the Law (2d ed., New York: Harper & Row, 1966) and Epilepsy Foundation of
America, The Legal Rights of Persons with Epilepsy (4th ed., Washington, D.C.: Epilepsy
Foundation of America, 1976). Only very recently has the law created entitlements, rather
than restrictions, for the handicapped. A few positive changes are reflected in American Bar
Foundation, The Mentally Disabled and the Law (2d ed., Brakel & Rock, eds., Chicago: Uni-
versity of Chicago Press, 1971 [cited hereinafter as Brakel & Rock]). Others will be discussed
throughout this chapter.
584 Stat. 1316, codified as amended at 42 U.S.c. 6001-6081 (1976).
6H.R. Rep. No. 1277, 91st Cong., 2d Sess. (1970) at 1970 U.S. Code Congressional and Admin-
istrative News 4714, 4717.
DEVELOPMENTAL DISABILITIES LAW 425
The secretary never exercised the power granted in this definition to extend
the benefits of the law to "closely related" groups. Because the legislation
was perceived by consumer groups to confer valuable benefits, however,
advocates for the autistic and for persons with dyslexia secured explicit
inclusion within the federal definition of "developmental disability"
between 1970 and 1976.
The definition was a source of continuing controversy. Some persons
felt its use of diagnostic categories excluded deserving and needy individ-
uals. Others felt the definition was insufficiently targeted-in other words,
too broad-and spread scarce funds too thinly with too little assistance for
those with the greatest need. In 1975 Congress ordered a study/o which was
completed and led to a substantial revision of the definition in 1978.11 The
new definition of developmental disability is a severe, chronic disability of a
person that:
1. Is attributable to a mental or physical impairment or combination of
mental and physical impairments
7With funding from the Developmental Disabilities Office of the Department of Health, Edu-
cation, and Welfare the Developmental Disabilities State Legislative Project of the American
Bar Association Commission on the Mentally Disabled (1800 M Street N.W., Washington,
D.C. 20036) (hereinafter the ABA Commission) has published a series of model state acts
dealing with the developmentally disabled.
80ne must beware of the effects of any effort at "modernization" of the law by substituting
"developmentally disabled" for "mentally retarded." Since the former is broader in some
ways than the latter, and perhaps narrower in others (see n. 9-12 infra), substitution of terms
may serve inadvisably to change the coverage of the substantive provision. For example, to
modernize a statute that prohibits mentally retarded persons from voting or permits their
institutionalization (both questionable in themselves) to cover the "developmentally dis-
abled" would be a significant restrictive act. New persons would be limited or subject to
incarceration. At the least, the merits of such a change should be thoroughly considered.
These would be far from "mere technical" changes.
9pub. L. 91-517, § 102(5),84 Stat. 1325.
IODevelopmentally Disabled Assistance and Bill of Rights Act of 1975, Pub. L. 94-103, §
301(b), 89 Stat. 506.
IIRehabilitation Comprehensive Services and Developmental Disabilities Amendments of
1978, Pub. L. 95-602, § 503(a), 92 Stat. 3004.
426 MICHAEL KINDRED
ADVOCACY
I"N.Y. Mental Hygiene Law § 29.09 (McKinney 1978). Although the New York Mental Health
Information Service originally was limited to mental health matters, it since has had its
jurisdiction extended to mental retardation issues as well. N.Y. Mental Hygiene Law § 9107
(McKinney 1978). See generally Note, The New York Mental Health Information Service: A New
Approach to Hospitalization of the Mentally III, 67 Colum. L. Rev. 672 (1967).
17N.J. Stat. Ann., Chapter 52:27E and especially §§ 52:27E-21 through 52:27E-27 (West Supp.
1979).
ISOhio Rev. Code Ann. § 5122.94 (Page Supp. 1978).
19pub. L. 94-103, 89 Stat. 496 (codified at 42 U.S.c. §§ 6001-6081 (1976). See especially 42
U.S.c. § 6012.
2OS. Herr, Advocacy Under the Developmental Disabilities Act (H.E.W. 1976); Herr, The New
Clients: Legal Services for Mentally Retarded Persons, 31 Stan. L. Rev. 553 (1979).
430 MICHAEL KINDRED
ENVIRONMENTAL BARRIERS
22The importance of the social system's norms and expectations in the definition of mental
retardation is explored in Mercer, Labeling the Mentally Retarded (Berkeley, California:
University of California Press, 1973).
23The problems addressed by this section concern physically handicapped persons. Thus,
"physical handicap" is the operative statutory concept. 42 U.S.c. §§ 4151-4157 (1976). While
many developmentally disabled persons have no mobility impairment, such impairments
are not infrequently an aspect of the developmental disability.
24Much of this section is based upon ABA Commission, Eliminating Environmental Barriers
(1979), supra note 7, which analyzes relevant federal and state laws and proposes a model
act for adoption by state legislatures.
25Pub. L. 90-480, codified as amended at 42 U.S.c. 4151-4157 (1976).
26 42 U.S.C. §§ 4151-4156 (1976).
increased the role of the federal government. Under regulations issued pur-
suant to that act, such programs now are required to ensure that all new
facilities are accessible and also to make adjustments in present programs to
ensure that they are generally accessible. 29
In the area of public transportation, the federal government also has
required that federally supported public transportation programs (which is
almost all of them) make "special efforts" to provide public transportation
availability to handicapped persons. 30 Debate rages on whether separate
transportation systems can compensate for the inaccessibility of the general
public transportation system, or whether vehicles used in general public
transportation also must be accessible to handicapped persons. 31
All states also have addressed the issue of environmental barriers to
some degree, although most state statutes leave much to be desired in terms
of both coverage and effective enforcement mechanisms. The ABA Com-
mission has provided a recent analysis of federal and state law in the area
and has proposed a model act for adoption by the states. 32
The primary role for psychologists in this area is an advocacy one. A
major priority must be placed upon securing comprehensive, effective state
statutes; psychologists can play a valuable role in the coalition that is
needed to secure such regulation over the opposition of powerful construc-
tion and other business 10bbies.33 State acts sometimes provide for public
advisory boards, which may provide a role for psychologists. Perhaps most
importantly, the psychologist can playa critical role within whatever insti-
tution or community he or she lives and works to encourage the removal
of its environmental barriers. The psychologist also can assist handicapped
persons with whom he or she works to recognize that the barriers are out-
side of the handicapped individual and to encourage the person to become
involved in self-advocacy efforts.
EDUCATION
345ee, e.g., Pennsylvania Association for Retarded Children v. Pennsylvania, 334 F. Supp. 1257
(E.D. Pa. 1971); Mills v. Board of EducatiOn for the District of Columbia, 348 F. Supp. 866
(D.C.C. 1972); Fialkowski v. Shapp, 405 F. Supp. 946 (E.D. Pa. 1975).
35pub. L. 94-142, 89 Stat. 773, codified at 20 U.S.c. §§ 1401-61 (1976).
36 20 U.S.c. § 1412 (1976).
37 20 U.S.c. § 1416 (1976).
38F. Weintraub, A. Abeson, & D. Braddock, State Law and Education of Handicapped Chil-
dren 11 (1971); S. Herr, The Right to An Appropriate Free Public Education, The Mentally
Retarded Citizen 252.
39 A current listing of state special education statutes is contained in T. Overcast & B. Sales,
ber of articles discussing them are available. 4U State statutes, regulations, and
plans vary considerably, but they should be available from each state's edu-
cation agency.
Second, severe ethical strains can develop. Conversion of the educa-
tional system from one that excludes handicapped children to one that
serves them is administratively, fiscally, and psychologically (for school
personnel) burdensome. Thus, in individual cases handicapped children or
their parents demanding appropriate services can find themselves in an
adversary posture to the school administration. The psychologist employed
by or paid on contract with the school system sometimes will be expected
by school officials to maintain a protective posture for the school. It can be
difficult to recommend expensive services that the psychologist knows the
school lacks. Nevertheless, the criteria for evaluation and recommendation
are the child's needs and the appropriate services for the child.
Third, the operative term in this law is handicapped child. The term
developmentally disabled is not used. "Handicapped child" is defined as
mentally retarded, hard of hearing, deaf, speech impaired, visually handi-
capped, seriously emotionally disturbed, orthopedically impaired, or other
health impaired children, or children with specific learning disabilities, who by
reason thereof require special education and related services. 41
.oE.g., S. Blakely, Judicial and Legislative Attitudes toward the Right to an Education for the Handi-
capped, 40 Ohio State 1. J. 603 (1979); Note, The Education of all Handicapped Children Act of
1975,1976 Mich. J. 1. Ref. 110.
41 20 U.S.c. § 1401(1) (1976).
psychologists. They then have the opportunity to see that the educational
system is aware of the child and can serve his or her needs, thus often alle-
viating some of the cause for familial concern.
2. Evaluation of handicap. A critical step in planning appropriate educa-
tional services is the accurate diagnosis of the handicapping condition.
Often psychologists are uniquely capable of assisting in this evaluation pro-
cess. Several different sorts of evaluation are called for by the federal law.
They can be categorized as preplacement evaluation, periodic reevaluation,
and independent evaluation. The law requires that every handicapped
child be evaluated prior to placement in special education services. 45 This
evaluation must be conducted by a multidisciplinary team46 and will gen-
erally be conducted by school personnel or persons on contract to the
school system. The school psychologist will often be a part of that team.
Where it is thought that the child may have a "specific learning disability,"
the regulations require that testing be done by a person professionally qual-
ified to do so. Psychologists are specifically mentioned. 47
The law also requires periodic reevaluations. These must be conducted
at least once every three years and more often at the request of the parents. 48
Provision is also made for independent evaluations, that is, evaluations
by persons other than school personnel or contract personnel. 49 Where the
independent evaluation differs from the school's evaluation and is utilized
to alter the placement suggested, the independent evaluation is to be at
public expense. 50 State law can provide for these to be at public expense in
other cases as well. In any case, a parent is entitled to secure an independent
evaluation and to have these considered by the placement team and any
hearing officer upon appeal. This is a critical role for the psychologist not
employed by the school system. The law requires the school system to keep
a list of persons qualified to conduct independent evaluations.51 Psycholo-
gists interested in this role should be sure they are included on such lists.
When parents have appealed a placement decision, the hearing officer also
may request an independent evaluation, in which case it is at public
expense.52
3. Development of the individual educational program (IEP). After the eval-
uation is completed, the law requires that a team prepare an individual edu-
cational program, specifying the services required by the child. 53 These
defines the latter to include "special education and related services to meet
their unique needs."61 "Related services" include "psychological services,"62
which are defined to include:
a. Administering psychological and educational tests and other assess-
ment procedures
b. Interpreting assessment results
c. Obtaining, integrating, and interpreting information about child
behavior and conditions relating to learning
d. Consulting with other staff members in planning school programs
to meet the special needs of children as indicated by psychological
tests, interviews, and behavioral evaluations
e. Planning and managing a program of psychological services, includ-
ing psychological counseling for children and parents63
10. Advocacy. Finally, it must be clear that within the educational con-
text the opportunities for the professional psychologist as advocate are
enormous. The transformation of the school system from an institution
excluding handicapped persons, or many of them, to one serving all hand-
icapped children requires creative advocacy.
Psychologists involved with children in the educational system will
have countless opportl,1nities to fashion prescriptive programs for handi-
capped children and to advocate their implementation. Effective interper-
sonal relations are essential to this process. Beyond that, the psychologist
can have a substantial impact by stressing the developmental potential of
the child that can be realized by, but only by, implementation of an effec-
tive educational plan for him or her. The psychologist also will have the
opportunity to identify recurrent problems within the educational system
that require systemic change to better serve all handicapped children.
Beyond the walls of the school, the psychologist who is armed with statis-
tics and illustrations from his or her experience can be an effective advocate
in the continuing efforts to secure appropriate laws to ensure effective edu-
cation for the handicapped and the appropriation of sufficient resources,
whether from the state legislature or through local tax levies.
ZONING
"O'Connor v. Donaldson, 422 U.S. 563 (1975) (refusal to reach right to treatment issue);
Southeastern Community College v. Davis, 442 U.S. 397 (1979) (restrictive interpretation of
prohibition against discrimination on the basis of handicap in 29 U.S.c. 794); Parham v. J.
R., 442 U.S. 584 (1979) (minimal due process protections approved in committing a child to
a state institution); Addington v. Texas, 441 U.S. 418 (1979) (proof beyond a reasonable
doubt not required for commitment on grounds that defendant is mentally ill and
dangerous).
72Comment, The Inapplicability of Municipal Zoning Ordinances to Governmental Land Uses, 19 Syr.
L. Rev. 698 (1968). The extent to which and manner in which the state can exercise this
power, however, has been challenged. Hillsborough Association for Retarded Citizens v.
Temple Terrace, 332 S.2d 610 (1976); Note, Governmental Immunity from Local Zoning Ordi-
nances, 84 Harv. L. Rev. 869 (1971).
13 Supra, n. 67.
14Por guidance in developing such ordinances, see R. Hopperton, Zoning for Community
Homes: A Handbook for Local Legislative Change (1975) and R. Hopperton, Zoning for
Community Homes: A Handbook for Municipal Officials (1975). These two publications are
available from the Ohio Developmental Disabilities Council, State Office Tower, Columbus,
Ohio.
75The coalition building process involved here is particularly delicate. On the one hand,
more substantial positive political support can be developed with a broad coalition. On the
other hand, political opposition can be considerably greater against a state or locallegisla-
tive approach embracing homes for offenders and addicts as well as persons who are devel-
opmentally disabled.
DEVELOPMENTAL DISABILITIES LAW 441
cated lobbying efforts. Again, coalition work must be the order of the day.
Psychologists can throw the personnel and fiscal resources of their local and
state associations behind these efforts. They also can become personally
involved through testimony, informal contacts, and letter writing. As on
many topics, the expertise and authority that psychologists can bring to
bear is important. Psychologists can testify to the needs of developmentally
disabled persons, their potential for productive lives in the community, and
the negative effect of segregation in institutions or urban ghettos.
86 5. Katz, R. Howe, & M. McGrath, Child Neglect Laws in America, 9 Family Law. Quarterly 1
(1975).
87 Stanley v. Illinois, 405 U.S. 645 (1972).
88e. Foote, R. Levy, & F. Sander, Cases and Materials on Family Law 64 (2d ed. 1976). M.
Wald, State Intervention on Behalf of "Neglected" Children: A Search for Realistic Standards, 27
Stan. 1. Rev. 985,1014 (1975).
444 MICHAEL KINDRED
sions rely explicitly upon that rationale for removing children from their
parents.
Two new concepts have appeared recently that may be signs of a more
interventionist approach. The first is "the best interest of the child."89 A
concept first developed for use in custody disputes between divorcing par-
ents, where the right of parenthood is equal/a it has since been utilized to
resolve conflicts between parents and the state or third parties.91 The diffi-
culty with its application in this context is that it permits the state to deter-
mine that any parent doing a passable job of parenting is not the best parent
that the child could have and that, therefore, "in the best interest of the
child" the child should be removed from the parents and placed in a pref-
erable home. While this may keep the concept from coming into general
use, there is a risk that it will be used in special cases where a judge feels
that a child should be removed from the home, but cannot find evidence of
the level of abuse or neglect that would generally be required for termi-
nation of parental rights. One well might fear that removal of a newborn
child from mentally retarded parents could be such a case, with stereotypes,
assumptions, and a novel legal doctrine replacing proof and analysis.
The second concept that has arisen is that of "intellectual stimulation"
as a requisite element of adequate parenting. In the case of In re McDonald,92
the Iowa Supreme Court said:
The juvenile court was "reluctantly convinced that because of this mother's
very low I.Q. she could never adequately take the proper care of their twins or
at least provide them with the stimulation in their home that they must have
to grow into normal healthy children." ... We conclude, as did the juvenile
court, that the best interests of the twins require termination [of the parental
tiesj.93
It is hard to imagine that the courts are prepared to examine whether par-
ents in general provide sufficient "stimulation" to their children and to
replace the parents if they do not. This seems to be a case of a rule having
been invented to intervene in the parent-child relationship where the par-
ent is mentally retarded. 94
89 See R. Drinan, The Rights of Children in Modern American Family Law, 2 J. Family L. 101 (1962);
Note, Alternatives to "Parental Right" in Child Custody Disputes Involving Third Parties, 73 Yale
L. J. 151 (1963); J. Goldstein, A. Freud, & A. Solnit, Beyond the Best Interests of the Child
(1973).
90Finlay v. Finlay, 240 N.Y. 429, 148 N.E. 624 (1925) (Cardoza, J.).
91 M. Paulsen, The Delinquency, Neglect, and Dependency Jurisdiction of the Juvenile Court in Justice
for the Child 68 (M. Rosenheim ed. 1962). McKay v. Ruffcorn, 247 Iowa 195,201,73 N.W.2d
78 (1955); Painter v. Bannister, 258 Iowa 1390, 140 N.w.2d 152 (1966); In re McDonald, 201
N.w.2d 447, 453 (1972).
92In re McDonald, 201 N.W.2d 447 (1972).
93Id. at 453.
94 [Pjarental "inadequacy" in and of itself should not be a basis for intervention, other than
the offer of services available on a truly voluntary basis. The term "inadequate home" or
"inadequate parent" is even harder to define than emotional neglect. There is certainly no
consensus about what types of "inadequate" behavior would justify intervention. Given
the vagueness of the standard, almost unlimited intervention would be pOSSible. Wald,
supra n. 88 at 1022.
DEVELOPMENTAL DISABILITIES LAW 445
Because the laws governing this topic speak in general and nondiscri-
minatory terms and are designed to serve a generally legitimate purpose, it
is unlikely that the solution is to be found in legislative reform. Neverthe-
less, critical roles exist for the psychologist. Counseling is primary. Where
a developmentally disabled individual is considering the possibility of hav-
ing a child, the psychologist may well want to explore the ramifications of
that decision. The ability of the potential parent to fill the contemplated
role may need to be explored. Where a developmentally disabled person
chooses not to have children because of difficulties contemplated in child
raising, or for any other reason, counseling about the ways to prevent par-
enthood needs to be explored. Where a developmentally disabled person is
about to assume a parenting role, the psychologist can be helpful in arrang-
ing for training in child care skills.
The psychologist also may have a role where state intervention is con-
templated. The first possible role is a general, educational one. Social work-
ers and judges who might be involved in the intervention process need to
learn that developmentally disabled persons often can be perfectly com-
petent parents and that the same standards of adequate parenting and pre-
sumptions of competence should be applied to them. Second, the psychol-
ogist can be important in the context of an active attempt to terminate the
parental rights of a developmentally disabled person. In some situations the
court may be authorized to order an evaluation of the home situation. The
psychologist must be prepared to examine how the home is functioning, to
describe the functional adequacy of the home objectively (without pre-
sumptions that the fact of disability may decrease the parenting ability), to
look for special strengths in the home environment that may relate to the
parent's handicap, and to prescribe support steps that might be taken by
social service agencies to assist the parent in functioning more adequately.
Of course, where the psychologist concludes that the child is neglected or
dependent in the usual legal sense of that term and that social service assis-
tance cannot remedy the situation, it is necessary to report that fact to the
court. The psychologist also may be called into the situation by the parent
or someone on the parent's behalf before the situation has reached the lit-
igation stage or in preparation for litigation. Here, as in the case where the
psychologist is appOinted by the court, it may be possible to affirm positive
aspects of the parenting situation and to prescribe social service assistance
or training in parental skills that may make the person a clearly adequate
parent and prevent the issue of separation from arising.
The issue of family planning has been mentioned at several points in
this section. This touches on a very emotional topic, and a difficult legal one:
sterilization. The nature of the legal issue will depend on state law, which
varies considerably from state to state.95 Some states have laws permitting
the sterilization of mentally retarded persons without their consent, upon
the authorization of a public official or private guardian, sometimes with
95For a discussion of the history of sterilization laws and a survey of state statutes, see Brakel
& Rock 207.
446 MICHAEL KINDRED
96Ruby v. Massey, 452 F. Supp. 361 (D. Conn. 1978); In re 1. G., 170 N.J. Super. 98, 405 A.2d
851 (1979).
97Skinner v. Oklahoma, 316 U.s. 535 (1942).
98 See notes 80-82 supra.
I02See generally S. Fox, The Law of Juvenile Courts in a Nutshell (2d ed. 1977); S. Fox, Cases
and Materials on Modern Juvenile Justice (1972).
I03Miranda v. Arizona. 384 U.S. 436, 448-454 (1966).
104ld.
losEscobedo v. Illinois, 378 U.S. 478 (1964); Miranda v. Arizona, 384 U.S. 436 (1966).
448 MICHAEL KINDRED
long required that, in order for a person to be tried for a criminal offense,
the person must be capable of understanding the nature of the proceedings
and cooperating with defense counse1. 108 The Supreme Court has said that
this concept is constitutionally mandated. 109 The issue can be raised by
either the prosecutor or the defense counsel; a judge with reason to doubt
the competence of a defendant before him has a constitutional obligation
to inquire into the matter llO and order an evaluation. Psychologists often
are asked to perform such evaluations. If the person is found competent
after evaluation, the trial proceeds. If he or she is found incompetent but
treatable to regain competence within a reasonable time, a period of treat-
ment may be ordered. Psychologists may be involved in such treatment. If
the person is found permanently incompetent, confinement is permissible
only pursuant to civil commitment procedures. lll (For greater detail on
incompetency in general, see Chapter 12.)
Another issue that can arise, and can involve psychological evaluation,
is the defendant's criminal responsibility. In most jurisdictions this issue
only can be raised by the defendant. The tests for criminal responsibility
vary from state to state, but a common one is whether flat the time of such
conduct as a result of mental disease or defect he lacks substantial capacity
either to appreciate the wrongfulness of his conduct or to conform his con-
duct to the requirements of the law."ll2 Some jurisdictions also have
adopted the concept of partial or diminished capacity that calls for explo-
ration of whether, for example, a defendant accused of first degree homi-
cide was capable of premeditation. ll3 Expert testimony from psychologists
may be admissible on either of these issues. (For greater detail, see Chapter
12.)
Once a conviction has been obtained, or an individual has been found
to lack either capacity to stand trial or criminal responsibility, questions of
disposition arise. Where the person is found incompetent or not responsi-
ble, a further evaluation and hearing may be required to determine
whether he or she fits requirements for confinement outside of the penal
system. Where he or she is convicted, the court will have to make decisions
I09Drope v. Missouri, 420 U.S. 162 (1975); Pate v. Robinson, 383 U.S. 375 (1966); Bishop v.
United States, 350 U.S. 961 (1956).
lloDrope v. Missouri, 420 U.S. 162 (1975); Pate v. Robinson, 383 U.S. 375 (1966). There is a
risk of prosecutors raising the issue to avoid a trial on a weak case, since a finding of incom-
petence to stand trial can result in at least some period of incarceration without trial or
conviction.
lllJackson v. Indiana, 406 U.S. 715 (1972).
U2American Law Institute, Model Penal Code § 4.01(1) (Proposed Official Draft, 1962). See
generally J. Goldstein, The Insanity Defense (1967); H. Weihofen, Mental Disorder as a
Criminal Defense (1954).
113See generally W. LaFave & A. Scott, Jr., Handbook on Criminal Law 325 (1972); P. Arenella,
"The Diminished Capacity and Diminished Responsibility Defenses: Two Children of a
Doomed Marriage," 77 Colum. L. Rev. 827 (1977).
450 MICHAEL KINDRED
PROHIBITION OF DISCRIMINATION
I21T. Gilhool, The Right to Community Services, The Mentally Retarded Citizen 173, supra
note 2.
452 MICHAEL KINDRED
The Court makes it clear, if it were not before, that there is an "unrea-
sonableness" dimension to discrimination. A psychologist can aid greatly
in the demonstration that exclusions and barriers to inclusion are unreason-
able by evaluations that emphasize graphically the positive competencies
123 442 U.S. 397 (1979) [cite to be filled in, case #78-711, decided 6-11-79]
124!d. at 414.
125ld. at 410.
126ld. at 412-413.
454 MICHAEL KINDRED
OTHER AREAS
There are a considerable number of other areas in which the law deals
with developmentally disabled individuals in such a way that the evalua-
tive and treatment skills as well as the advocacy skills and advisory wisdom
of psychologists can be of great importance. Guardianship and conservator-
ship proceedings require judgments about competence. Welfare entitle-
ments and vocational rehabilitation eligibility may require expert evalua-
tion of disability. Within residential programs and community sheltered
workshop programs psychological evaluation and program prescription
may be of vital importance. And, of course, to the extent that civil commit-
ment still exists, psychologists may be asked to evaluate the suitability of a
developmentally disabled person for institutional confinement.
CONCLUSION
130Virginia Pharmacy Board v. Virginia Consumer Council, 425 U.S. 748 (1976).
14
Malpractice Liability of Psychologistsl
R. KIRKLAND GABLE
1Because of the rapidly changing law in the area of malpractice and the diversity of decisions
in various jurisdictions, this chapter can present legal principles only in broad outline. If
legal advice or other expert assistance is required, the services of a competent professional
person should be sought.
2Insurance losses through malpractice suits against psychologists show great variability from
year to year but gradually and significantly have increased, e.g., approximately $13,000 loss
in 1964 to about $134,000 loss in 1973. (The loss in 1970 was approximately $260,000. This
resulted from the payment in one case of $210,000 paid in 1974, but aSSigned to 1970, the
year the claim was initiated.) Recent claims have run as high as $2,000,000.
457
458 R. KIRKLAND GABLE
MALPRACTICE-NEGLIGENCE SUITS
GENERAL INTRODUCTION
3See, Dawidoff, D. J. The Malpractice of Psychiatrists. Springfield, Ill.: Thomas, 1973, pp. 15-18;
Tarshis, C. B. Liability for psychotherapy. Faculty of Law Review, 1972,30,75-96.
'Feldman, W. S. The courts and the lallapaluza rule. Journal of Psychiatry and Law, 1976,4,
535-550.
5 ld. at 535-537.
6Sauer, J. G. Psychiatric malpractice-A survey. Washburn Law Journal, 1972,2, 461-470, p.
461.
MALPRACTICE LIABILITY OF PSYCHOLOGISTS 459
7See, Heller, M. S. Some comments to lawyers on the practice of psychiatry. Temple Law Quar-
terly, 1957, 30, 401-407, p. 402; Rothblatt, H. B., & Leroy, D. H. Avoiding psychiatric liability.
California Western Law Review, 1973,9,260-272, p. 263.
8See, e.g., Fernandez v. Baruch, 244 A.2d 113 (N.H. 1968).
9Tarshis, supra note 3, at 82.
lOSee, e.g., Shier v. Freedman, 206 N.W.2d 166, 174 (Wise. 1973); Pederson v. Dumouchel, 431
P.2d 973 (Wash. 1967) (en bane); Duckworth, G. F. Torts: Medical malpractice: Expert testi-
mony as affected by the "locality rule." Oklahoma Law Review, 1973, 26, 296-300, p. 300;
Tarshis, supra note 3, at pp. 82-83.
460 R. KIRKLAND GABLE
does not refer to an arithmetic mean. That would automatically make one-
half of the practitioners below average and thus legally negligent. It would
be more reasonable to interpret average to mean usual or customary.l1
In the past, practitioners were required to meet the usual and custom-
ary standards of practice within their own or similar localities. This was
known as the "locality rule." Among the reasons for it was the belief that
it would be unfair to hold the small-town practitioner to the same standard
as the practitioner in the more sophisticated urban area. This rule, however,
now has been substantially eroded!2 since most courts now look to the
nationally accepted or customary standards of the practitioner's particular
school of practice.!3 The locality may, however, still be considered as a factor
that might allow some modification or interpretation of the national stan-
dards. For example, some localities may not have resources available that
are necessary to meet those national standards usually considered desirable
and thus it may be unfair to penalize the practitioner.
Although the legally required standard may vary from jurisdiction to
jurisdiction, it is quite clear that the psychologist does not have to be the
best or the most skilled practitioner in his or her particular school of prac-
tice.!4 There is room for professional judgment, even error, before malprac-
tice liability may be imposed upon the practitioner. Yet, practitioners who
claim to be specialists are held to higher standards than the usual practi-
tioner. IS This is because it is reasonable to expect that a specialist has more
than customary skill in dealing with a disorder or problem. Typically, spe-
cialists have been required to use the care and skill customarily used by
other similar specialists throughout the country. As noted in Robbins v.
Footer/ 6 "Specialists are required to exercise that degree of care and skill
expected of a reasonably competent practitioner in his specialty acting in
the same or similar circumstances."
A person is held to the standard of care and skill of a specialist if that
person claims to be a specialist. Thus, for example, a psychologist who
claims to be a specialist in treating enuresis will be expected to be generally
as competent as other psychological specialists in the country who treat this
disorder. The psychologist will be held to this higher-than-usual national
standard regardless of whether he or she has had specialized training in the
treatment of the disorder.
IlDeleon, P. H., & Borreliz, M. Malpractice: Professional liability and the law. Professional
Psychology, 1978,9,467-477, p. 468.
12Chayet, N. L. Malpraetice-a break with the past. New England Journal of Medicine, 1968,278,
1275-1276.
13See, e.g., Pederson v. Dumouchel, 431 P.2d 973 (Wash. 1967) (en bane); Brune v. Belinkoff,
235 N.E.2d 793 (Mass. 1968); Robbins v. Footer, 553 F.2d 123 (D.C. Cir. 1977).
1fTarshis, supra note 3, at 82-83; Johnson v. United States, 409 F. Supp. 1283, 1292 (M.D. Fla.
1976).
15See, e.g., Kronke v. Danielson, 499 P.2d 156 (Ariz. 1972).
16 553 F.2d 123, 129 (D.C. Cir. 1977).
MALPRACTICE LIABILITY OF PSYCHOLOGISTS 461
given for the pain, no X-rays were taken to determine its cause and electro-
shock treatments were continued and increased in intensity and duration.
After discharge from the hospital, the patient was found to have a com-
pressed fracture of the ninth vertebra. The Committee on Therapy of the
APA had 10 years prior to the suit prepared a document entitled "Standards
for Electroshock Treatment" which had been approved by the Council of
the APA. This document read in part, "If the patient should complain of
pain or impairment of function, he should receive a physical examination,
including X-rays, to ascertain whether he has suffered accidental damage."2!
The Supreme Court of North Carolina concluded that the psychiatrist's fail-
ure to follow the "Standards for Electroshock Treatment" could be used as
evidence of malpractice.
The code of ethics of the profesional organizations to which practition-
ers belong also may be used by the courts to help determine the standard
of care required. Ethical standards are not, however, directly usable as legal
standards in determining negligence. As Tarshis observes,
The real problem is to what extent the ethics can be relied to be a guide to the
court in defining a standard of care. Their generality is self-defeating. There is
nothing that is directly and uniquely applicable to psychotherapy. The precepts
are directed at unethical behavior, not negligent behavior, and the two tests
may give different results. Ethical standards may be more or less rigorous than
negligent standards depending on the circumstances. However, they may still
be useful as corroborative of a reasonable standard of practice. 22
21Id. at 298.
22Tarshis, supra note 3, at 84.
MALPRACTICE LIABILITY OF PSYCHOLOGISTS 463
methods to use in treating a patient, and will not be liable for honest mis-
takes or errors of judgment so long as he was exercising a reasonable degree
of care and skill."23
Yet, although a practitioner may follow the generally accepted and cus-
tomary standards of practice, there may nevertheless be some small risk of
liability. This may result from the application of the so-called Lallapaluza
Rule previously mentioned. The court determines the standard to apply
even if that standard is beyond that of customary pracitce. For example, in
a well-known case imposing liability upon a hospital, Darling v. Charleston
Community Memorial Hospital,24 the Illinois Supreme Court agreed with the
hospital that it had followed the usual standard of practice. The court con-
cluded, however, that there are occasions when "a whole calling may have
unduly lagged" and a higher standard must be judicially imposed. 25 The
hospital was found liable. In an earlier case,26 a court decided that even
though it was customary for surgeons to accept the count of sponges made
by nurses this was not an acceptable procedure. A sponge left in the abdo-
men of the patient was negligent practice and the surgeon could be found
liable for malpractice.
More recently, the Supreme Court of Washington determined that two
ophthalmologists in joint practice were negligent for failing to give a
patient under 40 years of age a pressure test to determine glaucoma. 21 The
defendant argued that the generally accepted standard of professional prac-
tice did not require the giving of routine pressure tests to persons under 40
because the risk of glaucoma is rare in this lower age group. (Approximately
one person out of 25,000 under 40 may have glaucoma.) The court noted
that the test for glaucoma is simple, relatively inexpensive, and involves no
judgment. It then concluded, "Under the facts of this case reasonable pru-
dence required the timely giving of the pressure test to this plaintiff. The
precaution of giving this test to detect the incidence of glaucoma to patients
under 40 years of age is so imperative that irrespective of its disregard by
the standards of the opthalmology profession, it is the duty of the courts to
say what is required to protect patients under 40 from the damaging results
of glaucoma.,,28
23Johnson v. United States, 409 F. Supp. 1283, 1292 (M.D. Fla. 1976). See also Johnston v. Rodis,
151 F. Supp. 345 (D. D.C. 1957). rev'd on other grounds, 251 F.2d 917 (D.C. Cir. 1958); Slov-
enko, R. Psychiatry and law. Boston: Little, Brown, 1973, pp. 407-408.
24211 N.E.2d 253 (Ill. 1965).
2SId. at 257 citing the T. J. Hooper case, 60 F.2d 737, 740 (2nd Cir. 1932). In that famous case,
Judge Learned Hand wrote the decision in which it was decided that custom alone could
not establish the required standard. Tug boats such as the "Hooper" usually did not have
radio receiving sets to obtain weather reports but they were legally required to have them
in order to avoid loss and accidents. The T. J. Hooper, 60 F.2d 737, 740 (2nd Cir. 1932).
26 Ales v. Ryan, 64 P.2d 409 (Cal. 1936). See also Morgan v. Sheppard, 188 N.E.2d 808 (Ohio
Ct. App. 1963).
27Helling v. Carey, 519 P.2d 981 (Wash. 1974).
28 ld. at 983.
464 R. KIRKLAND GABLE
Finally, Roston and Sherrer9 have noted that an accountant was found
liable even though he followed "generally acceptable accounting princi-
ples." In commenting on this case, they suggest that the accountant's legal
defense that he followed acceptable practice "would be roughly comparable
to a psychologist defending his actions by alleging that he complied with
the professional and ethical standards of the American Psychological Asso-
ciation and had used his skills and abilities as most other psychologists
would."30
DERELICTION OF DuTY
29Roston, R. A., & Sherrer, C. W. Malpractice: What's new. Professional Psychology, 1973,4,
270-276.
3lJld. at 271.
31Slovenko, supra note 23, at 405.
32 E.g., Rothblatt and Leroy, supra note 7, at 268.
MALPRACTICE LIABILITY OF PSYCHOLOGISTS 465
be liable for either malpractice or battery (discussed later). The claim for
malpractice in this situation is the more common and current view.33 The
practitioner is considered negligent because practitioners have a duty (and
it is a generally accepted and customary practice) to provide adequate infor-
mation to the prospective patient.
Granting that some information must be given to a prospective patient
prior to obtaining consent, the issue becomes one of determining what that
information is. Although the legal requirements here are blurred and vary
from jurisdiction to jurisdiction, some guidelines might be suggested. The
relationship between the practitioner and the patient should be one of can-
dor and trust. It is sometimes said to be a "fiduciary" relationship in which
the practitioner must take particular care to be honest, fair, and concerned
with the welfare of the patient or client.34 In Cobbs v. Grant, 35 the Supreme
Court of California summarized the duty of disclosure in the following
manner:
[T]he patient's right of self-decision is the measure of the physician's duty to
reveal. That right can be effectively exercised only if the patient possesses ade-
quate information to enable an intelligent choice. The scope of the physician's
communications to the patient, then must be measured by the patient's need,
and that need is whatever information is material to the decision. Thus the test
for determining whether a potential peril must be divulged is its materiality to
the patient's decision.
alE.g., Shetter v. Rochelle, 409 P.2d 74, 86 (Ariz. 1965); Aiken v. Clary, 396 S.W.2d 668 (Mo.
1965); Miller v. Kennedy, 522 P.2d 852 (Wash. Ct. App. 1974); Wilson v. Scott, 396 S.W.2d
532 (Tex. Cir. App. 1965), aff'd. 412 S.W.2d 299, 301, 302 (1967); Aden v. Younger, 120 Cal.
Rptr. 535 (Calif. Ct. App. 1976) (dicta). Edwards, S. L. Failure to inform as medical malprac-
tice. Vanderbilt Law Review, 1970, 23, 754-774.
34See, e.g., Miller v. Kennedy, 522 P.2d 852, 860 (Wash. Ct. App. 1974); Dawidoff, supra note
4, Chapter IV, at 43-60.
35Cobbs v. Grant, 502 P.2d 1, 11 (1972) (en banc). To impose liability, there must be a causal
relationship between the failure to inform and the plaintiff's injury, i.e., proof that had the
plaintiff been fully informed he (or a prudent person) would not have consented to the
treatment. Id. at 11-12.
36See, e.g., Getchell v. Mansfield, 489 P.2d 953, 956 (Or. 1971); Mitchell v. Robinson, 334
S.W.2d 11 (Mo. 1960); Meisel, A. The expansion of liability for medical accidents: From
negligence to strict liability by way of informed consent. Nebraska Law Review, 1977, 56, 51-
152 (argues that the doctrine of informed consent is moving toward imposing liability upon
physicians that is similar to strict liability); Edwards, supra note 33, at 770.
466 R. KIRKLAND GABLE
37Holland v. Sisters of Saint Joseph of Peace, 522 P.2d 208, 211-212 (Or. 1974) (en banc),
quoting Waltz, J. R., and Scheuneman, T. W. Informed consent to therapy. Northwestern
University Law Review, 1969,64,638,640.
38Wilkinson v. Vesey, 295 A.2d 676, 689 (R.1. 1972).
39Id.
patient should be informed about (1) the diagnosis or purpose of the treat-
ment, (2) the nature and duration of the treatment, (3) the risks involved,
(4) the prospects of success or benefit, (5) possible disadvantages if the treat-
ment is not undertaken, and (6) alternative methods of treatment. 47
Focusing specifically upon treatment using behavior modification pro-
cedures, Tryon48 has discussed the disclosure necessary for informed con-
sent after treatment goals and options have been considered. He suggests
the following:
The therapist should describe the procedures that constitute the various treat-
ments, the length of time that treatment will require, the cost of such treatment,
and any possible side effects that could reasonably be expected to occur as a
result of the treatment. For example, if parents were being counseled to extin-
guish a child's temper tantrums by ignoring this behavior, then the parents
should also be told that extinction initially produces increased variability and
intensity of response; hence, the parents should expect the temper tantrums to
increase before they decrease. The parents should also be told that the child
may attempt to modify the parents' behavior with some new form of undesir-
able behavior. If aromatic ammonia (smelling salts) were to be used as the
unconditioned stimulus in an olfactory aversion treatment, then the client
would have to be told that repeated inhalation of aromatic ammonia can cause
vasodilatation and thereby produce headaches and nasal irritation.49
47 Adapted from Louisell, D. W., & Williams, H. Medical malpractice. New York: Matthew
Bender, 1960, § 22.01.
48Tryon, W. W. Behavior modification and the law, Professional Psychology, 1976,7,468-474.
49 Id. at 471.
SIlsee generally, Woods, v. Brumlock, 377 P.2d 520 (N. Mex. 1962); Wilkinson v. Vesey, 295
A.2d 676 (R.I. 1972); Louisell & Williams, supra note 47, at § 22.02; Pappas, G. Informed
consent: A malpractice headache. Chicago-Kent Law Review, 1970,47,242-252, p. 250.
51 See, Wilkinson v. Vesey, 295 A.2d 676, 689 (R.l. 1972).
52Edwards, supra note 33, at 770.
53see Cobbs v. Grant, 502 P.2d 1 (Calif. 1972) (en bane); Aden v. Younger, 129 Cal Rptr. 535
(Calif. Ct. App. 1976) (dicta).
468 R. KIRKLAND GABLE
54A specific finding of this type may be particulary necessary in those states that do not
include as a commitment criterion the patient's lack of insight or capacity to make treatment
decisions. In those states that do include this criterion for commitment, e.g., Hawaii, South
Carolina, and Utah, or provisions for treatment, e.g., Kansas, Michigan, and North Dakota,
a reasonable inference may be made that standard forms of nonintrusive treatment may be
conducted with nonprotecting committed patients. A table of state commitment criteria in
the 50 states and the District of Columbia may be found in Schwitzgebel, R. K., Survey of
state civil commitment statutes, in McGarry, A. L., Schwitzgebel, R. K., Lipsitt, P. D., &
Lelos, D. Civil commitment and social policy. Washington, D.C.: National Institute of Health
(Center for Studies of Crime and Delinquency), GPO, 1981.
55In situations where the consent is inferred and the patient expressly or indirectly refuses
to cooperate in treatment, express consent should be obtained from the court or a court-
appointed guardian or committee.
56See text infra at notes 89 to 100.
57Slovenko, supra note 23, at 399.
MALPRACTICE LIABILITY OF PSYCHOLOGISTS 469
"'[d. at 496-497. See also, Johnson v. United States, 409 F. Supp. 1283,1293 (M.D. Fla. 1976)
(prolonged commitment to be avoided).
60 247 F.2d 711 (3rd Cir. 1957); see also Stone v. Proctor, 131 S.E.2d 297 (N.C. 1963) text at supra
note 20.
61 See, e.g., Kleber v. Stevens, 241 N.Y.S.2d 497 (Sup. Ct. 1963). But many states provide priv-
ilege or immunity for practitioners involved in the judicial commitment process. For a
detailed discussion of malpractice and involuntary commitment, see Dawidoff, supra note
3, Chapter VIII, pp. 98-128.
62See, e.g., O'Rourke v. O'Rourke, 50 So.2d 832 (La Ct. App. 1951); Daniels v. Finney, 262
S.W.2d 431 (Tex. Civ. App. 1953).
63Bacon v. Bacon, 24 So. 968 (Miss. 1899).
MSee, e.g., Kleber v. Stevens, 241 N.Y.S.2d 497 (Sup. Ct. 1963) (vindictive husband).
65See, e.g., Beckham v. Cline, 10 So.2d 419 (Fla. 1942).
66S ee, e.g., DiGiovanni v. Pessel, 250 A.2d 756 (N.J. 1968); Kleber v. Stevens, 241 N.Y.S.2d 497
(Sup. Ct. 1963).
67 323 N.Y.S.2d 56 (Ct. Cl. 1971).
470 R. KIRKLAND GABLE
68 181 N.Y.S.2d 805 (Sup. Ct. 1959), modified, 198 N.Y.S.2d 65, 165 N.E.2d 756 (Ct. App. 1960)
(no liability imposed on claims of fraud and breach of contract). Note that plaintiffs alleging
physical contact have relied upon a wide variety of legal theories in addition to malpractice.
69 Id. 165 N.E.2d at 757.
7°E.G., Traver v. Feinstein, 331 N.Y.S.2d 150 (App. Div. 1972); Davis v. N.Y., 332 N.Y.S.2d 569
(N.Y. 1972).
71Abraham v. Zaslow, 1 Civil 33219, Sup. Ct. No. 245862 (Cal. Ct. App. Feb. 2,1975). See also
Psychologist faces malpractice charges. APA Monitor, September 1972, 3, 1.
MALPRACTICE LIABILITY OF PSYCHOLOGISTS 471
and beaten and couldn't get out of the situation."n After the session, she
allegedly suffered from acute anxiety, bruises, vomiting, and temporary
renal failure of both kidneys. The appellate court affirmed a judgment
against the psychologist because, in part, the treatment did not conform to
an acceptable standard of care.
Sexual relationships with patients or clients, although sometimes advo-
cated as therapeutically acceptable,73 have not been approved by the psy-
chiatric or psychological professions. The 1977 revision of the Ethical Stan-
dards of Psychologists expressly states that "Sexual intimacies with clients are
unethical.,,74 In the case of Zipkin v. Freeman/ 5 the psychiatrist took advan-
tage of a patient who "fell in love" with him. Not only was sexual intimacy
involved, but he also induced the patient to live with him and work on his
farm. She was encouraged to sue her husband and steal from him. On one
occasion, the psychiatrist gave her a pistol and directed her to go to her
husband's home where she was to "shoot anyone who got in the way and
to take anything she might want."76 This, of course, goes far beyond accept-
able practice.
In Roy v. Hartogs,77 a psychiatrist allegedly administered sexual inter-
course to a woman for over one year to cure her lesbianism. He was found
liable for malpractice. Sexual intercourse under the guise of treatment has
consistently resulted in civil liability and sometimes has led to criminal
charges of rape, seduction, assault, and battery, or criminal conversation
(wrongful appropriation of another person's property). The plaintiff in Roy
claimed she was misled. However, a dissenting judge noted that the plain-
tiff's mental competency was not at issue. "Is it not fair to infer, therefore,
that she was capable of giving a knowing and meaningful consent? For
almost one and a half years while this 'meaningful' relationship continued,
the plaintiff was not heard to complain. Upon the defendant terminating
the relationship, this lawsuit evolves."78 While consent does not eliminate
liability for malpractice, it may reduce the likelihood of legal actions based
upon other legal theories such as deception or unconsented touching, such
as assault and battery.
72 Id. at 3.
73E.g., Shepard, M. The love treatment: Sexual Intimacy Between Patients and Psychotherapist. New
York: Wyden, 1971.
74 American Psychological Association, Ethical Standards of Psychologists. Washington, D.C.:
76Id. at 759.
77366 N.Y.S.2d 297 (N.Y.C. Civ. Ct. 1975); 381 N.Y.S.2d 587 (Sup. Ct. App. Term 1976). The
defendant psychiatrist presented evidence of a physical disability that would not have per-
mitted him to have sexual intercourse with the patient. Nevertheless, the patient was
awarded $153,679.50 in damages. A later court asserted that the defendant "prescribed and
personally administered multiple, repetitive doses of 'fornicatus Hartogus' to the patient."
Hartogs v. Employers Ins., 89 Misc. 2d 468 (N.Y. Sup. Ct. 1977).
78Id. at 591.
472 R. KIRKLAND GABLE
8°Hawaii District Court, Honolulu, Docket No. 38745 (Nov. 19, 1973).
81Kardener, S. H., Fuller, M., & Mensh, I. N. A Survey of physicians' attitudes and practices
regarding erotic and nonerotic contact with patients. American Journal of Psychiatry, 1973,
130, 1077-1081; Kardener, S. H. Sex and the physician-patient relationship. American Jour-
nal of Psychiatry, 1974, 131, 1134-1136. A sample of 114 psychiatrists indicated that 5% of
those responding had engaged in sexual intercourse with patients.
82Wagner, N. Ethical concerns of medical students. Paper read at the 1972 Western Workshop
of the Center for Sex Education in Medicine, Santa Barbara, Calif., 1972. Cited in Kardener,
supra note 81.
83Kardener, supra note 81.
84Kardener, supra note 81, at 1136. (Berne, E. Principles of Group Treatment. New York: Oxford,
1966, p. 358 as cited in Kardener).
8SHolroyd, J. c., & Brodsky, A. M. Psychologist's attitudes and practices regarding erotic and
nonerotic physical contact with patients. American Psychologist, 1977, 843-849.
MALPRACTICE LIABILITY OF PSYCHOLOGISTS 473
86Leroy, D. H. The potential criminal liability of human, sex clinics and their patients. Saint
Louis University Law Journal, 1972, 16,586-603.
B7Perr, I. N. Legal aspects of sexual therapies. The Journal of Legal Medicine, 1975,3,33-38.
88 Id. at 98.
B9See, e.g., Hunt v. King County, 481 P.2d 593 (Wash. Ct. App. 1971). A useful listing of cases
appears in Slovenko, supra note 23, at 425-426.
90See Schwartz, V. E. Civil liability for causing suicide: A synthesis of law and psychiatry.
Vanderbilt Law Review, 1971, 24, 217-256, p. 246.
91See discussion in Perr, I. N. Suicide and civil litigation. The Journal of Forensic Sciences, 1974,
19,261-266.
92 244 A.2d 109, 112 (N.J. 1968) (psychiatrists not liable for release of a patient to the police
who four days later committed suicide).
474 R. KIRKLAND GABLE
the hospital on the theory that they failed to confine and supervise a dan-
gerous mental patient.
Cases such as these, however, reflect the exception rather than the gen-
eral rule in judicial decisions. The usual standard is whether a hospital or
practitioner followed that degree of care that a reasonably prudent person
would have exercised under the same or similar circumstances. This stan-
dard may take into account the uncertainties of psychiatric analysis and
"negligence may not ordinarily be found short of serious error or mistake,
and not necessarily when the error or mistake is serious."97 An illustrative
case is Johnson v. United States. 98 In this case, a released mental patient killed
his brother-in-law, wounded his wife, and committed suicide. The patient
received extensive evaluation and treatment prior to his release, but there
was an error in assessment with regard to his future dangerousness. In view
of the difficulty of predicting dangerousness and the current "open door"
policy of hospitals, the court found no liability. In the words of the Johnson
court:
Modern psychiatry has recognized the importance of making every reasonable
effort to return a patient to an active and productive life. Thus, the patient is
encouraged to develop his self-confidence by adjusting to the demands of
everyday existence. In this view, mental hospitals are not seen as dumping
grounds for all persons whose behavior society might find inconvenient or
offensive; institutionalization is the exception, not the rule, and is called for
only when a paramount therapeutic interest or the protection of society leaves
no choice. Furthermore, all the expert witnesses for both parties agreed that
accurate predictions of dangerous behavior, and particularly of suicide and
homicide, are almost never possible. Especially in view of this fact, the Court is
persuaded that modern psychiatric practice does not require a patient to be iso-
lated from normal human activities until every possible danger has passed.
Because of the virtual impossibility of predicting dangerousness, such an
approach would necessarily lead to prolonged incarceration for many patients
who could become useful members of society. It has also been made clear to the
Court that constant supervision and restriction will often tend to promote the
very disorders which they are designed to controL This is especially true when
the patient is suffering from paranoia and might view his custodians as mem-
bers of a "paranoid pseudo community" which is forming against him. On the
other hand, despite the therapeutic benefits of this "open door" approach, the
practice admittedly entails a higher potential of danger both for the patient and
for those with whom he comes in contact ....
The Court is aware that some psychiatrists adhere to the older, more cus-
todial approach. However, it has been proved to the Court's satisfaction that the
"open door" policy and the judgmental balancing test are an accepted method
of treatment. Therefore, no liability can arise merely because a psychiatrist
favors the newer over the older approach. 99
97Hicks v. United States, 511 F.2d 407, 417 (D.C. Cir. 1975).
98 409 F. Supp. 1283 (M. D. Fla. 1976) (the court noted the difference in facts between this case
and those in Merchants Nat'l Bank & Trust Co. v. United States, 272 F. Supp. 409 [D.N.D.
1967] wherein liability was found).
99 ld. at 1293.
476 R. KIRKLAND GABLE
The rationale expressed here seems sound and probably reflects the
current trend in this area of malpractice. However, as noted below, the
courts may at the same time impose an increasing duty to protect potential
victims. loo
As Tarshis notes:
The problem then is in the legal definition of emotional harm. The least rigor-
ous definition would extend liability for emotional upset, humiliation, grief,
anger-in other words any unpleasant emotion. It is clear that this degree of
mental suffering is not enough. The most rigorous definition requires a palpa-
ble bodily injury, such as a miscarriage. In this case recovery is really for the
physical injury, not for the emotional injury. A moderate definition is emotional
harm serious enough to require medical attention, for example, shock, neuroses,
psychosomatic disabilities, continued nervousness, or sleeplessness. This is the
type of emotional harm that would be found in psychotherapeutic cases. Of
course, the amount of recovery would vary with the gravity of the harm. The
difficulty is that there is no consensus on what emotional disturbances require
medical attention-normality is an open question.'03
I06This statement is probably correct. In support, the authors cite Zipkin v. Freeman, 436
S.W.2d 753 (Mo. 1968) and Hammer v. Rosen, 181 N.Y.S.2d 805, modified, 198 N.Y.5.2d 65,
165 N.E.2d 756 (Ct. App. 1960). Zipkin, a garnishment proceeding, involved an earlier
action in which the psychiatrist was found liable for mismanagement of transference that
included personal and social contacts and directions to commit illegal acts. The plaintiff
(patient) claimed inability to sleep and headaches as well as mental anguish, humiliation,
loss of respect of friends and family, and other complaints. 436 S.W.2d at 755-56, 759. In
Hammer, the plaintiff (patient) alleged bruises from the defendant's treatment as well as
pain and suffering. 151 N.Y.S.2d at 807,198 N.Y.S.2d at 67-68,165 N.E.2d at 757-58.
107 Supra notes 77-78.
478 R. KIRKLAND GABLE
disorders. This the majority of the court allowed. lOB No physical injury of
the conventional type was necessary for the plaintiff to succeed in the
recovery of $25,000 from the defendant. Yet, it is not clear as to what extent
this represents a possible emerging trend in case law as the cases are infre-
quent. In this particular case, the fact of mental injury was fairly clear
because of its preexisting nature. Thus, the court did not need to deal with
some of the problems of proof more commonly found in cases of alleged
mental injury or distress produced in the first instance by the practitioner.
108 A dissenting opinion appropriately suggested, "The relief sought by this plaintiff consti-
tutes the closest approach to a conventional action for seduction, and hence must be treated
as such." 381 N.Y.S.2d 587, 592 (Sup. Ct. App. Term 1976).
I09See discussion supra at notes 68, 69, 105.
1I0Supra note 3, at 72-73.
MALPRACTICE LIABILITY OF PSYCHOLOGISTS 479
lllSalzer-Ozaroff, B., & Mayer, G. R. Applying Behavior-Analysis Procedures with Children and
Youth. New York: Holt, Rinehart and Winston, 1977, p. 151; Schwitzgebel. R. K., & Kolb,
D. A., Changing human behavior: Principles of planned intervention. New York: McGraw-Hill,
1974, p. 63.
112Keeton, R. E. Legal Cause in the Law of Torts. Columbus, Ohio: Ohio State University Press,
1963, p. 8.
' l3 Id. at 10-11.
480 R. KIRKLAND GABLE
118Pappas, supra note 116 (citing cases involving medical treatment). See a/so, Darrah v. Kite,
301 N.Y.S.2d 286, 290 (N.Y. App. Div. 1969); Bang v. Charles T. Miller Hospital 88 N.W.2d
186 (Minn. 1958); Cox v. Stretton, 352 N.Y.S.2d 834 (Sup. Ct. 1974).
119E.g., Shetter v. Rochelle, 409 P.2d 74, 86 (Ariz. 1965); Aiken v. Clary, 396 S.W.2d 668 (Mo.
1965); Miller v. Kennedy, 522 P.2d 852 (Wash. Ct. App. 1974); Wilson v. Scott, 396 S.W.2d
532 (Tex. Civ. App. 1965), aff'd. 412 S.W.2d 299,301,302 (1967); Aden v. Younger, 120 Cal.
Rptr. 535 (Calif. Ct. App. 1976) (dicta); Edwards, S. L. Failure to inform as medical mal-
practice. Vanderbilt Law Review, 1970,23,754-774.
120 191 N.W.2d 355 (Mich. 1971).
482 R. KIRKLAND GABLE
mental status would be only that necessary to keep patients on the premises
or to prevent them from harming themselves or others. Assault and battery
in this case consisted of the involuntary administration of medication to the
patient.
properly authorized or witnessed and thus did not follow the required legal process. The
court permitted the plaintiff to have a new trial on c~mpensatory damages. Punitive dam-
ages were not permitted suggesting that malice might not have been involved.
MALPRACTICE LIABILITY OF PSYCHOLOGISTS 483
desirable, but courts and patients are likely to become quite upset with
deception. The professional relationship has sometimes been considered a
fiduciary one demanding a high degree of honesty because of the patient's
trust. One may not as once was attempted, trick a woman into signing her-
self into a mental hospital when she thinks she is signing a form for the
treatment of a physical complaint. In this particular case, Geddes v. Daughters
of Charity/24 the patient was also uncharitably held in the hospital for over
one year against her protests until she managed to contact an attorney.
In Meier v. Combs,!25 a university student demanded to see a university
president to discuss an alleged narcotics ring involving faculty members,
hypnosis of students in class, and bizarre sexual activities. He was referred
to the dean of men who arranged a conference with him in the company
of the medical director of the student health service and a clinical psychol-
ogist. They decided that he was hallucinating and to facilitate matters told
him that he would be taken by the campus police to nearby law enforce-
ment authorities to report his allegations. Instead, the campus police took
him to a mental hospital where he was held against his will. The required
commitment procedures were not followed. The court concluded that there
could be liability for false imprisonment.
In some states, there is broad statutory immunity for persons present-
ing information to the court relevant to the need for the commitment of
another person. 126 The person presenting the information should believe
that it is true and should not be acting out of malice. Under these conditions
of statutory immunity, there may be no liability for false imprisonment (or
negligence) even when the observation of the prospective patient is very
informal and brief.'27 The extent of the immunity varies greatly from state
to state.
124 348 F.2d 144 (5th Cir. 1965). See Marcus v. Liebman, No. 76-286 (Ill. Cir. Ct., Cook County,
1978) cited in Mental Disability Law Reporter, March 1978,2,557-558.
125 263 N.E.2d 194 (Ind. Ct. App. 1970).
126See, e.g., Rhiver v. Rietman, 265 N.E.2d 245 (Ind. Ct. App. 1970) (but dicta suggesting qual-
ified immunity if negligent); Williams v. Westbrook Psychiatric Hospital, 420 F. Supp. 322
(E.D. Va. 1976).
127Schwartz v. Thiele, 51 Cal. Rptr. 767 (Ct. App. 1966). See discussion infra at note 142.
128See discussion supra at notes 94-99.
484 R. KIRKLAND GABLE
example, gunshot wounds and child abuse. Some courts are reluctant to
enforce confidential communications or privileged communications when
confidentiality may result in clear, substantial harm to others as a matter of
public policy.129
A widely discussed case concerning this matter is Tarasoff v. Regents of
the University of California. 130 The legal action in this case was not for mal-
practice but for the recovery of damages for the murder of the plaintiff's
daughter. Briefly summarized, Prosenjit Poddar was seen as a voluntary out-
patient at a student mental health clinic by a psychologist for treatment.
The psychologist, recognizing the seriousness of Poddar's problems, and
because of Poddar's threats against his former girlfriend and his intention
a
to purchase gun, requested the campus police by letter to assist in the
commitment of Poddar. The police took Poddar into custody but, being sat-
isfied that he was rational, released him. No further attempts at commit-
ment were made because apparently the supervising psychiatrist decided
that commitment was not needed. The psychiatrist also directed that the
psychologist's letter and notes related to Poddar be destroyed. Shortly
thereafter, Poddar killed his former girlfriend as he had threatened.
The Supreme Court of California decided that "[O]nce a therapist does
in fact determine, or under applicable profeSSional standards reasonably
should have determined, that a patient poses a serious danger of violence
to others, he bears a duty to exercise reasonable care to protect the foresee-
able victim of that danger.,,13l The court was aware of the difficulty in pre-
dicting violence, but concluded that "The risk that unnecessary warnings
may be given is a reasonable price to pay for the lives of possible victims
that may be saved.11l32 Warning foreseeable victims was not specifically
required by the court. The duty is to "protect" the potential victim. That
might be accomplished by reasonable methods other than warning the per-
son such as by notifying the police, committing the patient, removing
instrumentalities of harm, modifying the intensity or method of treatment,
providing continuous community supervision (with the consent of the
patient), etc., depending upon the particular circumstances. It may be noted
that the duty to protect foreseeable victims was imposed in Tarasoff at, or
shortly following, the termination of treatment. (Dicta in the case would
also suggest that the same duty is required during treatment.)133
129Privileged communication refers to a legal right existing by statute that protects clients
from having their confidences revealed publicly without their permission during legal
proceedings. Generally, this right belongs to the client, not to the practitioner. The prac-
titioner is obligated not to reveal sensitive information unless there is some compelling
duty to supply information that outweighs the obligation to remain silent.
130 529 P.2d 553 (Cal. 1974), vac., reheard in bank, and alf'd. 551 P.2d 334 (1976).
131 [d. at 345.
132 Id. at 346.
133For a contrary interpretation, see Leonard, J. B. A therapist'S duty to potential victims: A
nonthreatening view of Tarasoff. Law and Human Behavior, 1977, 1, 309-317, p. 316.
MALPRACTICE LIABILITY OF PSYCHOLOGISTS 485
136See, Comment, Torts-Psychiatry and the law-Duty to warn potential victim of a homo-
cidal patient (Tarasoff v. Regents of the Univ. of Cal., New York Law School Review, 1977,
22, 1011-1023); Johnson v. United States, 409 F. Supp. 1283 (M.D. Fla. 1976); and text at
supra note 109.
137 See, e.g., Siegel, M. Confidentiality, The Clinical Psychologist, 1976, 30, 1 and 23 (strongly
opposed); Brooks, A. D. Mental health law, Administration in Mental Health, 1976,4,94-97.
(generally positive). Brooks suggests that attorneys also may have a duty to protect poten-
tial victims. Schindler, R. J. Malpractice-Another new dimension of liability-a critical
analysis. Trial Lawyer's Guide, 1976,20, 129-149 (sharply critical). Schindler notes that the
court requires the therapist to warn the threatened victim "discreetly." He then asks
whether the following letter should be sent by mail to the threatened person:
Dear Miss Jones,
One of my patients, John Smith, residing at 10201 S. Winthrop Boulevard, Los Angeles,
California, has confided to me that he intends to kill you with an axe. I and my colleagues
have made a judgment based upon our experience that it is more likely than unlikely that
John Smith will attempt to kill you with an axe. I, therefore, hereby discreetly advise you
that John Smith, my patient, is more likely than not likely to attempt to kill you with an
axe.
Very truly yours,
T. C. Higginbottom, M.D.
cc: John Smith Id.146
138 A useful discussion of privilege and confidentiality in group therapy according to federal
and state law including the Tarasoff decision can be found in Meyer, R. G., & Smith, S. R.
A crisis in group therapy. American Psychologist, 1977,32,638-643.
139 American Psychological Association, Ethical Standards of Psychologists. Washington, D. c.:
Author, 1977, Principle 5(a), p. 4.
486 R. KIRKLAND GABLE
It has long been recognized that a physician may be liable for breach
of contract in the performance of the duties of care and skill. l43 The contract
143Dawidoff, supra note 3, at 49, suggests that they remedy was long ago recognized in Black-
stone's Commentaries. Although malpractice actions may sound in either tort or contract, it
appears that there has traditionally been somewhat more preference for tort actions than
contract actions in the United States. Miller, T. W. Medical malpractice-Constitutionality
of limits on liability. West Virginia Law Review, 1978, 78, 381-390, pp. 381-82.
MALPRACTICE LIABILITY OF PSYCHOLOGISTS 487
may be either express or implied, and does not have to be in written form.l44
(A written contract does, however, tend to define the contractual obliga-
tions and provide usable evidence for litigation.) That contracts usually
exist in physician-patient relationships even though they are not express
can be demonstrated readily when patients fail to pay their bills. Physicians
may recover the value of their services by suing under a theory of breach
of contract even though there was no express discussion of fees with the
patients.
It is a reasonable assumption on the part of the physicians that patients
will pay for services, will follow instructions, will not conceal symptoms,
and will in other ways conform their conduct to the customary role of
patient unless there is an express agreement to the contrary.145 Similarly,
patients reasonably may assume that physicians will provide treatment
using at least ordinary care and skill. As noted in Noel v. Proud/ 46 "The
improper performance by a physician or surgeon of the duties imposed
upon him by reason of the professional services undertaken, whether under
a contractual relationship with the patient arising out of either an express
or implied contract of employment or the obligation imposed by law under
a consensual relationship, whereby the patient is injured in body and
health for which he seeks damages, is malpractice.// When the terms of the
contract for treatment are not express, they may be inferred from customary
practice or from the conduct of the parties in the particular case.
The obligations under a contract with a psychiatrist may not be entirely
mutual. 147 A patient, for example, may terminate therapy without incurring
liability for the cost of unattended sessions for which the therapist cannot
find patients. On the other hand, the therapist may not be permitted to ter-
minate therapy if the patient would be harmed thereby or if provisions for
alternative treatment are not made. However, these obligations are not
absolute or fixed. As Dawidoff suggests: "The physician may, perhaps, have
the right to discontinue the therapy if his fee is not paid, or absent reason-
able deferrals, there does not appear to be reasonable likelihood of its being
paid. Similarly, he may have a right to discontinue therapy if the patient
destroys some of his furniture, is uncontrollably destructive to a group
undergoing therapy together, or simply does not follow the doctor's orders.
This latter condition may be the most telling, for it means that the mutual
undertaking to pursue a therapeutic path is no longer being followed, and
as such, continuance under a mutual jOinder of the spirit in an effort to work
behavior change is no longer possible.//I48
It may be helpful to both the patient and the therapist to make certain
conditions of the treatment explicit at the outset. 149 It might be possible, for
example, to specify treatment goals or objectives prior to the initiation of
treatment. lso With institutionalized patients, certain goals might be contrac~
tually established as indicators of suitability for release. Sample treatment
contracts have been prepared by Adams and Orgel/51 Ayllon and Skuban,152
and Stuart. l53 Together, these contracts outline matters such as the treatment
objectives, treatment techniques, professional publications desCribing the
treatment techniques, possible undesirable side effects, fee arrangements,
assessment procedures, renegotiation of the contract, confidentiality of the
information provided by the patient, etc. Model contracts such as these
might be used and modified with legal consultation to meet the needs of
particular treatment situations.
Although contractually required treatment methods might be inferred
from the particular circumstances of a therapeutic situation/54 explicit
agreement ahead of time might prevent misunderstanding by clarifying the
therapist's responsibilities and patient expectations. For example, in the
treatment of patients with suicidal tendencies the use of restraint or force
may become an important issue. The patient and his or her family should
understand and agree to the possible need for reasonable restraint by the
therapist or institution. Alternatively, if the parties agree that no restraint
is to be used, then in the event of suicide (which might have been pre-
vented by restraint) the therapist or institution should not be contractually
liable. 155
The usual express or implied contracts between patients and therapists
do not guarantee cures or the remission of symptoms. The failure of a ther-
apist to achieve a cure or a specific result does not automatically indicate a
lack of proper care or skill on the part of the therapist. l56 However, if a
therapist wishes to promise a specific result or to use a particular treatment
technique, he or she may do so. In Nicholson v. Han/ 57 the court noted that
149Schwitzgebel, R. K. The right to effective mental treatment. California Law Review, 1974,62,
936-956, 951-52.
1soLombillo, J. R, Kiresuk, T. J., & Sherman, R E. Evaluating a community mental health
program: Contract fulfillment analysis. Hospital and Community Psychiatry, 1973, 24, 760-
763.
lSI Adams, S., & Orgel. Through the mental health maze: a consumer's guide to finding a psychother-
apist, including a sample consumer/therapist contract. Washington, D. c.: Public Citizen's
Health Research Group, 1975.
152Ayllon, T., & Skuban, W. Accountability in psychotherapy: A test case. Journal of Behavior
Therapy and Experimental Therapy, 1973,4,19-30.
153Stuart, R B. Client-therapist treatment contract, Champaign, Ill.: Research Press, 1975.
154Stewart, v. Rudner, 84 N.W.2d 816 (Mich. 1957). Failure to perform Caesarean section in
light of circumstances resulted in breach of contractual obligations.
IssSchwitzgebel, supra note 145.
156See, e.g., Johnston v. Rodis, 151 F. Supp. 345 (D. D.C. 1957), rev'd on other grounds, 251 F.2d
917 (D.C. Cir. 1958) (electroshock therapy).
157 162 N.W.2d 313 (Mich. App. 1968). See also Hawkins v. McGee, 146 A.641 (N.H. 1929).
MALPRACTICE LIABILITY OF PSYCHOLOGISTS 489
a psychiatrist may enter into an express contract for psychiatric services that
contains a warranty of cure. In this case, the psychiatrist allegedly stated
that he would improve the plaintiff's marital relations, but in fact he had a
sexual relationship with the plaintiff's wife. Eventually the marriage was
terminated by a divorce decree obtained by the plaintiff's wife. The defen-
dant, however, was not found liable on contract grounds because the verbal
agreement made between him and the plaintiff was not sufficiently clear.
The most typical type of special agreement made by a therapist with a
patient involves some form of reassurance. It is tempting for a therapist to
tell a patient that everything will be fine. Such a statement may be thera-
peutically beneficial. The therapist, however, also must deal with the
patient in candor and must honor the patient's trust even when the prog-
nosis is poor. The balancing of these therapeutic and legal obligations by
the therapist may be difficult in some situations and the law regarding this
matter is unsettled. Yet it is fairly clear that the therapist must not mislead
the patient if the patient specifically asks about possible risks or results. Spe-
cial care must be taken to avoid concealing risks. Thus, a physician who
orally agrees and warrants that no harm will occur as a r.esult of an opera-
tion may be liable if harm subsequently occurs,us In Johnston v. Rodis/59 the
psychiatrist's promise that "everything would be all right" and his state-
ment that shock treatments are "perfectly safe" constituted a legally bind-
ing warranty. Some reassurance of the patient is permitted. But this reas-
surance should generally not be at the expense of withholding information
about material risks that may affect the patient's decision to participate in
treatment. l60
There is little doubt that the legal liability of psychologists has been
expanded in the past decade. Nevertheless, some or even much risk of lia-
bility may be reduced by improving the patient's understanding of the
professional relationship. Prior to its initiation, there should be a mutual
discussion of expectations, risks, and matters that might raise professional
or legal issues. For example, it might be useful to discuss with the patient
the limits of confidential communication. 161 In fact, this is required by Prin-
ciple 5(d) of the Ethical Standards of Psychologists: liThe psychologist is
responsible for informing the client of the limits of confidentiality."162
158 Noel v. Proud, 367 P.2d 61 (Kan. 1962). Operations produced a severe loss of hearing.
159 151 F.Supp. 345 (D. D.C. 1957), rev'd on other grounds, 251 F.2d 917 (D.C. Cir. 1958). With-
holding information from a patient about possible risks may also subject the therapist to
liability for misrepresentation. See, e.g., Woods v. Brumlop, 377 P.2d 520 (N.M. 1962).
160See text supra at notes 34-53.
161 See Bersoff, D. M. Therapists as protectors and policemen: New roles as a result of Tarasoff?
(Although ethical standards are not the same as the standards of acceptable
practice that are used to impose legal duties upon practitioners, they may
reflect a general professional agreement about the desirability of a practice.)
The patient should be informed that substantial threats to injure identifia-
ble others may not be kept confidential, although a client who has been
given notice of this may choose to limit the type of information or details
provided to the practitioner. If information is to be collected that might be
made available to schools, other public agencies, or insurance companies, it
may be desirable to inform the prospective client of this fact.
If the proposed treatment involves nonerotic physical contact, this also
might be discussed ahead of time with the client to avoid misinterpretations
and misunderstandings. Written consent should be obtained from the pro-
spective patient in marriage counseling or for the treatment of sexual dys-
function or variation. Consent of the patient's spouse (if any) also should
be obtained because that person may be substantially affected by the treat-
ment through changes in the patient's behavior.
Some practitioners tape record or video tape the patient's consent and
the discussions related to it. Although this has the advantage of conve-
niently recording much detail, it is not absolutely necessary. Written con-
sent, properly witnessed, is satisfactory. The consent form may contain a
statement of the major items discussed such as the possible benefits and
risks of the proposed treatment. In this way it is fairly certain that the
patient's consent is an informed one.
If misunderstandings or difficulties arise during treatment, consulta-
tion with other qualified colleagues may be desirable. When consultation is
sought before taking a particular course of action, it might be used in court
to indicate non negligence in matters such as the duty to protect third par-
ties from danger. 163 It also may be useful to keep extensive notes of encoun-
ters or sessions with patients where palpable negative transference, para-
noia, or other symptoms are present. 1M
In any event, accurate and nonspeculative records should be kept.
Thoughts about possible diagnoses, speculations, tentative hypotheses, and
observations, on the other hand, may be recorded separately as personal
notes. These notes should not be made a part of the treatment record
because the treatment record, in contrast to personal notes, may in certain
legal situations be viewed by the patient, his attorney, the courts, public
agencies, and other agencies with legitimate interests.
If difficulties with the patient arise, the patient might be referred to
another practitioner for treatment. Alternately, another practitioner might
be involved jointly in the treatment program. If the patient has been
referred to another, however, a good faith effort should be made to con-
ACKNOWLEDGMENTS
495
496 RICHARD R. KILBURG
Most psychologists are not directly aware of this aspect of their profes-
sionallives and someone with training and conceptual skills in this area is
a rarity indeed. The purposes of this chapter are to present some basic prin-
ciples and skills of management in a format that the average psychologist
can readily grasp and use. Because of the extensive range of management
knowledge, however, the presentation will not be comprehensive. Rather,
it will contain the most relevant issues and principles with sufficient exam-
ples so that their application by psychologists should be readily understood.
SURVIVAL
Although this may seem like a somewhat melodramatic use of the term,
the single most important issue anyone faces is survival. This can assume a
variety of meanings depending on one's perspective. For me, survival
means being able to obtain sufficient resources to live an adequate personal
and professional life which is not forshortened by forseeable and hence
preventable misfortunes. To some extent it may take on the dictionary
meaning of outliving or o~tstruggling one's peers, colleagues, etc. This,
however, is a subset of the major theme. Getting your share and contribut-
ing your share are the essence of this issue.
All psychologists live and work in environments with other people.
All of those others also are struggling with the issue of survival. The effec-
tive professional recognizes this as a basic parameter of nature and uses it
as a theme around which to mobilize energy, talents, and skills for the work
at hand. The extent to which the professional succeeds at this most basic
task depends of course on a host of other things.
ORGANIZATION
Von Bertalanffy (1960), states that "the problem of life is that of orga-
nization" (p. 12). Since we have defined living and hence life in terms of
THE PSYCHOLOGIST AS A MANAGER 497
RESOURCE ALLOCATION
Moving away from these more global issues, the professional is imme-
diately confronted by the "how to" questions. What skills, abilities and
experiences can facilitate the process of actualization? Perhaps the most
basic issues involve the development and allocation of resources that are to
be devoted to these tasks. For example, the foundation of all professional
resou!ces is time. It is the one dimension that remains absolutely rigid. Each
day contains only 24 hours. Each portion of these hours is allocated to dif-
ferent roles, tasks, and functions. When a day is consumed, it cannot be
recovered; when time is wasted, it cannot be recycled. To be sure, other
resources such as energy level, intelligence, character structure, and support
systems come into play. But they all rotate around what you do with your
time. A key challenge then focuses on how to use the time and the other
resources time represents most effectively in the pursuit of actualization,
organization, and survival. If you've ever had the feeling that others are
passing you by and that your activities are not as well organized as they
might be, then you have confronted resource allocation issues.
Resource allocation may sound like another buzzword or phrase, but it
is not. Embedded in it are a complex of issues that include: planning, eval-
uation, program development, stress management, setting and effecting
prioritizing strategies, budgeting, accounting, supervision, and so forth.
Unless professionals develop and implement resource allocation techniques
they will continue to experience a feeling of marking time and become
obsolete while watching the growth of their career decline. Since inade-
quate or limited resources is a fundamental fact of most of life, managing
limited resources effectively makes all the difference in the struggle to
actualize, organize, and survive.
INTERDEPENDENCE
tions, communities, and societies. Each of these is itself a social system with
various elements, components, and subsystems. Any complex social system
or overlapping systems involve behavioral ecology which produces a stun-
ning array of psycho-social-economic niches for individuals, groups, and
organizations to fill and offers the psychologist basic opportunities for sur-
vival. It is not merely that there are jobs to be done, roles to be played, or
services to be delivered. The concept of niche goes well beyond this to
include an all-encompassing symbiosis between the capacities of the indi-
vidual and his or her behavioral subsystems or components and the needs
of the niche. Thus, an individual can have a set of skills needed by or for a
niche but not the right attitudes, values, or cultural experiences to make a
good "fit" or vice versa.
The fit between the individual and niche(s} is a dynamically interact-
ing process determining survival for the individual as well as for the envi-
ronment. Broadly defined it involves the process of adaptation. Piaget
(1977) states that adaptation is comprised of cognitive and behavioral assim-
ilation and accommodation. Assimilation involves the integration of new
"action schemata" by interaction with the environment(s}. These action
schemata are behavioral patterns that can react to and act on a situational
reality so as to "transform" it in some way. Accommodation is the process
by which the individual uses these action schemata to adjust to changes in
old environments or to completely new situations. These are the basic
behavioral building blocks on which the whole adaptive process rests.
Action schemata are gradually organized into new types of behavioral
and conceptual skills called "concrete operations." These add many dimen-
sions to the adaptive capacity of the organism. If all goes well, they evolve
into "formal operations," a logico-mathematical, auto-regulatory, cognitive
structure. When fully developed, formal operations represent the most
important tool humans possess for adaptation. For example, approaches to
new environments or new niches can be much more successful if these cog-
nitive and behavioral skills are systematically applied to the problem of the
fit.
Any environment will have a set of requirements for the various niches
(e.g., as a clinician, administrator, or consultant) it contains. These require-
ments can be skills, knowledge, experience, attitudes, etc., with the individ-
ual having to go through a sequence of stages as he or she attempts to adapt
to those requirements. The requirements of each niche can vary widely,
with the success of the adaptation determining the probability of the indi-
vidual's survival in that environment.
Assuming that the psychologist possesses formal operations, has cho-
sen or has been placed in a given environment, and faces adapting to a
given niche, he or she will begin a behavioral transformation that, when
successfully completed, will result in an excellent fit between that psychol-
ogist and the niche. Figure 1 presents a flow chart of this process roughly
following the discussion of Braham (1973).
At the point of origination, when individuals enter into the environ-
ment, they are toti-potential. This suggests that their intelligence, skill,
THE PSYCHOLOGIST A.S A MANAGER 501
-
POINT OF ORIGINATION
EVALUATION
I
EVALUATION
I
STAGE IV INTEGRATION
EVALUATION
I
STAGE V TRANSFORMATION/EMERGENCE -
reward subordinates are extremely powerful tools that a manager must use
wisely and in the best interest of the individual and the organization. Pun-
ishment and strict direction are even more powerful tools and demand the
utmost tact and knowledge when they are applied. It is hard to imagine that
people will hang on every word you say looking for nuances of meaning
that could affect them and yet "leader-watching" occupies a central place in
the life of every organization.
Psychologists in independent practice certainly have considerable
experience with the functions of leadership in their own organizations.
Often a leader's capacity to pick out a key problem or issue to focus on per-
mits the energies of a group or organization to be concentrated and to
become productive. This seemingly simple task enables an outpouring of
resources and a rewarding of investment for everyone involved. The leader
who directs and motivates the activities of others with simple words of com-
fort and support or who reminds people of promises made and tasks to be
performed is engaged in some of the most delicate human behavior possi-
ble. The success or failure of almost every human venture rides on what is
said or left unsaid, done or left undone. Professionals who perform well
have an understanding of the leadership function and they are able to
apply it broadly on behalf of many people and in the service of a variety of
issues.
The last role in the interpersonal triad is that of liaison. According to
Mintzberg (1973) a crucial aspect of managerial behavior involves devel-
oping a reciprocating network of human and professional relationships.
This network becomes a central resource in the working life of any profes-
sional, for life usually consists of what other people bring to you. Infor-
mation, job offers, political contacts, opportunities to grow or decay, prob-
lems, battles, friendship, trust, love, and hate are all part of what the liaison
role brings to a psychologist. In any environment, in any niche, a psychol-
ogist must deliberately and self-consciously develop and maintain a net-
work of relationships. To do so is to further guarantee the probability of
success and survival.
As an example, let us take the professional who is opening a private
practice, described earlier. He or she began with 15 clients and numerous
problems, dreams, and skills. Where are additional sources of income to be
found? How can more referrals, contracts, etc. be developed? A significant
part of the answer to these questions comes from the liaison function. The
psychologist in this situation can begin with the local or state psychological
association. Volunteering to serve on a committee or work on a project
brings immediate returns in the establishment of relationships with other
psychologists, many of whom also may have a practice. Discrete questions
and answers can lead to discoveries of referral sources, opportunities for
contracts, etc. One also learns more about the services available in the com-
munity and about problems, populations, or areas that may be lacking in
services or expertise. If, for example, there are not many psychologists
working with people going through divorce, children with learning disa-
508 RICHARD R. KILBURG
will be forthcoming shortly but that the period for proposal development
and submission will be short. Armed with this new information, the psy-
chologist disseminates it to key individuals in his or her home agency and
a proposal is initiated. Several days later another agency director calls to
chat about the latest developments on the state level and asks if the psy-
chologist has any new information. The psychologist says that there may
be some new initiative but that it is only a rumor. The other director rings
off with some information and some misinformation.
Questions of ethics and honesty raised by such an example are obvi-
ously central to the management of information. Although the psychologist
in the above example did not deliberately mislead the other professional,
information was withheld to maintain an advantage. These decisions are
crucial for the survival of any organization and they occur very frequently.
Functioning as an effective spokesperson obviously can playa critical part
in the adaption of an individual or an organization and should always take
place within a strong moral and ethical framework.
The last, and perhaps most important, tetrad of management roles con-
cerns the decision-making functions in an organization. The results of a
professional'S decisions determine success or failure, transformation or
decay, survival or death in various aspects of his or her career. Each of us
represents, in large measure, the outcome of most decisons that we have
made. Genetic and environmental factors play an extremely important role
in a person's development, but in the end, it is what a person chooses to do
with what heredity and environment offer that determines the kind of
human being that individual will turn out to be.
This element of choice is seen in the lives of individual professionals.
Decisions concerning vocational pathways, courses, supervisors, and most
importantly job opportunities will shape the professional as surely as does
genetic inheritance. A student choosing coursework in program evaluation,
behavioral assessment, biofeedback, and behavior modification is clearly
designing a map of his or her future knowledge, skills, and professional
area of interest. Saying yes to these areas and no to psychodynamics, psy-
choanalytic psychotherapy, and projective testing will give a clear picture
of the intentions, abilities, and theoretical affinities of the future profes-
sional. Similarly, choosing to work in a rural community mental health cen-
ter will yield a different career path than choosing an academic job. For
these reasons, decision making is one of the most crucial skill areas for a
professional to develop.
Mintzberg delineates a continuum of strategic decisions confronted by
an organization. At one extreme are entrepreneurial decisions characterized
as having long-range and far-reaching consequences for an organization.
They are systematically planned and implemented with an eye toward max-
imizing constructive change. On the other hand of the continuum are
crises. These are relatively short-term disturbances that are managed as
swiftly as possible with the goal of immediate resolution of the difficulties.
In the middle are a wide variety of problems with varying degrees of com-
THE PSYCHOLOGIST AS A MANAGER 511
plexity and effects on the organization. The decisional roles focus on the
type of decisions being made.
As an entrepreneur, the professional uses the data collected as a monitor
and liaison to develop a clear picture of the demands and needs in the envi-
ronment and his or her capacities as a psychologist to meet those demands
and needs. Based on this cognitive map, the professional plans and imple-
ments strategies designed to change the organization and to maximize the
possibilities for survival and the process of actualization. When working
with others, the functions of delegation and supervision are subsumed
under this role. In this capacity, the professional seeks to implement deci-
sions through the work of others.
Returning to our earlier example of the budding private practitioner
with 15 clients, large overhead costs, and magnificent aspirations, this
professional obviously has some entrepreneurial decisions to make. Let us
assume that he or she discovers through newly formed linkages with other
professionals that there are serious gaps in the service delivery network for
the elderly and the handicapped. Other, traditional areas have more than
adequate coverage. What can he or she do?
After determining the magnitude and nature of the needs of these pop-
ulations, the professional then examines his or her own technical capacity
to meet those needs. Attitudes and motivations to work in the areas are
assessed along with the economic possibilities. Gaps in knowledge and
skills are identified and an education and training program may be under-
taken. Simultaneously, the professional may initiate public relations and
collaboration efforts in those areas for which the person already has skill.
After providing some services, the process of transcendence or transfor-
mation is well underway and almost automatic. Referrals and contractual
opportunities may well depend on the capacity to perform excellently.
However, the problem of how to obtain new referrals and thus resolve
finan:ial difficulties has been replaced by the problem of what really needs
to be done and how competent the individual is to do it.
The direction-setting entreprenuerial decisions merely set the stage for
the role of resource allocator. Mintzberg defines this as the core of any orga-
nization's strategy-making function. The professional controls a network of
possible resources from which to draw. Chief among these are time, energy,
capital, and expertise. Equipment, material, reputation, and in organizations
with more than one employee, the resources of subordinates also are under
the professional's direction. Achievement of the goals of any set of entre-
preneurial decisions depends in large measure on the efficiency and effec-
tiveness with which the resources are managed to reach those goals. Mintz-
berg states that some of the more important components include careful
scheduling of time, authorization of actions, planning and programming
work activities, budgeting, accounting and evaluation, and modeling or
role-playing alternative scenarios. These key processes by which resource
allocation is accomplished will be discussed in more detail later.
A third decisional role for the professional is as a negotiator. This is an
512 RICHARD R. KILBURG
Assuming that the basic management roles are understood and can be
referred to, we shall now turn to the managerial characteristics of profes-
sional work. Here again we will follow the discussion of Mintzberg (1973)
closely, adapting it where appropriate. He describes six sets of work char-
acteristics that we will address here: "(1) the quantity and pace of the man-
ager's work, (2) the patterns of his/her activities, (3) the relationship, in his/
her work between action and reflection, (4) his/her use of different media,
THE PSYCHOLOGIST AS A MANAGER 513
going? What is the status of that new program? Are the new employees
settling in? What do the funding patterns look like for the next year? The
questions and the possible answers are endless.
This type of activity is somewhat less chaotic for the full-time practi-
tioner, although there are special circumstances involving the mental sets
concerning each client that must be maintained. The intimate details of the
lives of up to 50 to 70 persons at one time must be competently managed
so that each individual feels unique and attended to. This is the main task
of practice and a formidable one to even the most experienced practitioners.
Here again the capacity to shift attention, mood, and resources quickly and
efficiently is crucial. The demands of a person with an anxiety-ridden neu-
rotic problem will vary a great deal from those of a hyperaggressive person
with a paranoid character disorder. Yet each must be met with empathy,
patience, wisdom, and understanding. This is an incomparable human
accomplishment when it is done well. When done poorly it can be life-
threatening to client and psychologist alike.
Graduate school is an environment that rewards reflective thinkers and
planners. Those persons who have the capacity to absorb information and
integrate it carefully, with time to extend many collateral lines of thought,
are typically successful academicians. In professional practice, the nee<;ls
and demands of the work setting and clients make careful reflection a chi-
mera dancing on the wind produced by the next meeting. While there is
clearly a place for reflection in the decisional roles in particular, the pace of
professional activity constantly leaves one with the feeling that there is
more to be done. This fact and feeling breeds an adaptive preference for
action over thought, doing vs. being.
In school, papers and reports are drafted and redrafted as facts, impres-
sions and metaphors are honed to a fine point of communication. In full-
time practice, one often has time to say things once and even then in an
abbreviated form. The desires for perfection and craftmanship are con-
stantly played off against the needs of the other client in the waiting room,
the parents or school on the telephone, the bills that must be paid, etc. This
tension is palpable by every psychologist. Those who thrive on variety,
adaptability, and not looking back seem to adjust more readily to the
demands than more narrow-minded and rigid types of people, especially
where the environment demands more generalist kinds of functions and
services. The latter psychologists can protect themselves by narrowing their
fields of interest and specializing. This permits a greater degree of control
but sacrifices a broad scan of activities. To survive in a managerial capacity,
one surely must enjoy the action, for it is typically nonstop.
According to Mintzberg, "the manager uses five basic media: the mail
(documented communication), the telephone (purely verbal), the unsched-
uled meeting (informal face-to-face), the scheduled meeting (formal face-
to-face), and the tour (visual)" (p. 38). Here again the parallel is clear for
psychologists in formal managerial roles. Typically, the mail is treated in as
brief a time period as possible. Telephone calls are short and numerous as
THE PSYCHOLOGIST AS A MANAGER 515
a resource base, and a communication network for his or her own practice?
Sources of funding, newly developing programs, opportunities to develop
linkages that may serve as referral sources, and possible contracts for con-
sultation are available as a function of the liaison and monitoring role.
Thus, the psychologist's relationship to a variety of contacts is central to
survival and growth.
The final characteristic of managerial work applicable to professional
practice deals with the blend of rights and duties that professional psy-
chology thrusts upon the practitioner. As the psychologist moves into fully
autonomous functioning and leaves behind the system of supervisory
checks and balances that are the hallmark of training settings, there is a
brief moment in which an exhilarating sense of freedom and capacity for
meaningful personal expression is experienced. To be sure, there is a real-
istic base to this experience. To a certain extent the psychologist can now
say yes or no without necessarily seeking permission. In particular, accord-
ing to Mintzberg, "(1) the manager is able to make a set of initial decisions
that define many of his own long term commitments and (2) he can take
advantage of these obligations" (pp. 51-52). In reality, however, each yes
decision brings a host of confining and delimiting restrictions on the indi-
vidual's freedom to act. Thus, accepting the offer of a full-time job imme-
diately constricts opportunities and focuses abilities and resources into a
much narrowed domain. Although this is perfectly normal and fits within
the context of our conceptual approach to profeSSional development and
transformation, if the decisions are not made wisely there can be serious,
long-term consequences. In addition to the constraints of the job and set-
ting, the professional soon learns the lessons of resource availability and
allocation. There is never enough time or energy to do what is needed.
Finally, a third area of limitation centers on the regulatory restrictions of
various governmental laws, regulations, and policies and the policies and
standards of the profession of psychology.
Thus the new psychologist trades the constraints of the training insti-
tution for the constraints of the society, the marketplace, and the profession.
It is definitely arguable as to where the most time or opportunities for
actualization occur. The wonderful moment of freedom is quickly replaced
by the chronic frustrations of short resources, interdependency, and life as
a creative process full of struggle. For the commitment to this career, society
does reward the professional psychologist with certain status, prestige, and
authority, and there are the rights that achievement brings to the individ-
ual. Simultaneously, however, society imposes duties and responsibilities
to insure insofar as practicable that the rights are not abused.
The picture I have presented is one of a maturing, complex, dynamic
organism/organization (a psychologist) interacting with an environment or
niche and struggling with the issues of survival, organization, optimization
and actualization, resource allocation, and interdependence. In order to
promote efficient and effective professional development, I have employed
an overview of Mintzberg's descriptions of managerial roles and character-
istics of managerial work and attempted to demonstrate how the practicing
THE PSYCHOLOGIST AS A MANAGER 517
psychologist can and does perform management work and functions while
serving as a psychologist. This has been done to familiarize you, the reader,
with some basic tenets of management and to convince you of the impor-
tance of effective management skills for professional psychologists.
What follows is an overview of 10 principles of management that are
drawn from Sherman (1966) in order to provide some of the basic rules of
thumb that guide most managers. I shall then proceed to a somewhat more
detailed presentation of several of the most difficult problems in manage-
ment and professional practice.
Sherman's principles are as follows:
There are four major areas of management that typically produce sig-
nificant problems for psychologists-planning and problem solVing,
power-dependency relations, resource allocation, and conflict management.
This overview is a difficult and dangerous undertaking because each of the
topics is extremely complex and has merited lengthy treatment by many
authors. In condensing these areas, it is necessary to oversymplify and over-
generalize, thus distorting the richness of the available resources. Refer-
ences for additional reading will be provided for the four areas and I urge
you to continue your exploration.
THE PSYCHOLOGIST AS A MANAGER 519
This is the most important set of concepts and skills for any profes-
sional to master. Planning and problem solving functions are involved in
literally every phase of a psychologist's job. Each of the management roles
and characteristics of professional work is based on planning and problem-
solving abilities.
Figure 2 presents a flow chart outlining the various facets of planning
and problem-solving processes. Here again, we see the basic parameters of
systems theory in operation, as the figure delineates the major elements of
a planning structure and specifies their relationships. Assuming that you
want to achieve a given set of goals or objectives, which is not always the
case, then this model provides a way of approaching and accomplishing
change in an organized framework.
In Step 1 of this model, the interaction between the environment niche
and the professional produce a set of needs and constraints directly related
to the major issues of survival, organization, etc. outlined earlier. These
needs and constraints can be characterized as a set of factors that usually
produce a number of opportunities, necessities, and/or problems. The
opportunities relate directly to those aspects of the niche and professional
that lead to an increased probability of actualization. The necessities relate
to the minimal set of circumstances that result in a sufficient fit so that the
Step 2.
+
OPPORTUNITIES, NECESSITIES AND PROBLEMS WHICH INITIATE
Step 3.
+
PLANNING PROBLEM·SOLVING CYCLES
---
~
3a. Analyze Environment·Organization Status
-
3e. SpJify major objectives and criteria
+
--
3f. Evaluate alternative strategies for achieving objectives
and goals '
3g.
+
Select optimal or maximal strategies
+
-
3h. Specify action plan (behavioral statement of who, what, when,
where, how, cost, etc.)
3i.
+
Implement and monitor phase·by·phase
3j.
+
Evaluate outcome(s)
niche can be used by that professional to survive. The problems result from
both necessities and opportunities, as the psychologist organizes to meet
these challenges.
The primary cognitive and behavioral skills that are used involve a
cycle of planning-problem solving activities usually applied to large and
small problems alike. The average professional typically will be engaged in
simultaneous cycles on any number of problems or opportunities. Often
multiple cycles are required on particularly thorny problems. These multi-
ple problem exercises occur seemingly without major effort in areas in
which the individual possesses considerable expertise or experience. New
or complex problems more frequently produce a conscious sense of work-
ing on or through difficult issues or times.
The opening step of a problem-solving cycle should consist of an anal-
ysis of the status of the environment and organization (psychologist). This
roughly corresponds to the needs assessment phase of any project (Bell et.
al., 1976; Kilburg, 1978) or the force field analysis outlined by Lippitt, Wat-
son, and Westley (1958). Briefly stated, the professional attempts to identify
the key factors, problems, needs, restraining and driving forces, and capac-
ities that are present in the professional-niche interface at a given time.
Norville (1978) presented formats for organizational and functional self-
evaluation that provide a useful series of questions with which to approach
this assessment task. Such questions as: (1) "What are the present strengths
of the organization?" (2) "What are the present weaknesses of the organi-
zation?" (3) "What major threats will the organization face in the next five
years?", (4) "What is the fundamental purpose of our organization?" (pp.
26-27), can lead to very important insights concerning the status of the
organization-environment. When conducted properly, this assessment will
result in a fairly detailed picture that almost automatically presents views
of key opportunities and/or problems. This leads into the next phase of the
cycle.
Since most assessments acquire data only at selected times and on lim-
ited dimensions, some sort of prioritizing procedure is usually employed
either implicitly or explicitly. Often this limited data set must be further
defined in light of the more specific values, attitudes, or opinions of the
professional. Prioritizing and delimiting the raw data should produce a
clear set of problems and/or opportunities. If clarity is not obtained, then
the process of analysis should continue.
Assuming for the moment that obvious problems and/ or opportunities
exist, then the next stage of the cycle should be entered. The problems and/
or opportunities are translated into broadly formulated and stated goals.
There may be one or more of these goals.
Often overlooked in many planning models, the assumptions upon
which these goals are founded must be identified and clearly set forth.
Clear goals cannot be set with an inadequate understanding of their foun-
dations. Explicitly stating these assumptions often leads either to modifi-
cation or elimination of goals and/ or to more detailed specification of objec-
tives or targeted subgoals. The criteria by which an objective judgement of
THE PSYCHOLOGIST AS A MANAGER 521
What is the psychologist really good at and poor at? What services are avail-
able in the community? Which populations are underserved? The answers
to these questions should lead to the definition of opportunities, necessities,
and problems in the situation. For example, the necessities are to meet the
$500 per month requirements for overhead and an additional $800 a month
for personal expenses. This $1,300 per month is the economic baseline for
survival. Let us assume that the 15 clients provide a gross income per month
of approximately $900, leaving the practitioner $400 in the red. One prelim-
inary conclusion the professional reaches is the need for from four to eight
new clients to break even. The question is how to obtain the necessary
referrals.
This necessity and its attendant problems lead the professional into a
planning-problem solving cycle. Assuming that some of the steps men-
tioned earlier already have been taken, if the individual belongs to the local
or state psychological association, is actively participating, and has
reviewed the local human service scene carefully, he or she may discover
that there are inadequate services for the elderly and developmentally dis-
abled and their families along with a number of other smaller opportuni-
ties. The professional problems identified center on a lack of specific knowl-
edge and skills and a complete absence of professional ties to these
populations. An examination of personal and professional preferences and
environmental opportunities leads to the decision to develop a special pro-
ficiency in geriatric psychology as a way of providing a long-term solution
to the financial problem. No immediate solution to the short run cash flow
problem is seen.
The goal can be stated then as: (1) financial independence and profes-
sional stability, (2) increasing cash flow, and (3) developing a special pro-
ficiency. The key assumptions include: (1) the professional in question has
sufficient skill, motivation, and knowledge to survive in private practice; (2)
the community has sufficient need for psychological services to provide
support; (3) the professional has sufficient resources to experiment for six
months; (4) there are opportunities to contact the human service agencies
relating to the elderly. These goals and assumptions result in the following
specific objectives: (a) review the major literature in geriatric psychology
during the next three months of evenings, (b) informally alert friends and
acquaintances of professional availability, (c) obtain a position on the board
of a local agency serving the elderly, (and d) investigate availability of
supervision and training opportunities.
Clearly the planning process has taken a basic need for more clients
and increased cash flow and a set of environmental constraints and yielded
a set of four fairly specific objectives to achieve as a way of meeting the
needs within those constraints. Let us now briefly examine how the objec-
tives can be converted into action.
When considering alternative courses of action a large number of vari-
ables should be included. Le Breton and Henning (1961) state that any plan
has 13 dimensions: complexity, significance, comprehensiveness, time,
THE PSYCHOLOGIST AS A MANAGER 523
ence on services to the elderly is being held in a distant city and the prac-
titioner has made arrangements to attend. The initial need and constraints
have been met as the goals and objectives were achieved. However, the two
elderly clients have led to the realization of several areas of skill and knowl-
edge deficiency. New plans need to be made. The process continues as a
transformation has begun.
In this brief and successful example, we see all of the major factors in
planning and problem-solving operating. These are real issues for thou-
sands of psychologists in widely differing settings. Although much of the
content may vary from person to person and situation to situation, the par-
adigm remains as a valid, generic approach to professional problems. With-
out these organized models, each new situation is often treated as com-
pletely unique. In fact the structure and process usually are similar across
problem situations and that should be the key lesson of this section.
Although some references have been cited in the foregoing pages, the
reader may wish to consult Bennis, Benne, and Chin (1969); Brady (1973);
Burgwall, Reeves, and Woodside (1973); Davis (1978); Drucker (1973); Fried-
man (1967); Holland (1976); Littlestone (1973); McConkey (1972); and Zee-
man (1976) for further information.
POWER-DEPENDENCY RELATIONS
power and vice versa. Emerson (1962) further detailed four basic types of
operations that are used when power relations are unbalanced. If actor B
perceives that he or she is weaker in a relationship, balance can be restored:
"1) If B reduces motivational investment in goals mediated by A" (p.
35). (B can withdraw from A)
"2) If B cultivates alternative sources for gratification of those goals"
(p. 35). (B develops new relations apart from A )
"3) If A increases motivational investment in goals mediated by B" (p.
35). (B gives status to A)
"4) If A is denied alternative sources for achieving those goals" (p. 35).
(B forms a supportive group or coalition.)
Kotter (1978) expands on these principles and suggests that the tech-
nique of "power / dependence analysis" (PDA) can be used to identify job
dependencies and the power strategies necessary to manage them. He sug-
gests a list of questions that can be used to delineate the power-dependence
features of any position. They are as follows:
1. Who are and what does the profeSSional depend upon?
2. How important is each dependency?
3. What is the basis of each dependency?
4. Are any of the dependencies inappropriate or dysfunctional?
5. If they are dysfunctional what has created the pattern?
6. How much effective power-oriented behavior does the profes-
sional engage in?
7. Is that behavior sufficient to manage the dependencies?
8. If the behavior is not sufficient, what changes need to be made?
9. Is the professional capable of the change?
10. Does the professional's generation and use of power have negative
consequences for him or her?
11. If there are consequences, what are they? (p. 39)
Kotter (1979) went on to outline the basic forms of effective power
behavior. Briefly, and consistent with power-dependence theory, he sug-
gests the following types of behavior:
1. Gain control of tangible and/or scarce resources-budgets, employ-
ees, buildings, equipment, decision-making responsibilities, referral
sources, etc. All of these can provide realistic power bases for the
professional to employ in the struggle for survival.
2. Obtain and control information-that is the most frequently used
power strategy of professionals. Most often, information is acquired
via the expertise of the psychologist. After appropriate manipula-
tion, the information is used ethically for the benefit of the c1ient(s)
and/or the psychologist.
3. Establish favorable relationships-building friendships, establish-
ing interpersonal obligations or achieving sufficient expertise so as
526 RICHARD R. KILBURG
the other actors in the situation assume neutral stances toward the plans
and actions of the professional.
Thus, the psychologist attempts to obtain and control information
regarding the psychology of aging, the local elderly population and their
needs, and the existing sources of aid for them. Furthermore, he or she tries
to establish favorable relationships with colleagues through telephone calls
and participation in the activities of the psychological association. Finally,
relationships with the agency board are formalized. The professional uses
the new information to influence decisions indirectly as legitimate new
expertise is brought to bear in the situation. The new referrals result in both
a planning and a power success as the approach enables the psychologist to
pay the bills and reduce the dependency on the existing clients.
In this case, the professional was capable of making the appropriate
changes. In addition, the increase in power was obtained at no particular
negative cost to any other single actor. The new relationships and new
referrals are managed with an attitude of mutuality, as effective services are
exchanged for money and information. Such successful, nonmalignant out-
comes are not associated with all instances of power generation and use by
professionals. In fact, many critics, including professionals themselves,
complain bitterly that the accumulation of power by professionals does not
result in effective outcomes for people in many instances. These critics
claim that the information, resources, relationships, and ability to generate
identification, pursuasion, and indirect influence are seldom used for the
benefit of the clients or society at large. Strategies and tactics aimed at spe-
cific individuals and/or groups must be scrutinized from a variety of per-
spectives before they are implemented. To do otherwise could well be
unethical in the extreme.
This view of power-dependence should not be taken as the last word
on the subject. However, as the example indicates virtually every major type
of human interaction has aspects of power-dependence in it. Regardless of
the service setting, the organizational configuration and/or mission, and
the personal attributes of the individuals involved, it is vital to understand
these aspects of human behavior and to be able to initiate effective changes
when assessment calls for them. For those working groups and organiza-
tions, this need often is obvious. It is hoped that our example illustrates that
these facets of behavior are equally crucial for practitioners in any setting.
RESOURCE ALLOCATION
TABLE 1
List of Professional Cost Centers
1. Service delivery
(a) Evaluation
(b) Therapeutic services
(c) Consultation
2. Environmental relations
3. Professional development
4. Business management
THE PSYCHOLOGIST AS A MANAGER 529
M T W T F S S TOTALS
ACTIVITY CENTER
1. SERVICE DELIVERY
(a) Evaluation
fbI Therapeutic
Services
Ie) Consultation
2. ENVIRONMENTAL
RELATIONS
3. PROFESSIONAL
DEVELOPMENT
4. BUSINESS
MANAGEMENT
TOTALS
1. SERVICE DELIVERY 80 40
tal Evaluation 10
leI Consultation 0
2. ENViRONMENTAL RELATiONS 80 40
3. PROFESSIONAL DEVELOPMENT 0
4. 8USINESS MANAGEMENT 40 20
It is obvious from the report that this psychologist has fallen far short
of the initial goals set. In line with our earlier discussions, this is readily
explained by the lack of solid referral sources, problems in establishing a
business, and need to focus on developing excellent relations with the
human service community. If the data continued to look like this every
month, one could predict that drastic changes would be necessary after six
or nine months. Cost accounting with fiscal, as opposed to temporal,
resources would reveal either a picture of rapidly accumulating debts or
rapidly declining financial reserves as cash flow consistently proved unable
to meet the basic monthly expenditures.
The data presented earlier revealed a monthly net of $900 for this 80
hours of service ($12.50 per hour). The strategy that was designed to solve
this problem was implemented after this first month. The quarterly report
shown in Figure 5 reveals the temporal and financial results of the plan.
A pattern of improvement in the percentage of time spent in direct
services and increases in the revenue is readily apparent. Although a deficit
of $600 was incurred during this first quarter, two-thirds of it occurred dur-
ing the first month. The plan successfully generated sufficient income to
meet the deficit and gave evidence that indicated that the practice was soon
to move into the black. Other strategies for increasing the efficiency and
effectiveness of the management strategies are discussed thoroughly by
Mackenzie (1972).
The concepts and techniques described above, along with the rudimen-
tary examples of their implementation, represent basic approaches to these
most difficult problems. Regardless of the focus of activities, every profes-
sional psychologist continues to confront significant problems in planning,
power-dependency relations, and resource allocation throughout his or her
career. Solving these problems means the difference between success and
failure, survival and growth as a professional, or decay and ultimately death
THE PSYCHOLOGIST AS A MANAGER 531
3. PROFESSIONAL DEVELOPMENT 5 1
4. BUSINESS MANAGEMENT 45 8
CONFLICT MANAGEMENT
Our last major problem area is one about which most psychologists
know a great deal, human conflict and its management. I am therefore,
assuming that a broad theorectical discussion of the issues is unnecessary.
Instead, I will focus on a model that emphasizes those practical and opera-
tional features of conflict management that the individual professional can
identify and master. This discussion will follow closely those of Watson
(1969) and Bernstein (1965).
Figure 6 presents a flow chart that outlines the stages of a typical con-
flict. As has been discussed, the environmental context, for us the psychol-
ogist-niche interface, presents many de facto opportunities and probabili-
ties for conflict. Indeed, the adaptational process of transformation almost
CONFLICT
BARRIERS f---o RESULTS
~
ENVIRONMENTAL
CONTEXT f- ISSUES -- - -- CONFLICT
BEHAVIORS - - - --
COSTS &
TRIGGERS f---o BENEFITS I-
1 1
FIGURE 6. Stages of a conflict (adapted from Walton, 1969).
532 RICHARD R. KILBURG
TYPE
SUBSTANTIVE EMOTIONAL
INTRAPERSONAL
INTERPERSONAL
ORGANIZATIONAL/GROUP
INTERORGANIZATIONAL/INTERGROUP
ENVIRONMENT
CONCLUSION
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2,79-105.
Barker, R. C. Ecological psychology: Concepts and methods for studying the environment of human
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VII
VALVES AND INTERESTS AFFECTING
PROFESSIONAL DECISION-MAKING
16
Psychology, Professional Practice, and the
Public Interest
GOTTLIEB C. SIMON
Implicit in the title of this chapter is the idea that there can be a gap-
potentially a very large one-between the interests of psychology as a
profession and the interests of our clients and society as a whole. To George
Bernard Shaw's contemporary followers, those who believe with him that
all professions are conspiracies against the laity, it hardly could be other-
wise. For many practicing psychologists, however, this idea may seem not
only unacceptable but unthinkable. To them, a profession, because it is
predicated on the service ethic, must perforce be in the public interest.
Nonetheless, professionals, like other people, are guided not only by our
desire to do good for others, but by our desire to do all right for ourselves.
There is more than one aspect to our motivation. We are influenced not only
by the public interest, but by our guild interests: the desire for increased
income, social acceptance, influence, and power. The problem for us, and
for SOciety, is that these separate interests can and do pull us in different
directions. When they do, which way will we turn? Former APA president
M. Brewster Smith (1976) has called attention to the "natural tendency" of
"APA lobbying and related activity ... to gravitate toward the guild rather
than the public interest component" (p. 2).
The emergence of the public interest movement in recent years is evi-
dence that many people, including some professionals, believe that profes-
sions have "gravitated" too far toward their guild interests. Professionals
are accused of overcharging clients, conspiring to eliminate competition,
perpetuating socially wasteful and inequitable arrangements, and generally
541
542 GoTTLIEB C. SIMON
placing their good and welfare before that of their clients and society as a
whole.
Yet, those psychologists who would gravitate toward the public inter-
est face many obstacles. One is our training. We have been socialized to
avoid controversy and conflict (e.g., Ad Hoc Committee on Advocacy, 1969).
If, despite this equivocating influence, we still are inclined to pursue
change, we find that we lack the necessary training and knowledge to be
effective. More importantly, those professionals who would nevertheless
follow their conscience, who would give their attention to individuals who
have the greatest need for their services; who would prevent problems
instead of rehabilitating the victims; who would expose official wrongdo-
ing, too often are forced to choose between their own job security, personal
advancement, or material comfort and their professional values.
The gap that exists between our efforts as professionals, individually
and collectively, will not close until we-or others-are able to alter the
"reward structure" that governs our behavior so that there is increased coin-
cidence and less conflict between our self-interests and the public interest.
This chapter, I hope, will provide some help both for the long-term goal of
modifying our reward structure and the more immediate needs of profes-
sionals who wish to serve the public interest more effectively. It contains
information that is intended to clarify the meaning of "professional activity
in the public interest"; articulate some of the more salient areas of conflict
between our guild interest and the public interest; and present some prac-
tical suggestions on increasing one's effectiveness as a professional in the
public interest.
2Known as the Pareto criterion or Pareto optimality, Held (1970) summarizes the concept:
Assuming that only individuals themselves are able to assign values to their own utilities,
Pareto asserts that the "welfare" of a group of individuals may be considered to increase if
at least one individual in the group is made better off-in terms of their utility values-
without anyone being made worse off. Then, of any social state, if it is not posSible to make
a change without making at least one individual worse off, the state may be defined as
being Pareto-optimal. And any change may be Pareto-optimal if it benefits at least one
other individual and harms none. (pp. 107-108)
544 GOTTLIEB C. SIMON
3The conflict between actions that promote one's special interest and those that maximize
one's shared interests has received considerable attention in environmental circles as the
tragedy of the commons (see Hardin, 1968; Bardin & Baden, 1977). The "tragedy" occurs when
there is unlimited access to a common property-range land, spring water, or clean air-
that is in limited supply. Unless everyone practices conservation, the "commons" will be
destroyed. However, in the absence of some form of social control, it is in each person's
(greatest) interest to go on using the commons to the fullest; to hold back would mean only
benefiting someone else who declines to conserve voluntarily. The ultimate result, of
course, is everyone's loss. Thus while it would be in everyone's interest to restrict the use
of the commons by the public as a whole, it is in no one's interest to reduce their use
unilaterally.
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 545
the total amount of money that producers extract from consumers may be
immense, the extra amount paid by any individual consumer is too small to
motivate him or her to organize and fight back. 4 The increased recognition
of this state of affairs has fueled the consumer movement and the demand
for consumer / public representatives on licensing boards, public service
commissions, and other bodies in order to counter the influence of special
interests.
3. The public interest is what benefits the public as a thing in itself. This
approach regards the public interest as something other, or more, than the
sum of its constituent parts. This type of definition is typically labelled
"organismic" or "unitary" and carries a "mystical" connotation. (Inasmuch
as the public is regarded as an emergent characteristic, this also might be
called a "gestalt" definition.) Examples are not that readily generated. Ulti-
mately though, the public interest is the preservation and well-being of the
community "as a fellowship of common norms and common life, for it is
this form of order which gives meaning to human existence" (Cochran,
1974). Significantly, it is possible to argue from this perspective that the
continuity of the community, as an identifiable organization (organism),
over time should take precedence over the continued existence of even a
majority of its current members. In this case the conflict of individual and
peting interest groups.s (In this way it is more like preponderance defini-
tions than organismic ones.) In order for society to function an acceptable
balance must be found among these contending groups. This in turn
implies the need for a decision-making process that allows each interest a
fair hearing; but it does not imply that each group will receive anything
more than a hearing or due consideration. In some cases the definition may
assume that only the active participants in a dispute need to be involved;
in other cases the interests of "third parties" are explicitly considered a part
of the process, for example, the interest of consumers in a labor-manage-
ment dispute. In some cases the public interest is said to be represented by
the private interests in toto; in others, it is believed necessary to consider a
residual interest, that is, the public interest, that is left over when all of the
purely private interests are considered. Thus in many states a special office
such as The People's Counsel has been set up to represent the public inter-
est in utility rate hearings. The peculiar result is that the public interest is
simultaneously one of the parties in the process as well as the result of the
process.
In considering the public interest as one of the interests that must be
viewed in a proper process, the question arises as to the status of commonly
called "public interest groups." It is charged, for example, that"Any orga-
nized group of people constitutes a special interest-by definition" (Citi-
bank, 1978, p. DI6). Similarly, "it is conceivable that everyone from Plato's
philosopher-king to Ralph Nader is only doing what makes him feel good,
and any talk about the common welfare is so much window dressing"
(What is the public interest? 1974, p. 60). The thrust of these criticisms is
that the public interest is "just another special interest."6 Without trying to
5Cochran (1974) is highly critical of this approach. He feels strongly that the public interest
is more than a process:
The public interest must have a moral content. It is not a procedure, but a pronouncement
on the result of a procedure, an indication of good and evil. (p. 346)
He decries, moreover, the current preference for the public interest over the older term,
the common good. The use of this term, Cochran claims, is "itself an indication of just how
fundamental has been the shift in the assumptions underlying the contemporary ideas of
the purpose of politics" (p. 353).
6Mobil (1979), one of the large oil companies that has been heavily criticized by public inter-
est groups for its anti-consumer policies, placed advertisements in papers around the coun-
try to promote the idea that public interest groups are really special interest groups repre-
senting "an extremely selective" interest-that of college-educated, middle-class people:
We are delighted that the media seem to be growing more aware that the interests
advanced by many of the public interest lobbies are actually 'special' interests-limited
interests, often held by extremely small groups who are in obvious disagreement with the
American majority. Some are "no-growth" or even negative growth advocates, repelled by
the American lifestyle; many dislike the market economy, and the unruly freedom it
entails, others want to bring business firmly under government's thumb ....
We welcome this new skepticism about the 'public interest' label, and about who is
really entitled to it. We think the media should be especially careful about granting it to
small groups who are-on the record-anti-growth, anti-business, anti-energy, and dedi-
548 GoITLIEB C. SIMON
Other writers have used or recognized its function as "a general commend-
atory concept" (Flathman, 1966). Thus, it has been described as a "hair-
shirt" that "has offered many a public servant and citizen an uncomfortable
and persistent reminder of the unorganized and unrepresented (or under-
represented) interests in politics" (Sorauf, 1962, p. 639); and it has been
called a "spur to conscience ... and a reminder that private interests are not
exhaustive of the public interest" (Pennock, 1962, p. 182). Although it is,
perhaps, the least precise, this meaning may have the most general, com-
mon usage.
In summary, to say that something is in the public interest means var-
iously that: it benefits everybody, or most people, or that it does not benefit
cated to an elitist, big-government view of America. That's a very small, very special inter-
est, a long way removed from the goals and ideals of the American people. (p. C2)
Berry's (1976) definition of a public interest group is relevant. Rather than defining the pub-
lic orientation of a group by the number of its members, Berry looks at the beneficiaries of
its program. Does it seek a collective good, or one that selectively benefits its members
(stockholders, employees, etc.)?
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 549
a few at the expense of many others, or that everyone's interests are taken
into account before a decision is made, or that it is consistent with deeply
held customs or beliefs, or that it contributes to government policy, or that
it is government policy, or that it has emerged out of a proper decision-
making procedure, or that it is necessary for the survival of the community
qua community and the well-being of future generations, or simply that it
is "right" and "good."
It might seem from the foregoing that the problem in defining the pub-
lic interest is largely a lack of agreement at the theoretical level. Actually,
most writers, if pressed, would probably admit that they shared Walter
Lippman's (now unfashionable) definition of the public interest as "what
men would choose if they saw clearly, thought rationally, acted disinter-
estedly and benevolently" (Lippman, 1955, p. 42). The difficulty is deciding
if people have acted clearly, rationally, disinterestedly and benevolently.
That is to say, how does one validly operationalize any given definition?
Even the proceduralists who attempt to avoid the pitfalls of substantive and
normative definitions are left with the job of determining which particular
procedure best reveals the public interest in fact.
One may agree theoretically that the public interest is the sum of all
individual interests but still argue that the expressed preferences of the
majority are not a "true" statement of their aggragate interests. Thus, some
years ago, when Newton Minow was chairman of the Federal Communi-
cations Commission he informed the broadcasting industry that: "I am here
to protect the public interest," which he went on to explain was not the
same as "what interests the public" (quoted in Held, 1970, p. 86). (Concom-
itant with the effort to define the public interest, as opposed to individual
or special interests, is the problem of defining the concept of interest and
distinguishing it from wants and preferences.) It is not hard to recognize
that we all do things-eat too much, drink too much, watch TV too much-
that we enjoy but are not good for us. It is one thing, of course, to experi-
ence this as individuals and another as a society. What happens when we,
the public, want something that is not in our collective interest? Who deter-
mines that it is not in our interest? Does the present generation have the
right to make choices for succeeding generations? Definitions of the public
interest do not by themselves answer these questions. Our ambivalence in
answering these questions is reflected in our readiness at times to praise
public officials for following their conscience in voting against a politically
popular program and at other times to accuse such officials of paternalism
and elitism for trying to thrwart the popular will. Let us therefore examine
the concept of the public interest as used in practice.
7Consider this exchange between Ralph Nader and two Washington Post reporters ("Ralph
Nader Assesses," 1979):
Q. Who is the so-called consumer that you represent? And when you say you are working
in the public interest, just who's public interest is that?
A. In some cases, that can be pretty black and white. Most consumers don't like lemon cars,
they like cars to be corrected when they are faulty. They don't like to be cheated in their
insurance policies because of jargon and obscure provisions in the policy such as cancer
insurance policies. In the more difficult issues, it's a matter of judgement. How much a
group really represents the consumer is determined by a track record ... if you are dealing.
with a very sophisticated issue with lots of shades of gray, then you'd have to look at it
and make your own judgement. But we are looking at many issues of black and white, like
the Love Canal situation, that just common sense and common observation would make
you conclude that a particular issue is pro-consumer. (p. F2)
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 551
American Civil Liberties Union, and the NAACP Legal Defence Fund.
What identifies them as pro bono organizations is not their nonprofit status
or concern for indigent clients, but their commitment to providing a voice
for people or policies that might otherwise go unheard. s According to
Green (1975), a prominent member of the public interest bar, those who
identify themselves as "public interest" lawyers "have taken the legal
defense fund models a step further." Instead of representing a specific vic-
timized minority, on issues of human rights, "today's public interest law-
yers," Green says, "represent a victimized majority on issues of economic
rights" (p. 21). (Green thus shifts from a strictly procedural perspective to a
preponderance orientation). Not all public interest lawyers would agree
with Green's stress on economic rights, but they would go along with his
description of public interest law as promoting "public policy causes and
causes that would otherwise go unrepresented" (p. 21). Marks et ai. (1972)
defined public interest law in a similar manner as "that which includes both
efforts to democratize participation in the legal processes and policy efforts
addressed to the overall good of the community" (p. 51).
Modeling themselves after public interest lawyers, economists and
accountants have developed their own versions of professional activity in
the public interest. Both the economists and accountants have been con-
cerned that special interests are able to dominate policy debates. Says one
accountant:
Our point of view is that financial data can be interpreted in a number of ways,
but if one side of a particular controversy doesn't have access to accounting
expertise, there may be only one interpretation available. (Accounting, News-
week 1974, p. 58)
The economists, similarly, charge that not only is the general welfare "typ-
ically neglected" but "those most affected by the outcome of public
debates-the aged, poor, workers, women, minorities and consumers-
"seldom have the technical information they need to defend their interests
(Jones, Washington Post 1973, p. L1). The Public Interest Economics Center
in Washington, D.C., tries to right this imbalance in two ways: by doing
contract research on selected problems and by doing free consulting with
other, issue-oriented public interest groups (including testifying before
congressional committees). Accountants for the Public Interest, based in Los
Angeles, also have conducted policy oriented studies (e.g., analyzing the
cost-effectiveness of institutional versus community care for problem chil-
dren) but in contrast with other public interest professionals, they do not
SIn Doe v. Scott, an Illinois abortion case, one group of public interest lawyers took a position
for a woman's right to elect abortion, a position that was opposed, in the name of all unborn
children, by another public interest group. In the last analysis, all effort by public interest
and private law firms-whether for regular or public interest clients-must be viewed
against a single ideal: the maximization of representation so that all relevant parties are
heard from on any issue touching on decisions of public policy (Marks, Lewsing, & Fortin-
sky, 1972).
552 GOTTLIEB C. SIMON
engage in advocacy; they let the figures speak for themselves. In addition,
these accountants emphasize direct client services. Thus they provide free
or low-cost tax help to the poor and financial management aid to minority
business firms and nonprofit community groups (Aug, 1977; Wright, 1978).
The situation with public interest science is a bit different inasmuch as
scientists, in their roles as scientists, do not perform services for clients.
Thus, while there have been some suggestions that public interest scientists
should assist local, neighborhood groups who would not ordinarily have
access to scientific expertise (see Sullivan, 1975), those who call themselves
public interest scientists typically are involved in broad, policy issues of
national scope. The Center for Science in the Public Interest thus has
devoted most of its resources to preparing reports and educational materials
on a variety of consumer and technological issues from aerosol sprays and
asbestos to food additives and nuclear energy. Von Hippel and Primack
(1972), however, see public interest science as more than public education
on important scientific issues. It is education and advocacy that counterbal-
ances what they see as the inherent tendency of the federal government
and large corporations, with their enormous centralized power, to distort
information that threatens their interests. 9
The public interest movement in these other diSCiplines has helped to
inspire analogous activity within psychology. This activity has been wide-
ranging and is described in the following taxonomy:
1. Donate professional services to those otherwise unable to obtain them. The
expectation that an occupational group will provide some of its services for
free (i.e., on a pro bono basis) to needy individuals or causes is one of the
informal signs that it is considered a profession. This expectation develops
from the consensus that service to humanity is what distinguishes a profes-
sion from a technical occupation (see Goode, 1960). Accordingly, the Ethical
Standards of Psychologists (American Psychological Association, 1979)
specify that ethical psychologists "willingly contribute a portion of their
services to work for which they receive little or no financial return" (p. 5).
This standard is in keeping with the idea that client need comes before the
professional'S (financial) self-interest. Thus, in defining the characteristics
of psychology as a "good profession," the APA cites the commitment of
psychologists "to make their services accessible to all persons seeking such
services, regardless of social and financial considerations" (American Psy-
chological Association, 1968, p. 10).
9Critics sometimes charge that the members of the public interest movement are elitist, seek-
ing to substitute their preferences for those of the majority as expressed in the market place
or the ballot box. These critics confuse elitism with dissent. The work of Primack and von
Hippel (1974), for example, is best understood as a reaction against (technocratic) elitism, not
a case for it. Primack and von Hippel see public interest science not as a campaign to replace
one set of government scientists with another, but as an effort to demystify official science,
to open executive branch decision making to Congress and the public, and, thus, to demo-
craticize decisions involving science.
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 553
sional and lay groups ). But social forces, such as poverty or racial discrim-
ination, are not the only influences. There also are internal-guild-influ-
ences that interfere with the ability of psychologists to respond more fully
and promptly to consumer needs. During the turbulence of the 1960s and
early 1970s psychologists were encouraged to respond to changing social
conditions by developing new techniques (such as draft counseling and hot
lines), by modifying old ones (such as culturally biased tests) and learning
the culture and language of new and neglected client groups. Although
some psychologists sought training in new skills and modified their prac-
tices, others resisted these moves and adhered rigidly to the forms and con-
tent of prior professional training with its official imprimaturs. Still others
ignored certain needs because they did not seem to require the skills unique
to psychologists or because they threatened to blur the distinction between
psychologists and other professionals, or, worse, between psychologists and
nonprofessionals. The argument, from the point of view of the public inter-
est advocate, is that the need for appropriate and timely service should take
precedence over prior training and formal job descriptions in determining
what, where, and how psychologists do their work.
3. Apply technical expertise and knowledge to the identification and solution
of pressing social problems. Impetus for action of this sort is rooted in psy-
chology'S service orientation. Thus the bylaws of the American Psycholog-
ical Association (APA) state that the APA's purposes include advancing psy-
chology "as a means of promoting human welfare" while its Board of
Professional Affairs is to foster "the application of psychological knowledge
to the promotion of the public welfare at both state and national levels"
(American Psychological Association, 1975). Although considerable atten-
tion has been given in the last 10 to 15 years to solving significant social
problems (Korten, Cook, & Lacey, 1970), most of these efforts refer to psy-
chologists in their roles as scholars and scientists, not as practitioners. In so
far as applied psychology is concerned, the primary activity relates to the
formulation and evaluation of social policy. For example, psychologists are
urged to advise policymakers on the psychological implications of impor-
tant social policies. An important example of this work would be sugges-
tions concerning the relation of work motivation and welfare (Bauer, 1971;
Goodwin, 1975). The readiness of some psychologists to work with govern-
ment decision-makers in implementing policies aimed at resolving social
issues depends, of course, on whether they accept a definition of the public
interest as being equivalent to official policy. Although some apparently
regard program evaluation as intrinsfcally in the public interest, questions
have been raised here too. Thus, Krause and Howard (1976) refer to the
"evaluation of services in the public interest, where by 'public interest' we
mean only to indicate that the interests of all affected parties ought to be
taken into account" (pp. 4-5). Other possible activities for psychologists
seeking to serve the public interest by resolving social problems involve
the innovative application of established professional procedures. The use
of group dynamics in the late 1960s to reduce interracial conflict is one
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 555
example that illustrates this suggestion. Another was the use of personnel
selection methods to develop a personality profile for identifying potential
"skyjackers" (Daily & Pickrel, 1975); noteworthy also was the concern of the
authors for potential abuse of civil liberties in the application of the profile.
4. Withholding the application of professional skills and expertise. The con-
cern for the public welfare has led some psychologists and others to work
for more "relevant" and accessible services. On the other hand, still others
oppose the expansion of such services, particularly where public funding is
concerned. The latter have maintained that psychotherapy, for example, is
without demonstrable effectiveness and that private remuneration and
insurance reimbursement therefore constitute consumer and public "fraud"
(see Scriven, 1974). Other critics do not dispute that therapy may be effec-
tive in amerliorating individual suffering, but hold that such treatment pro-
duces undesirable social side effects. These side effects include (a) fostering
adaptation to an inherently unhealthy environment, (b) stigmatizing legit-
imate dissent as personal maladjustment, and (c) focusing personal and soci-
etal attention on intrapsychic phenomena instead of upon social structures,
all of which leads to (d) inhibiting socially beneficial change (Halleck, 1971;
Hurvitz, 1973; Ryan, 1971; Talbott, 1974).
An analogous situation exists with regard to "impersonal" services as
illustrated by the continuing controversy over the use of intelligence tests
with minority children. There is wide agreement among socially concerned
psychologists that educational tests developed and standardized on white
middle-class children are not appropriate for use with children of different
racial or class backgrounds. Therefore, some propose the use of special
norms or regression analyses when the tests are used with "disadvantaged"
students (Cleary et al., 1975). Others, however, maintain that the tests are
intrinsically deficient and serve racist and oppressive functions that are not
neutralized by technical refinements. Their position is that society is better
served by abandoning the use of the tests altogether (Bernal, 1975; Jackson,
1975).
It also has been argued that efforts by psychologists to use their exper-
tise to solve social problems may aggravate rather than ameliorate these
problems. Among the concerns that have been expressed are: (a) the pos-
sibility that contemporary psychological technology is inadequate to con-
tribute usefully to the solution of critical social problems and that its
attempted application will induce a false sense of security that allows our
problems to worsen; (b) the presence of psychologists in certain programs
will be exploited as "window dressing" and used to legitimize oppressive
social control functions; (c) that to the extent that psychological techniques
prove effective they will provide a small political and economic elite with
additional instruments for consolidating their power (e.g., personnel selec-
tion or the use of "social reinforcement techniques" in controlling campus
or ghetto riots); (d) due to their intrinsic psychogenic bias, psychological
interventions will lead to person-blaming strategies instead of attempts to
correct fundamental deficiencies in our social institutions; and (e) these
556 GOTTLIEB C. SIMON
their expert knowledge or insider status (see Edsall, 1975; Nader, Petkas, &
Blackwell, 1972). It should be noted that in contrast to the affirmative appli-
cation of professional expertise to the solution of pressing social prob-
lems-discussed in item 3 above-professional knowledge here operates as
a brake to counteract governmental and industrial mis-application of profes-
sional service and knowledge. Thus, a federally employed psychologist
might disclose that the government was illegally preparing personality pro-
files of political dissidents using information stolen from confidential clinic
files; a psychologist working for a pharmaceutical company might reveal
that data showing the adverse side effects of psychotropic drugs had been
suppressed by company officials; a school psychologist might expose the
waste of thousands of taxpayer dollars for obsolete educational materials;
and a Veterans Administration psychologist might go to a press conference
to complain that the well-being of elderly patients was jeopardized by
bureaucratic needs to reduce inpatient populations (Simon, 1978). As with
whistle blowing in general, these efforts are designed to protect the inter-
ests of innocent parties and to keep the "system" honest.
IOThe terms advocate and change-agent will be used interchangeably in this chapter. There are,
however, some significant conceptual distinctions that should be noted in labelling the
activity under discussion. Three dimensions in particular demand attention: First, is the
person who is offering the proposals under consideration "affiliated" or "unaffiliated" with
the organization that he or she is trying to influence (Hornstein, Bunker, Burke, Bindes &
Lewicki, 1971). Generally, this means, is he or she an authorized or a self-appointed change-
agent? The situation is complicated, however, when a private practitioner is asked by a
client to intervene on the client's behalf before some agency. In this case while the psy-
chologist is authorized by the client, he or she remains "unaffiliated" from the agency's
point of view. Second is the person a member of the organization or an outsider? Third,
are the proposals constructive and developmental or are they critical and restraining?
Although the term change-agent was proposed by Lippett (1958) to refer to an autho-
rized outside professional, hired to promote the organization's development, and while
much of the literature holds close to this usage, the term has been used widely to refer to
any type of social change, from psychotherapy to revolution. Patti (1974), seeking a more
restrictive term, suggests internal advocacy to describe the efforts of unauthorized, inside-
professionals who work:
in their roles as profeSSional employees ... for the purpose of changing the formal policies,
programs, or procedures of the agencies that employ them, in the interest of increasing the
560 GOTTLIEB C. SIMON
In following this advice, advocates also should avoid the obverse error,
assuming automatically that the powers-that-be will reject their proposals.
This will avoid taking a defensive and, possibly, self-defeating posture. The
authors also suggest that this assessment not be limited to the formal head
of the organization. The actual decision-maker may be someone at a lower
echelon who acts as an "internal filter" or someone outside the organization
to whom the organization's titular head is beholden.
When it is not possible to predict the administration's likely attitude
with confidence in advance, the best strategy may be to act as if the admin-
istration will be cooperative, but at the same time to be prepared for antag-
onism. ll If the administration later proves hostile to new ideas or fails to act
in good faith, the cooperative strategy can be abandoned. In the meantime
the advocates will have built a record demonstrating their own reasonable-
ness and trusthworthiness. Finally, it should be understood that the con-
sensus-conflict dichotomy is employed for analytic convenience. Most real
situations will involve aspects of both consensus and conflict in a constantly
fluctuating combination.
COOPERATIVE STRATEGIES
If one assumes that the administration shares his or her basic values
about the professional activity in question, the advocate's strategy should
stress persuasion and education. Three major types of arguments have been
suggested for use under these conditions: (1) Appeals to the organization's
mission. This argument attempts to show how the advocate's proposal is
necessary if the organization is to meet the purpose it claims for itself. Thus,
for example, a correctional psychologist might argue against prolonged sol-
llThis is not to imply either that people in positions of authority are always against change
or that they are all of one mind; sympathetic members of the administration can be impor-
tant allies. Rather, administration (and decision-makers) is used in preference to target system,
which, in the specialized language of social change theorists, refers "to those persons who
directly influence or are formally responsible for making decisions on the changes pro-
posed by the action system" (Patti & Resnick, 1972, p. 54). Similarly, advocates will be used
in preference to action system which "means those persons or groups that consciously join
in planned collective activity to change some aspect of the organization's policy or practice"
(Patti & Resnick, 1972, p. 51).
562 GOTTLIEB C. SIMON
itary isolation of a prisoner on the grounds that it interferes with the insti-
tution's stated goal of rehabilitating offenders; a school psychologist might
propose a school breakfast program on the grounds that hunger interferes
with the school's job of educating children. (2) Promises of increased effi-
ciency. Here, changes in policy are justified on the basis of their capacity
for saving the organization time or money that it could use for other activ-
ities. For example, expected reductions in absenteeism, increased employee
morale, and expanded productivity have persuaded a number of, organiza-
tions to adopt alternative work schedules such as four-day work weeks and
part-time employment. (3) Warnings of potential costs. This is really the
opposite of the preceding item. For example, a psychologist working in
industry was successful in eliminating the use of a psychological test battery
that did not meet professional standards only when he demonstrated to his
superiors that continued use of the test would make the company vulner-
able to job discrimination law suits.
Although arguments such as these can be helpful, it must be acknowl-
edged clearly that administrative decisions are not the products of a strictly
rational process (Whyte, 1969). Accordingly, advocates should avoid focus-
ing all of their efforts on demonstrating the objective costs or benefits of
the policies under discussion. They should also recognize that decision-
makers are influenced by affective and "political" considerations that may
not be immediately apparent. Thus, they should make some effort to iden-
tify and assess the hidden or "illogical" factors that may be relevant to their
proposals before they approach the decision-makers formally. Downs (1967)
has observed that:
The people who normally initiate or propose changes in a large organization
are not usually the ones who decide whether those changes will be carried out.
As a result, the conditions that cause an organization's lower-level officials to
make proposals for change are not necessarily the same ones that cause its
higher-level officials to adopt them. (p. 195)
In short, if you want to see your proposal accepted, and if you want to avoid
"spinning your wheels," you must pay attention to the "hidden agendas"
of the individuals in the organization you are trying to influence.
The contents of many of these agendas are summarized in a National
Institute of Mental Health (NIMH) sponsored "distillation" of principles of
planned change (1972). According to this study, program innovations are
most likely to be adopted when: (1) they seem relevant to recognized orga-
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 563
nizational needs; (2) they are compatible with existing values and ways of
doing things; (3) they offer more advantages, intrinsic or extrinsic, to the
organization and its staff; (4) the benefits are tangible and readily demon-
strated; (5) they are simple and easy to implement; (6) they can be reversed
if necessary; (7) they can be introduced gradually, one step at a time; (8)
they can be tried out on a pilot basis in one part of the organization; and
(9) they have high credibility, for example, the backing of highly respected
and trusted persons or groups.
On the other hand, innovations may be resisted to the extent that it
appears that they: (1) will result in a loss of status or prestige; (2) will dimin-
ish the importance attached to existing skill or knowledge; (3) will cause a
devaluation in perceived competence or ability; (4) are inconsistent with
the staff's values and job orientation; (5) will produce unpredictable and
unfamiliar situations; and (6) are being forced upon people. Internal advo-
cates must consider these issues in advancing their ideas.
Innovations also are more likely to be adopted when the nature and
implications of the changes are made clear. Accordingly, advocates should
ascertain the extent to which others appreciate and understand the specific
need for the proposed changes. In particular, every effort should be made
to dispel unfounded fears concerning job security and salaries. Concern that
change will affect job status and prestige negatively may be combatted most
effectively if it can be shown satisfactorily that change actually will enhance
status. It is also recommended that once a proposal for change is accepted
by the administration it be implemented with the collaboration of those
affected by it with ample opportunity for their feedback and modification
of the proposal as indicated.
The NIMH report placed heavy emphasis on the value of listening to
those who oppose the advocates' proposals:
It is often hard for the advocates of a new idea to emphathize with those who
don't go along. It is helpful to recognize the important social role of the defend-
ers who try to conserve valuable elements of the old in the face of a tumult of
change (Klein, 1968). Emphathizing with them, the progressives can enter a dia-
logue which may result in amendments which permit broader support of the
new idea. Failure to respect differences in values is likely to bring a backlash of
increased resistance. (p. 29)
Paradoxically the report proposes that change efforts are more successful
when an idea's shortcomings as well as its benefits are discussed:
It is particularly important that participants feel free to express their doubts and
negative feelings. Promoters of a change find it hard to believe that a frank
facing of disagreement and obstacles may win more converts than does elo-
quent exhortation in favor of their proposal. Yet this has been the experience
of many change consultants (Zander, 1962; Beene, 1962a; Glaser, 1966; Glasser
& Taylor, 1969). Conflict may be more creative than bland agreement. (p. 29)
authority of the organization or those who run it. However, when a profes-
sional seeks to put an end to a deeply imbedded practice or attempts to
block the organization's introduction of a policy that he or she regards as
harmful, a very different situaton obtains, and some additional "thoughts
for the change agent" are in order.
CONFLICT SITUATIONS
TAKING ACTION
Going through channels also may protect the (internal) advocates' job
security as well as their reputation and credibilityY It also is frequently
suggested that bringing one's grievances or suggestions to others in the
organization will help the advocates correct any errors in their analysis as
well as point out unexpected points of resistance before going to higher-
ups or outsiders. Such contact also may produce new information to buttress
existing arguments in favor of the proposal. Additionally, this process may
help to identify potential allies or supporters within the organization. Of
12This is particularly true of public employees. The courts have held that they may be fired,
under certain conditions, if their public criticism disrupts the smooth operation of their
agencies but not for making the same criticism in an internal petition even if it too creates
internal disruption. Thus government employees are protected against punitive actions
when their disclosure "took the form of a letter to an agency superior but not if it took the
form of a letter to a newspaper editor." (Eastman, 1975; Lindauer, 1975, p. 541)
The justification for limiting the freedom of speech of public employees, according to
the Supreme Court (Pickering v. Board of Education, 1968), is the need to take into consid-
eration "the interest of the State, as an employer, in promoting the efficiency of the public
services it performs through its employees" (p. 568). Clearly, much depends on how agency
efficiency is defined. For instance, a psychiatric nurse who had been dismissed on the
grounds that her public allegations that patients in her institution were sexually abused
and medically neglected created "staff anxiety," won her job back when the court found no
evidence that patient care had suffered (Lindauer, 1975). Moreover, Carl Goodman (1975),
General Counsel of the U.S. Civil Service Commission, has raised:
the question of whether agency efficiency can ever be damaged if the charge of unlawful
conduct or criminal actions is true ... it would seem that when an employee receives no
satisfaction from governmental channels and as a consequence goes public-and the
charges are in fact true-the employee's conduct should be protected. The efficiency of the
service would be benefitted by such conduct. (p. 16)
Although there would seem to be much merit to Goodman's argument, it must be noted
that, to date, it has not been authoritatively reviewed by the courts. Accordingly, while
there is some evidence of improvement (e.g., Matthews v. Washington, 1976), Miller's ear-
lier observation (1972) that "the law at present provides very little protection to the person
who would blow the whistle" (p. 25) remains generally true.
568 GOTILIEB C. SIMON
course, doing this also may drain the advocates' energy or make them vul-
nerable to administrative pressures to end their advocacy. After considering
these issues, particuarly the argument that the advocates have failed to
exhaust organizational channels, Suchotliff et al. conclude:
Even though we consider the channels lament to be an attempt to discredit dis-
senters, and deflect them from the basic issues, we would suggest that channels
be used when possible, in order to be certain in each case that they are not a
myth. (p. 234)
ApPLYING PRESSURE
130n occasion those in higher echelons in the organization will be much more receptive to
the concerned professional's complaints or suggestions than those superiors occupying
"middle management" positions. When this happens, there is, of course, no need to go
outside the organization.
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 569
OTHER TACTICS
drawn from using various tactics in widely differing locations under vary-
ing circumstances, however some generalizations appear possible.
Negotiations. When conducting negotiations advocates should try to
neutralize the psychological advantages enjoyed by those in opposition.
This might be accomplished by meeting on "neutral territory." Care also
should be taken that a strategy and spokesperson is decided upon before
the meeting. Henley (1973) provides some more specific suggestions on this
point. In general, advocates should try to keep in mind the opposition's
perception of the situation when carrying out their tactics. For example,
when conducting negotiations, Oppenheimer and Lakey (1965) recommend
that the negotiators try to do two things: "(1) describe the results of change
as less than the [opposition] suppose, and (2) describe the results of not
changing as more threatening than the results of change" (p. 24). Sometimes
the other side will try to get the advocates to see the situation from their
viewpoint as a way of co-opting the advocates. IS For instance, they may
assert that they are in sympathy with the advocates' objectives, but for var-
ious reasons insist that the time is not right for a decision. They may explain
their other problems and attempt to show how it is necessary not to "rush."
When this occurs, Oppenheimer and Lakey suggest that the advocates get
the administration to go on the (written) record as officially in favor of the
desired change in general. This wlll make it difficult for them to evade this
commitment. These writers also suggest that "The negotiators should try to
foresee all possible evasions which the opponent might introduce, and
anticipate them, using workshops and sociodrama to brief the negotiating
team" (Oppenheimer & Lakey, 1964, p. 25).
Token Offers. In the course of negotiations the opposition is likely to
make a token offer that gives the appearance of change without altering the
status quo in any substantial manner. This manuever can divide the ranks
of the advocates. Some will be willing to accept the token as a way of end-
ing the controversy and returning to normal activity. Others will want to
continue the pressure until the total change objective is achieved. Thus, the
opposition's move will be hailed simultaneously as evidence of good faith
or a first step to change and also as a sign of intransigence. Even if the offer
does not turn the advocates against each other, it still creates a problem. If
the token is accepted, the momentum for change may be dissipated. If it is
rejected, the opposition will be in a position to claim that the advocates
aren't being reasonable, aren't bargaining in good faith, or that they have
hidden motives. Suchotlif et al. (1970) had to confront this problem in pro-
15For instance, administrators may tell protesting employees to withhold publicizing their
critical views on the grounds that outside critics will use their criticisms to harm the entire
organization. The protesters, the administrators may argue, should realize that they share
a common enemy with the administrators and direct their efforts to the proper target. Con-
cerned professionals should consider arguments such as these seriously, but they also
should realize that they may be devices used by the administrators to defuse challenges to
their authority and silence criticism.
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 571
moting patients' rights in the state mental hospital where they worked.
They advise:
When responding to offers which appear to be tokens, we recommend the fol-
lowing: Accept whatever the system offers, be clear about the objectives you
wish to reach and set a time limit for reaching your goals utilizing the existing
structure. In short, we suggest that the minimal conditions for meaningful
reform must be operationally defined, and a time limit set in which this is to
occur. (emphasis added) (p. 234)
Whistle Blowing. Suppose normal channels have been exhausted, all the
time limits have expired, but conditions have not improved. At this point
it is likely that advocates will consider going "outside" for support. This
can be a very costly decision. Suchotlif et al. (1970) warn that "when one
seeks allies outside the system he must be prepared for very adverse con-
sequences since at the point where the issues are made public the battle
lines are drawn" (p. 238). Accordingly, this step should be taken only after
careful thought. Nader (1972) suggests that those considering blowing the
whistle on their organization ask themselves the following questions:
1. Is my knowledge of the matter complete and accurate?
2. What are the objectionable practices and what public interests do they harm?
3. How far should I and can I go inside the organization with my concern or
objection?
4. Will I be violating any rules by contacting outside parties and, if so, is whis-
tle blowing nevertheless justified?
5. Will I be violating any laws or ethical duties by not contacting external
parties?
6. Once I have decided to act, what is the best way to blow the whistle-anon-
ymously, ovet:tly, by resignation prior to speaking out, or in some other way?
7. What will be likely responses from various sources-inside and outside the
organization-to the whistle blowing action?
8. What is expected to be achieved by whistle blowing in the particular
situation?
the fight has been intense and the advocate begins to perceive herself or
himself as the lone target. He or she defines the situation as "bad" without
the perspective of others affected by the situation-especially those who are
most vulnerable to retaliation for unsuccessful change attempts. Advocates
need to be able to check their own tendency to view themselves as "mar-
tyrs" and to substitute their wishes for those of the people, colleagues, or
clients they want to help.
Finally, despite the best planning and the greatest diligence, the
change effort may fail. What should the advocate do then? One alternative
is to wait for another opportunity to press for change. In the interim it may
be possible to persuade a few more people. of the need for change or to
modify some related policies that will make it easier to achieve success the
second time around. For instance, the advocates may attempt to alter the
decision-making process so that it is more responsive to their concerns. But
if the gap between what the organization is doing and what it should be
doing is too great, concerned professionals may face a crisis of conscience,
especially if they are employed by the organization. Will they be endorsing
an unethical situation if they remain affiliated with the organization? And
if they leave what will happen to the people they leave behind? These ques-
tions will be considered in the next section.
ETHICAL DILEMMAS!6
Value preferences and ethical dilemmas must be confronted all along the
way. Where does one draw the line? What means may one use to oppose
deleterious conditions or policies? How does one strike a balance between
present problems and future possibilities? These problems are not limited,
obviously, to deciding whether to participate in advocacy efforts. Deciding
not to become an advocate involves the same issues. Advocacy thus is not
just a problem for a few self-appointed "zealots," it is a subject that is woven
inextricably throughout the fabric or professionalism, although this is not
always acknowledged (see Stein, 1974).
There always will be more to do than anyone person can accomplish
(Kohl, 1976). Consequently, there are continuously occasions when choices
must be made between alternate courses of action. Ironically, it is the person
who tries to make a difference who is apt to be criticized for not doing more,
while the other person who hangs back doing nothing goes unnoticed.
Concerned professionals should attempt to prepare themselves for this per-
verse situation and not be startled when bystanders have criticism instead
of compliments. The purpose of this section is to highlight some of the
choices implicit in professional practice and to ofer some suggestions to
stimulate further consideration of these issues.
1. Limited time and resources may force a choice between satisfying
immediate needs and achieving a long-range solution. For instance, a
school psychologist who works to convince the decision-makers to expand
services to children with learning problems may be criticized for failing to
take action to help this year's children. Those who undertake to provide
supplemental efforts for today's pupils will be open to the criticism that
they are doing nothing to improve an admittedly inadequate system and
thus may be contributing to its continuation. Clearly, doing something of
help to both present and future students would be the optimal solution. But
if one cannot help both groups simultaneously a choice must be made.
While it is impossible to say here that the needs of today's clients are any
more or any less important than those of tomorrow's clients, failing to make
a choice on behalf of either group is the least acceptable alternative.
2. A related problem concerns the institutionalization of advocacy ver-
sus reliance on short-term approaches. Although a serious problem will
invite the concerned professional to take unilateral action, the change effort
renewal programs in the public interest often prove to be of benefit to downtown business
interest and adverse to inner city ghetto interests. (p. 27)
They refer to this as the public interest fallacy. "One of the reasons," they write, "that many
professions embraced the concept of advocacy is that it provided an alternative to the public
interest fallacy .... The purpose of advocacy for the disadvantaged in a pluralistic society
is to promote the interests of individuals and groups which have heretofore lacked the
resources to make themselves heard" (p. 28). Without denying the validity of their analysis
of certain programs such as urban renewal, I believe that it is the intent of many committed
professionals to promote (Le., advocate) policies and programs that are, in fact, in the public
interest.
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 575
may collapse if the advocate should depart from the scene prematurely.
This may not only further delay remediation of the situation, if it occurs at
all, but may also lead to a delay in the development of effective methods
for reacting to future problems. Consequently, it is necessary to weigh the
costs of a slower, less efficient change with effort that will lead to longer-
lasting and regenerating efforts. All other things being equal, democratic
principles as well as expediency would recommend a broad-based effort
leading to the institutionalization of change over an individualistic and
more immediate approach (Havelock & Havelock, 1973).
3. Another sort of ethical dilemma arises when advocacy of one group's
interest may harm the interest of another equally deserving group. Pressure
on a government unit to improve an institution for the retarded might, for
example, result in a reduction of the budget intended for homemaker ser-
vices to the aged. Many similar conflicts can be imagined, particularly when
the economy is contracting. Government officials have been known to
exploit these situations and to playoff one group against another. Profes-
sionals concerned about the plight of a particular group with whom they
have come into contact as a result of their professional duties must consider
whether they will advocate a solution to the needs of that group exclusively
or consider the needs of other groups. A strategy that would satisfy the
needs of several groups simultaneously would not only resolve the ethical
problem here, but it would also allow the building of a strong coalition that
would have more "clout" than weaker individual constituencies.
4. Sometimes professionals feel an ethical conflict when their employer
and the direct recipient (or subject) of their services are in conflict. Is first
allegiance owed to the organization or to the "client"? Is it ethical, for
instance, to criticize one's employer in public for policies that are detrimen-
tal to service recipients? ("Client" is not the correct word to describe job
applicants, school children, prisoners, and others who are the objects of psy-
chologists' services, but who do not contract voluntarily for or select these
services.) The presumed ethical problem arises from the apparently conflict-
ing elements of the 1963 Ethical Standards of Psychologists. Psychologists
were admonished to "respect the rights and reputation of the institute or
organization with which (they are) associated" and also to "protect the wel-
fare of the person or group with whom (they are) working" (p. 3). The con-
flict between these principles was more apparent than real. No organization
has a right to harm human beings. Moreover, its reputation cannot take
precedence over human welfare, particularly when the manifest purpose of
the organization is the promotion of individual or community well-being.
The 1979 revision of the standards makes this clear. The principle relating
to responsibility to one's organization (7.d.) recognizes that psychologists
may find it necessary to disclose confidential information about the orga-
nization when this is in a client's interest. The principle asks only that the
concerned psychologist attempt to effect change within the organization
before releasing confidential information. The responsibility to blow the
whistle on an employer who uses professional services "in a way that is not
576 GoTTLIEB C. SIMON
17This situation illustrates the need for an APA Defense Fund for Professional and Scientific
Responsibility that would offer a range of services from free legal counsel to low interest
loans to psychologists whose employment is jeopardized or adversely affected by their con-
cern for the public interest. Defense funds of this sort are currently operated by the Amer-
ican Chemical Society, the National Association of Social Workers, and the National Edu-
cational Association.
18Weisband and Frank (1976) commenting on the reactions of government officials maintain
that:
If a course of action is perceived to be so wrong, so unethical or ill-advised, as to warrant
a person separating himself from those embarked upon it, is it not wrong-and undermin-
ing of faith in the whole system-to leave in such a way as to give the public the impres-
sion that all is well? The high government official who sees serious wrongdoing may justify
staying on if he can thereby mitigate the effects of the evil. Or he may quit and 'go public:
But to resign in silence or with false reassurance to the public that there is nothing wrong
may be the least ethically defensible course of all: the buying of a separate peace at the
expense of the entire process of responSible government. (p. 12)
578 GOTTLIEB C. SIMON
the question: Is this a professional thing to do? Thus, for instance, carrying
a sign on a picket line is apt to be regarded by many people of high status
as "unprofessional" (Stein, 1974). Upon examination it appears that objec-
tions that advocacy efforts are unprofessional come down to saying that
these efforts do not involve specialized training or that they violate stan-
dard occupational etiquette. 19 It is important, therefore, when this issue
comes up, to ask in what sense is something labeled "unprofessional." Is
reference being made either to the professionals' purpose or to the quality
of their practice? Or is "unprofessional" being used as a synonym for
"uncouth" or, perhaps, "immature" behavior? Sometimes a rightful concern
for decorum may obscure more fundamental and important professional
interests, for example, the conditions of professional practice. Increasingly,
institutionally employed professionals, including lawyers and physicians,
are finding it necessary to walk picket lines and participate in other actions
usually associated with lower status employees when "their working con-
ditions do not permit them to be professionally responsible to their clients
and to themselves" (Hentoff, 1973, p. 31).
Sometimes the professional status of an advocacy effort is questioned,
not because it is considered vulgar in some way, but because it does not
require extensive training or use of specialized technology unique to
applied psychologists; as, for example, writing a letter to a public official.
According to this "technocratic" view, psychologists act as professionals
only when they do something that they alone can do by virtue of their
special training or their licenses. Those things that anyone can do are there-
fore not considered professional actions. But the fact that nonpsychologists
can perform a certain operation does not imply logically that psychologists
should not also do it. The absurdity of such an argument is readily apparent
when common experience is considered. Almost anyone can read a ther-
mometer and write, but it would make no sense to conclude that these
actions therefore lie outside the role of the phYSician, qua phYSician. There
are many acts that are relevant, or even integral, to being a competent
professional even though they do not require special expertise. For
instance, anyone who discovers an unsafe product can and should file a
report with the appropriate agency, but a psychologist who uncovers a haz-
ardous product in the course of conducting a market research on the prod-
uct has a special professional responsibility to make a report since the dis-
covery came as a consequence of being a professional.
Committed professionals will realize that the objections to advocacy
efforts noted above spring not from professionalism but for professionism,
which by analogy to scientism, is a tendency to emphasize the trappings
and conventions of professional activity rather than its purposes or goals.
19 A
less antagonistic position recognizes advocacy as a legitimate "professional" endeavor,
that is, one requiring specialized training and experience, but holds that psychologists
should not engage in advocacy since they rarely have the requisite preparation (e.g., see
Lawrence, 1970).
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 579
BATTLING BURNOUT
LICENSING
20Laws that regulate who can use a particular job title traditionally have been called certifi-
cation laws. Those that regulate who can practice a certain occupation, whether or not the
person employs the usual job title, have been called licensing laws. Unfortunately, this
terminology has not always been followed by state legislatures. As a result Hogan (1979)
recommends that laws that regulate practice be called "practice" laws and those that reg-
ulate titles be called "title" laws. Laws that do not require a person to pass an examination
or meet other requirements, such as holding an academic degree, but do require listing
oneseif with a state agency, Hogan terms "registration" laws. Finally, due to the impreci-
sion that has developed, Hogan uses "licensing and licensure ... interchangeably ... (to)
include both title and practice acts and registration" (p. 238).
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 581
profession's interest. Many critics, on the other hand, argue that occupa-
tionallicensing laws, including psychology's, do not benefit the public and
in fact may cause some harm. This is an especially serious charge inasmuch
as the sole justification for government's regulating occupations is the con-
cern for the public interest (see American Psychological Association and
Conference of State Psychological Associations, 1955). Thus, the preamble
to virtually every psychology licensing or certification law cites the need to
protect "the public health, safety and welfare" as the basis for the legisla-
tion. Regulation is expected to provide this protection by (1) preventing
unqualified charlatans from posing as psychologists and (2) by deterring
unprofessional conduct on the part of bona fide psychologists. As we shall
see, critics deny that regulation achieves its purposes. Even if regulation is
effective, critics maintain that the costs of this "protection" outweigh its
benefits. Let us review these arguments.
Competence
The first aim of regulation is to assure that all persons holding them-
selves out as practitioners are, in fact, competent psychologists. 21 In pursuit
of this goal, state laws require that anyone seeking a psychology license
must have a doctorate in psychology and must pass an examination in psy-
chology. In most cases, candidates also must demonstrate that they are "of
good moral character" and have had a certain amount of "acceptable" expe-
rience. These requirements, and others that may be imposed, rest on the
assumption that they are necessary for the competent (and ethical) practice
of psychology. Unfortunately, there appears to be little evidence to support
this critical and fundamental assumption. For example, Hogan (1979), in his
Combs argues that standards in licensing laws should be set so the public has access to
competent practitioners, "At the same time," he adds, "they must not be so high as to
exclude from service practice persons who fill real public needs" (p. 560). The failure to
follow this advice, he warns, can result in a profession pricing itself out of the market. The
psychologists in one state insisted on standards for publicly employed psychologists that
were so high that the state could not find anyone who would accept the job at the salary
that the state was willing to pay. "The jobs still needed to be done, however, and several
hundred jobs are now filled by persons with little or no training in psychology whatever"
(p.560).
582 GOTTLIEB C. SIMON
Darlak (1979), who has reviewed the research literature comparing the
effectiveness of professionals and nonprofessionals in a variety of human
service situations, comes to a similar conclusion:
The central finding from these comparative studies is that the clinical outcomes
that paraprofessionals achieve are equal to or significantly better than those
obtained by professionals. (pp. 84-85)
22The 1978 Annual Report on the Licensing Examination Program of the American Associa-
tion of State Psychology Boards, as excerpted in the AASPB Newsletter (National Written
Examination, 1978) states:
Not only must it be demonstrated that a test measures what it purports to measure, but also
empirical evidence must be provided to show that what it purports to measure is clearly
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 583
left to say only that those who "score low on a test easily mastered by most
of their peers should find some other name than 'psychologist' to describe
themselves" (Ricks, 1973, p. 5). This, of course, begs the central question of
whether "psychologists," as defined by state laws, are any more qualified
to practice psychology than those who are forced to use different labels to
identify themselves.23
But suppose that licensing and certification requirements, contrary to
available evidence, are effective in screening out unqualified practitioners.
What assurance is there that a person licensed 10 or 20 years ago is still a
competent practitioner? Licensure is supposed to guarantee that everyone
practicing a regulated activity is a competent practitioner, not just the newly
licensed. There are very few licensing laws, considering all professions, that
require evidence of continuing competence and few of these require reex-
amination. In most cases continued competence is presumed. In some states,
practitioners are required to continue their education, and hence maintain
their competence, by accumulating a specified number of "credits" through
attendance at conventions and other professional meetings. Rarely, how-
ever, must the practitioners demonstrate mastery of the new information to
earn their credit. Thus, if there is any reason to question the value of uni-
versity training programs, there is even more reason to question the value
of the less structured and less well organized continuing education pro-
grams. This state of affairs cannot help but foster the suspicion that licens-
ing and certification serve to promote professional goals and not the public
interest.
related to what people actually do in their jobs and how competently they do it. In the case
of licensure, the behavioral correlates of incompetence are as important to identify as those
of competence. In the case of psychology licensure in particular, all of those demands take
on a special urgency. It is to this field of professional expertise that others look for the tools
which will demonstrate the validity of their assessment techniques, and they have every
right to expect psychology to provide a workable methodological paradigm.
There has been no lack of awareness of this growing urgency on the part of state
boards or their Association.... The boards have pressed for evidence of validity which
meets current standards; the Executive Committee has pressed for planning and research;
and the Examination Committee, at a 1976 brainstorming session in consultation with the
Professional Examination Service (PES), came up with no less than sixteen study concepts.
At its meeting in March, 1977, the Examination Committee unanimously adopted a
resolution expressing its strong concern; that professional psychology has done less
research in validating its own licensing examination than is essential to maintain the integ-
rity of the examination, given the state of federal legislation and regulations in this area.
(p.12)
Stigall (1979) has turned this problem around. Commenting on the general absence of
competency-based measures of performance for the professions, he notes one reason for
this is the prohibitive cost. He then goes on to say, "Moreover, it has not been established
that education and training are unrelated to competent practice" (emphasis added) (p. 37).
23Paradoxically, the lack of validity for certification exams does not mean in and of itself that
we should do away with certification. Consumers have a right to know the contents of a
product-or the training of service person-whether or not the contents have demonstra-
ble value. Certification laws, then, might be compared to truth-in-packaging or truth-in-
menu laws. If consumers have a right to know whether they are getting a brand name
product, then it is hard to see why they would have any less right to know what kind of
"psychologist" they are seeing.
584 GOITLIEB C. SIMON
Enforcement
The self-serving nature of professional regulation, critics claim, is also
evident in the poor performance of regulating unethical practice. Yet, iron-
ically, such regulation is the other primary justification for licensing. Stud-
ies in a number of different professions indicate that disciplinary actions
are "insignificant" given the total number of practitioners. In addition,
there is "a tendency toward leniency even in the relatively few cases that
result in formal board action" (Department of Health, Education and Wel-
fare, 1971, p. 33). Psychology appears to conform to this pattern. According
to Hogan (1979), discipline by psychology boards is "virtually non-exis-
tent." He reports that complaints to psychology boards average roughly one
a year for each year that a board has been in existence. Up to 1972, he writes,
only five licenses had been revoked. Frequently, it appears that disciplinary
action is motivated by the desire to protect the profession's image and pre-
vent public criticism (that might undermine self-regulation) rather than by
the "ethical salience" of the misbehavior (Carlin, cited in Hogan, 1979, p.
260). Part of the boards' poor performance may be due to the fact, in the
view of most observers, that they generally have little money, are poorly
administered, and lack investigative skills.24 As Hogan (1979) and others
have noted, "The result is that the public is only protected from relatively
infrequent and extreme offenses" (p. 262). These offenses, moreover, typi-
cally are already covered by laws against fraud, theft, and physical assault,
including rape. It is not difficult to come to the conclusion that the function
of disciplinary bodies is not so much to protect the public against profes-
sional misconduct, per se, but to promote the perception-however incor-
rect-that there is an effective enforcement mechanism for misconduct.
The difficulties apparent in enforcing ethical conduct also can be seen
in preventing unqualified (i.e., unlicensed) individuals from practicing.25
24 Another explanation proferred by critics for the lack of enforcement efforts is that licensing
boards are typically "captured" by the profession they are established to regulate. Cum-
mings (1979), a past president of the District of Columbia Psychological Association
(DCPA), recalls his role in the establishment of the licensing board for the District of
Columbia and illustrates the capture phenomenon:
Only one thing remained to be done in the licensing sphere. A Board of Psychologist Exam-
iners had to be selected from the many nominations which Mayor Washington had
received, and Bill, as president of DCPA, was asked to direct the selection. I was happy to
say yes to his invitation to join him in this task. We arrived at the Mayor's office one late,
winter afternoon, and, with the help of several aids that the Mayor had put at our disposal,
we completed our nominations. (Our "slate" was named as the first Board of Psychologist
Examiners the next morning.) (p. 1)
25Strangely, advocates of occupational regulation do not always acknowledge the importance
of inhibiting the activities of "charlatans." Responding to Deutsch's claim (1958) that New
York's certification law had not curtailed the activities of charlatans in that state, Katzell
and Thompson (1958) two proponents of the law, responded:
We have come across little evidence that bears on either side of this argument; but in any
event, the direct effect on charlatans is only one of the public benefits anticipated.... At
least equally important are the eventually improved training standards for applied psy-
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 585
Costs
Even if licensure could successfully insure competent and ethical prac-
tice, it would not follow automatically that it was in the public interest. It
would stlll be necessary to weigh the benefits of licensure against its costs.
According to standard economic theory, licensing unavoidably increases
the cost of professional services to the consumer. It does this in a number
of ways. By conferring a monopoly on one group of providers, licensing
reduces the number of providers and gives the licensed group the power to
further reduce the supply over time. Fewer providers mean each provider
can charge more. With lessened competition, consumers also will have less
access and influence over the services that are provided. Further, licensing
typically results in additional educational and other entry requirements. 27
As the length of training increases, cost also goes up. The cost of training,
and deferred income, must be picked up by the public through educational
Solutions
Taken by themselves the criticisms of licensing and certification of psy-
chologists if valid support the conclusion that these laws should be repealed
28"The medical profession is often cited as a case where special costs are greater than private
costs. It is usually said that 'incompetent' physicians may diagnose a disease incorrectly and
thus start an epidemic. To complete the argument, it is necessary to contend that this is
more likely or more damaging than the possibility that, if the inexpensive medical practi-
tioner is made unavailable, the consumer will neglect to consult a physician at all, thus
starting an epidemic" (Moore, 1961, p. 110).
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 587
Conclusion
In the early 1950s psychologists were concerned about their profes-
sional survival. Statutory regulation was seen as a way of guaranteeing psy-
chology's independent existence which was then threatened by the pow-
erful medical profeSSion. Thus, Ellis (1953) advised his colleagues that
"Licensure offers psychologists maximum protection against minimal
changes in medical practice acts or other restrictive actions initiated by
other profeSSional groups" (p. 552). This opinion was widely shared. 30 Sig-
nificantly, Ellis (1953) also argued for licensure (practice laws) over certifi-
cation (title laws) by pointing out "The fact that psychiatrists and phYSicians
have officially advocated that psychologists be certified rather than licensed
shows that psychology would obviously benefit more from licensing than
certification" (p. 552). How licensure would "obviously" benefit the public
is not quite so clear.
In addition to its defensive value, statutory regulation also was
regarded as leading to a number of positive professional benefits. These
included psychologists being excused from jury duty, obtaining tax deduc-
tion rights for their clients, and protection of confidential communications
from their clients. Regulation, especially licensure, also has been seen as a
30The APA and CSPA (1955) committees on legislation also reported that:
Formal recognition implies that members of that occupation have the right to practice their
occupation; in a sense, then, their social role and their existence are protected. (p. 729)
Notice that the report refers to "formal recognition." It does not limit this benefit to licens-
ing or certification.
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 589
means of achieving increased dignity and social status.3! But, apart from
confidentiality, what are the benefits to the public? Virtually all of the pub-
lic benefits claimed for practice laws can be obtained with less restrictive
legislation such as title laws or registration, as Hogan (1979) has shown.
Nevertheless, psychology has consistently sought the most restrictive leg-
islation politically possible, regulation of practice over title, the doctorate
over the M.A., and so on. Why? To some critics, the answer is clear-greed.
Money may not be absent as a motive, but there are other guild motives
that also are operating. Professional autonomy and freedom from interfer-
ence and domination by others also are clearly involved. So is a concern for
status.
It is difficult to avoid coming to the conclusion, then, that psychology's
fear and envy of medicine, and its desire for the perquisites of full-fledged
professional status, have led to the placing of guild interests before the pub-
lic interest in the manner of licensure. Whether this is a fair and valid con-
clusion will be seen in psychology's willingness to support licensing
reforms such as professional disclosure in the years to come.
CONCLUSION
31A quarter century ago when the drive for licensure was moving into high gear the APA
and California State Psychological Association committees on legislation (1955)
commented:
The argument (for licensing psychologists) is frequently supported by references to the fact
that the medical profession is licensed. Such an argument obviously overlooks the fact that
this is also true of a host of other occupations with less prestige as, for example, beauticians
and barbers. (p. 739)
Deutsch (1958) has contrasted the fact that nuclear physicists with Ph.D.s are not licensed
while mechanics with only a high school education are. Goode (1960), in a sociological
analysis, argues that licensure and status are both the result of an occupation's accumulation
of specialized knowledge and its service orientation, that is to say, its crystalization as a
profession. Nevertheless, the belief remains strong among members of emerging profes-
sions that licensure produces status (see DHEW, 1971).
Perhaps, then, psychology's concern with regulation can be interpreted by analogy to
Weber's concept of the Protestant Ethic. According to Weber, the 17th century Calvinists
were driven to accumulate capital, not for its own sake, but because they were seeking a
sign that would tell them if they were among the Elect who would enter Heaven. In a
parallel fashion, psychologists may be motivated to achieve licensure or certification not
because of its presumed instrumental value in achieving higher social standing, but because
of its symbolic value in confirming their worth to society. This idea is evident in Deutsch's
observation (1958) that many of her colleagues regarded New York State's certification of
psychologiSts as a sign that "we've finally made it as a profession" (p. 646).
590 GOTTLIEB C. SIMON
32 After a wide-ranging survey of public interest lawyers sponsored by the American Bar
Foundation, Marks, Lewsing, and Fortinsky (1972) conclude:
On analysis it turned out that what was needed was not a new definition of profeSSional
effort but simply a reassertion of the classic or traditional definition involving service
ahead of gain. This, however, might be "new" for the profession as organized today. (p.
52)
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 591
A similar trichotomy has been followed in the criteria for the APA
Award for Distinguished Contributions to Psychology in the Public
Interest:
(1) A courageous and distinctive achievement in the science or profession of
psychology which makes a material contribution to the solution of one of the
world's more intransigent social problems; (2) A distinctive and innovative con-
tribution which makes the science and/ or profession of psychology more acces-
sible in a positive manner to a greater number of persons; and, (3) An integra-
tion of the science and/or profession of psychology with social action in a
manner beneficial to all. (Conger, 1977, p. 433)
MIn professional practice, as in science, purpose, not technique, should be paramount. This
desideratum, however, may conflict with "guild" considerations, such as prestige, money,
and professional dominance. Commitment to a goal, be it increasing our understanding of
nature or giving service to the sick, is not as readily monopolized as is the use of a particular
technology. Since exclusive control over practice is both a goal and a condition for social
recognition, there is a great temptation for practitioners, particularly those in newly devel-
oping areas, to emphasize methodology above all else. Goode (1960) notes this development
in a discussion of this "newer type of profession" where:
there is no precise social definition of the juncture at which the client may properly call
on professional help, or even of the problems served by the profession. Rather there is a
definition of skills and knowledge, that is, of the field. The sociologist-professional cannot
identify his problem as the physician who says: "I heal the sick," but must identify his skill:
"I solve sociological problems" (p. 906)
The tendency to define one's activity exclusively by the contents of one's tool box may lead
to socially irresponsible practice. For its effect on science see Kaplan's (1964) discussion of
the "law of the instrument" and Chein (1972) on "scientism" in psychology. See also the
discussion of advocacy and professionalism on pp. 577-579.
PSYCHOLOGY, PROFESSIONAL PRACTICE, AND THE PUBLIC INTEREST 593
more sober, and being more attached to society's rules and norms than the other
applicants, and the norms which are established" (personal communication
emphasis added). Puzzled why these attributes should disqualify her for the
job that she wanted, the young woman filed a complaint with the Reno
Civil Service Commission. According to local news reports (Barber, 1978, p.
12), the psychologist wrote to the Commission in defense of his actions:
I must say that police work is rather obviously not very "nice" work and if the
department wishes to choose persons possessing certain personality traits
which seem to be most consistent with the present constituency of the police
force and with the type of work to be done, then such a decision may seem
reasonable under the circumstances. This, however, must be a matter to be taken
up with the police chief and not with me, for as I explained, I am only an agent
carrying out with exactness and care the professional duties assigned to me. (emphasis
added)
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VIII
POLITICAL AND REGULATORY
PROCESSES
17
The Changing and Creating of Legislation
THE POLITICAL PROCESS
PATRICK H. DELEON
601
602 PATRICK H. DELEON
they pleased. Rarely are bills enacted into public law merely because they
are theoretically a "good idea." Politicians pass bills 'because they want to.
This does not mean that Dr. Doe cannot, or should not, now attempt to
modify the Psychology Licensing Act in order to bring state employees
under its provisions. It instead means that she must go about accomplishing
her objective in a slightly different fashion.
What Dr. Doe should have done was first to build a natural constitu-
ency of concerned individuals and organizations who eventually would
stand firmly and publicly behind her proposal. Note that at this initial stage
Dr. Doe should not worry about how actually to draft a bill. Nor should she
deliberate on the specifics of the modifications to the Psychology Licensing
Act that she will eventually propose. These particulars will, of necessity,
evolve at a later date. If Dr. Doe commits herself to specifics during the
preliminary stages, she will only create additional points for argument. In
addition, she should be aware that especially in her early attempts to
develop public support, she will repeatedly come across apparently well
intending individuals, including her psychologist colleagues, who will
enumerate the myriad of reasons why her proposal cannot be enacted into
law. Although this will be disheartening, she should persevere. Any pro-
posed change in the scheme of things is unsettling and even frightening
for some people. Dr. Doe's therapeutic and clinical skills should help her
in aSSisting her natural allies to overcome their initial apprehension.
There typically will be three distinct types of groups that potentially
will be affected by her efforts to modify the Psychology Licensing Act. The
first, and perhaps the most obvious, will be those that will directly benefit
from the proposed changes; for example, patients (who may not be inclined
to be involved) or psychologists who seek to enhance the prestige of their
profession. The second will be those that perceive themselves to be
adversely affected; that is, governmental employees who cannot now meet
the present requirements set forth under the Licensing Act. The third, and
probably the most influential group, consists of those "tangential" organi-
zations such as the Mental Health Association or the League of Women Vot-
ers who admittedly will not directly benefit from the actual substance or
content of Dr. Doe's bill even if it becomes law. However, these organiza-
tions can benefit from the process of being involved with Dr. Doe and her
colleagues in the legislative effort. Organizations such as the League of
Women Voters command considerable respect. They earn this respect by
being vocal spokespersons for legislative issues such as Dr. Doe's that are
found to be in the best interests of the state's citizenry. In essence, individ-
uals such as Dr. Doe provide substantive expertise; the League of Women
Voters provides legislative credibility. To the extent to which Dr. Doe is
successful in getting these three categories of "special interest" groups to
publicly endorse her proposal, her prospects of eventual legislative success
will be significantly enhanced.
In deciding how to approach the various potentially supportive indi-
viduals and organizations, Dr. Doe should think through, in as specific
606 PATRICK H. DELEON
terms as possible, exactly what benefits each of them might receive from
their involvement with her proposal. She also should attempt to identify a
particular member of each organization, preferably an individual on its leg-
islative committee, who would be willing to make the organization's
endorsement of the proposal his or her personal goal. It may seem obvious
that it is more difficult for an organization to refuse to endorse formally a
proposal that one of its own members is enthusiastically championing;
however, this point is often overlooked. For the local psychological associ-
ation, Dr. Doe's proposal would mean a chance to develop its legislative
contacts and hopefully have a successful accomplishment to discuss in its
meetings and to write about in its newsletter. It also would help solidify its
professional status. Dr. Doe also should arrange to be appointed to the asso-
ciation's legislative committee in order to be in an appropriate position to
sheperd her own bill through the various stages. For the private practition-
ers, the proposal would provide an additional opportunity to put pressure
on the state Mental Health Authority to examine the extent to which it can
afford to provide direct services, rather than contract these out to the private
sector. To the university faculties, this could mean both an opportunity for
their graduate students to obtain practical experience in being "social
change agents" by working directly on a legislative proposal and a chance
to develop a potentially increased audience for any continuing education
courses that the Psychology Licensing Act eventually might require.
For those "tangential" groups such as the Mental Health Association,
the League of Women Voters, and the other professional societies, includ-
ing the local Nurses and Social Worker Associations, Dr. Doe's proposal
provides a concrete vehicle for increased collegial collaboration. By sup-
porting the efforts of the local psychological association, each of these other
groups will in turn be developing a potential prestigious ally for similar
public expressions of joint support on a matter of more germaine interest
to their own membership. But probably of even greater practical signifi-
cance is the simple fact that Dr. Doe's proposal will provide their legislative
committees with a socially meaningful proposal that they then can debate
internally and eventually support publicly. One never should underesti-
mate the extent to which individuals who get themselves appOinted to var-
ious legislative committees thoroughly enjoy discussing proposals, taking
positive stands, and then being able to report back their actions to their own
constituencies.
Although the development of active support for the proposal by these
groups is absolutely essential, by itself it is not sufficient. To be successful
eventually, Dr. Doe also must undertake direct negotiations with those
individuals who potentially will be adversely affected by the proposal.
There is nothing more devastating to a bill's ultimate chances than to have
those who it would directly effect suddenly proclaim in a loud and highly
emotional manner, during public hearings that it was being "snuck by
them," or "railroaded down their throats," or that its proponents never had
bothered even to discuss it with them. To treat any group in such a cavalier
THE CHANGING AND CREATING OF LEGISLATION 607
phone calls from other state employees. However, if the expressed and
active support of the chief of the Mental Health Authority can be obtained,
and he or she is personally willing to press for the particular proposal being
included as a part of the department's and thus the Administration's legis-
lative package, then many (but unfortunately not all) of these self-pro-
claimed "gate-keepers" will focus their attention on other proposals that
seem to have less overt support.
If Dr. Doe has done her homework well and created a general consen-
sus of "grass-roots" support among the state psychologists, the chief of the
Mental Health Authority undoubtedly will endorse the proposal, if for no
other reason than to keep his employees happy. Keep in mind, however,
that if one decides to use the administrative route, once the proposal
becomes an Administration bill, it no longer belongs to Dr. Doe or to the
state psychologists, it is the Administration's bill. Unless the spokesmen of
the Administration believe in its merit and are sufficiently educated as to
its value, it will be expendable and vulnerable. Additionally, since political
circles are small circles, especially within any given content area such as
"health" or "mental health," the proposal undoubtedly will come to the
attention of all those individuals or organizations who have any related
"vested interests." Thus, in asking the Administration to introduce such a
bill, one should never try to conceal any supporting or opposing data that
might be available, since such information probably will be made public by
one of these other individuals or organizations which in turn would lead
to a breach of trust that may never be repairable.
If Dr. Doe decides against the Administration route and concludes that
she wants to maintain more direct control over the proposal's evolution, she
then must choose a legislator whom she will ask to introduce her bill. In
the best of all possible worlds, Dr. Doe would be a close personal friend of
the chairman of the committee that has jurisdiction over her proposal.
The chairman would then introduce the bill.
Usuaily, however, she will be faced with an entirely different choice:
either polling members of the local psychological association to find out if
anyone knows a particular legislator well enough to ask him or her to intro-
duce the bill as a personal favor, or sending a subgroup of the psychological
association's legislative committee to meet with the chair of the relevant
legislative committee to request that he or she introduce the bill on their
behalf. In either case, the chance of immediate success, or even success the
first year the bill is introduced is remote. As I suggested earlier, most leg-
islators, primarily due to their lack of mental health expertise, do not feel
comfortable discussing mental health legislation and as a result take a very
cautious approach in pressing for its enactment.
Earlier, I referred to the legislative process as being analogous to psy-
chotherapy with dysfunctional families. Like a family therapy session, the
legislative process must be orchestrated on two distinct tracks. One is based
on interpersonal relationships, where as many favors as possible are done for
one's "friends" or "contacts." The other track emphasizes the content, or
610 PATRICK H. DELEON
subject matter expertise, that a given committee chairman and his staff have
developed in order to pursue some long-range objective. (For example, the
health committee might want to increase the level of accountability evident
in the health services that are being provided in its state. To accomplish
this, whenever possible, they will recommend the enactment of bills that
will bring the "present state of things" closer to their ultimate objective.)
In conducting family therapy, awareness of these two levels, relationship
messages and communicational content, is essential. Successful therapy
requires that the content of what is being expressed be congruent with the
underlying interpersonal process. (For example, the expressed anger is
being directed by the member who is in fact frustrated, and that it is at the
person that he or she is really concerned about.) Similarly, when a partic-
ular legislative proposal is consistent with the objectives of both of the
interpersonal and the content tracks,. then there is maximum likelihood of
passage. Either one alone is generally not sufficient.
As Dr. Doe becomes more sophisticated with the intricacies of the leg-
islative process, she will begin to appreciate the importance of each proce-
dural step. She will, for example, learn that typically there is considerable
value in the mere step of having her bill introduced (Le, formally placed
on the appropriate committee's legislative agenda) even if it is only by a
member of the minority party or ''by request" (Le., the legislator presents
it not as his own proposal but as a favor for someone else). Admittedly,
under the latter two conditions, there is not a very significant likelihood of
the bill's enactment into law immediately. Yet, the introduction of a legis-
lative bill in itself is a concrete symbol of success for its supporters. A gen-
erally unexpected consequence is that such a step often carries sufficient
import to convince others of the proposal's worth. Those within the profes-
sion who previously had "serious concerns," often become the strongest
backers of the proposal and in so dOing, they may make special contribu-
tions in tightening and clarifying the rationale behind the endeavor. True,
many of Dr. Doe's professional colleagues will naively assume that the bat-
tle is won, although as we realize, the work has only just begun.
There are a number of possible steps that Dr. Doe and her colleagues
might wish to take next. The actual bill could serve as a specific focus for
the legislative efforts of the entire psychological association's membership.
Individual members could arrange meetings with the elected officials from
their own districts and ask them to support the bill. If the specific procedure
exists whereby the politician can formally "cosponsor" the bill, such sup-
port can be requested. He or she also can be requested to enter a similar bill
in his or her own name or to write the committee chair expressing personal
support. The advantage of these more formal endorsements is that they
clearly demonstrate legislative "grass-roots" support for the measure, which
significantly enhances the likelihood of the committee's eventual favorable
action. Cosponsorship is especially helpful if the legislator actually is a
member of the committee that has jurisdiction over the bill. As I alluded to
earlier, however, one of the specific functions that every committee is sup-
THE CHANGING AND CREATING OF LEGISLATION 611
posed to serve is to act as a "natural buffer" for the entire legislative body
for bills within its jurisdiction. Once the majority of a committee recom-
mends passage, there is not supposed to be any more than token opposition.
For this system to function smoothly, each committee must accept the
responsibility of ensuring the legislature as a whole that few of their indi-
vidual constituents will strenuously object to the passage of a particular bill.
Thus, if a cpmmittee member's decision to recommend enactment is made
lightly, this very basic and absolutely crucial sense of trust will be seriously
compromised. The cosponsorship of a committee member is quite difficult
to obtain, but it is very Significant. Committee members speak for more than
just themselves as individuals, they also speak for the entire legislature.
Once a bill is formally introduced, there is typically a highly institu-
tionalized process through which it eventually must proceed in order to
become law. Each of these steps is really quite distinct and has a very dif-
ferent objective. Dr. Doe and her supporters can have input into every one
of the steps and, with appropriate preparation, their contribution can be
extremely Significant.
The first major hurdle for the proposal is the scheduling of public hear-
ings on its merits. Although this sounds like a fairly routine matter, it is
probably the most difficult to achieve. Without such hearings, it is only
under extremely rare circumstances that the proposal will advance. On bills
that would significantly alter present policy, it often takes one or two leg-
islative sessions, over the course of several years, before hearings are sched-
uled. This reluctance to schedule the hearings is difficult for most psychol-
ogists to understand. During their professional careers, psychologists tend
to develop a decision-making style that emphasizes the systematic gather-
ing of comprehenSive data before making final decisions. Thus, the public
hearing process would intuitively seem a most reasonable procedure with
which to obtain the basic information needed to decide on the proposal's
overall merits. However, to a legislator, the mere fact of holding hearings
is in itself almost a commitment to act favorably upon the bill. It is not a
mere data gathering exercise. This substantial difference in orientation is
one most psychologists do not appreciate.
Hearings are scheduled because the chair of the legislative committee
with jurisdiction authorizes them to be scheduled-not because they nec-
essarily should be scheduled. The best way for this scheduling to occur is
for the chair to want to chair the hearings, or for a ranking member of the
committee specifically to request that they be scheduled. If the chair decides
to schedule hearings on Dr. Doe's proposal this will be a substantial com-
mitment of valuable time: time to prepare for the hearing, time to actually
sit in the room and listen to the witnesses, time to sort through and evaluate
the testimony that will be presented, and time for subsequent discussion
and votes. By definition, this is time that must be taken away from other
proposals that may have more merit or more overt support (e.g., the Admin-
istration's program, or those bills being pushed by major labor unions). The
agreement to schedule hearings is no small concession.
612 PATRICK H. DELEON
If the committee chair does decide to hold hearings, there are a number
of useful things that Dr. Doe and her supporters can do. First, they can pro-
vide the committee staff with a detailed, but very straightforward "briefing
memo" of what the proposal would accomplish, what it would cost, and the
various pros and cons. This memo should evolve from at least one informal
meeting with the committee staff with whom Dr. Doe discusses the pro-
posal's merits and answers questions. These questions will indicate the
extent to which psychology has an educational job to do. They may include,
"What is a psychologist?" "How much training does he or she possess?"
"How do psychologists differ from medical doctors?" "Does the state uni-
versity have a psychology program?" "Isn't it a part of the medical school?"
During sessions such as these, psychologists will become aware of the
extent to which a single introductory psychology course seems to be the
basis of a not-too-favorable image of their profession in the minds of these
staff members. The staff may be recently graduated, aggressive young attor-
neys, eager to display their interrogratory skills. In some fortunate situa-
tions, much of this tedious baseline educational process already will have
been done by, for example, previous psychology advocates or by students
placed as interns with the legislative committee. Such familiarity should
not be assumed, however, nor does it preclude the need for a detailed jus-
tification of the proposal.
The next task for Dr. Doe is to help the committee staff think through
which witnesses should be invited to testify. On the one hand, once the
hearing data is scheduled and publicly announced, the major "special inter-
est" groups such as the medical association and the insurance lobby will
become aware of the proposal and will decide on their own whether or not
they want to testify. However, many groups that might be interested in
working in a collegial relationship with the psychological association typ-
ically are not in the mainstream of this communicational flow and may not
be aware of the hearings unless they are specifically alerted. This is not due
to any conscious effort to keep anyone uninformed, but because, as a prac-
tical matter, some groups rely on volunteers to serve on their legislative
committees rather than hire professional lobbyists, and these volunteers
usually simply do not have sufficient contacts to obtain the information
required. Although the necessary information is readily available at no cost,
one has to understand the legislative system in order to learn where to look
for it.
Dr. Doe and her supporters should do the leg work themselves to
ensure that an appropriate cross section of their expected supporters request
to testify, write, and have available the reqUired 30 or so copies of their
formal written testimony, and then actually show up at the hearings and
wait their turn to be called as interested parties. On an issue such as this
one, it would be useful to have some experienced mental health center
chiefs testify in support, to have the state psychological association presi-
dent emphasize the proposal's similarity with the national American Psy-
THE CHANGING AND CREATING OF LEGISLATION 613
he/she does not feel personally threatened by the experience with the com-
mittee. Obviously, Dr. Doe should make a specific effort to ensure that each
of her allies is as comfortable as possible throughout the process.
In testifying, each witness should be urged to have a personal goal and
to engage whatever legislator happens to be in the room in an intimate
person-to-person discussion about the issues being discussed. To the extent
to which one can get a legislator interested enough in your issue that he or
she actually will raise a question-not matter how insignificant it may
seem-one has succeeded. One tactic that is especially effective in this
regard is to begin one's testimony by thanking the chair for allowing you
to take some time from his or her busy schedule, indicate that you would
like to have your written testimony submitted into the formal hearing
record, and then request permission merely to highlight your testimony in
an effort to save the committee time. The chair almost always will give
approval and will appreciate your thoughtfulness in doing this. You can
then emphasize the highlights of your argument and present them in as
cogent a manner as possible, looking directly at the chair all the time rather
than reading from a prepared text. If one does decide to employ this tactic,
it is helpful if you have already rehearsed this "spontaneous" presentation.
Utilizing this type of format also allows you to maximum opportunity to
respond in a personal manner to any unexpected or emotional issues that
earlier witnesses may have brought up. One should not feel constrained by
the actual prepared text of one's own testimony but instead should be will-
ing to respond spontaneously to the situation as it exists at that time.
If Dr. Doe has been successful during her briefing session with the
committee staff, the chair would have before him or her a series of "sug-
gested questions" that he or she might ask-questions that Dr. Doe actually
wrote out herself. These questions will be phrased to place controversial
issues in such a light that they will be most favorable to Dr. Doe's cause.
For example, "Dr. Doe, do you mean to tell me that there are no quality
controls on our state psychologists and that those who cannot afford private
psychologists or psychiatrists possibly receive lower quality services merely
because these practitioners do not have to meet the continuing education
requirements that our committee passed last year? That's incredible!" To the
spokesman for organized medicine who very well might be expected to
oppose the bill, the chair might ask "Would you please explain to me why
it is that organized medicine feels that they should oppose another profes-
sion's efforts. to upgrade the quality of its own services? Is it not a fact that
a similar effort is right now being made within your own profession to have
the medical licensing act modified in exactly the same manner?"
These types of questions have several purposes. First, they serve to edu-
cate the committee chair about the subtleties involved in the proposal while
personally involving him or her in the debate. As a result, he or she will
be more likely to follow through on his or her own initiative during the
forthcoming "mark up" sessions. To the extent to which the chair feels that
there are subtleties that he or she does not understand, he or she naturally
THE CHANGING AND CREATING OF LEGISLATION 615
signature. A veto is possible, but on a bill such as Dr. Doe's this would be
highly unusual.
Once Dr. Doe's proposal has become public law, the question of its
actual administration remains. For example, now that the state psycholo-
gists are included, or rather not expressly excluded from the provisions of
the Psychology Licensing Act, who is going to put pressure on the present
employees of the mental health centers to take the examination? Further,
as a purely practical matter, what is to happen if one of them fails the test?
These questions deal with the issue of how the law is to be implemented
and administered. Generally, these matters are resolved through detailed
implementing "rules and regulations" rather than actual legislative
language.
Implementing rules and regulations are promulgated by the appropri-
ate regulatory board in compliance with the state's administrative proce-
dure act. As a minimum, this requires public notice, opportunity for com-
ment, and formal publication. Once issued, the regulations have the force
of law but are modifiable through the same process of public notice, hear-
ing, and republication. Although the administrative regulatory agencies
generally are conscientious about fulfilling their responsibilities, a formal
inquiry by Dr. Doe and her supporters would probably facilitate the imple-
mentation of the law. In a proposal as straightforward as Dr. Doe's there
should not be any difficulty as the agency staff will be as objective and non-
arbitrary as possible. However, there can be incidental slips unless an inter-
ested party is concerned enough to inquire and raise appropriate questions.
If progress is not made after a reasonable period of time, Dr. Doe should
ask the state attorney general to intervene and ensure that the intent of the
state's laws are fulfilled. For psychology this would be a rare situation; how-
ever, if necessary, Dr. Doe should pursue this avenue. Laws enacted by the
legislature ultimately rely on the executive and judicial branches for their
implementation. One is not being hostile by asking for this implementa-
tion; one is merely insisting on one's rights.
Another job remains for Dr. Doe and her colleagues. It relates to the
all-important interpersonal track that was referred to previously. Politicians
exist to serve their constituents. Having enacted a bill at Dr. Doe's request,
it is only fitting that the committee chair or the bill's prime sponsor recieve
the recognition that he or she deserves and expects. To put it bluntly, what
good is it to do psychologists a favor if they don't realize what you have
done for them? Accordingly, Dr. Doe and her supporters should ensure that
their supportive legislator knows that they are appreciative of the assistance.
There are a number of possible to convey this all-important message
effectively; for example, the local psychology newsletter could carry a for-
mal letter of appreciation and photograph of the legislator shaking hands
with Dr. Doe. The association's executive committee could ensure that the
legislator receives a formal "certificate of appreciation" at the next annual
convention with appropriate press coverage. One way that would be espe-
618 PATRICK H. DELEON
cially meaningful to the legislator would be for Dr. Doe and her supporters
to arrange a "coffee hour" for him or her. They could have 40 or 50 of their
friends who are in the legislator's own electoral district meet at a centrally
located home with coffee and light refreshments being provided by the
host. The elected official could then be formally introduced, appropriately
complimented, and provided with a forum to address his or her constituents
for 15 to 20 minutes. Following this, he or she could answer questions, min-
gle with the crowd, and generally get to meet those in attendance on an
informal basis. Although this may sound very Simplistic, these are the indi-
vidual voters who keep him or her in office, and it is their favor that he or
she wants. By providing the official with the opportunity to meet them on
such a positive note, Dr. Doe now has done the legislator a favor in turn.
Favorable publicity and voter satisfaction are the basis of getting reelected.
In the United States it increasingly is individual voters, not political parties,
who keep elected officials in office.
If Dr. Doe and her friends wished to become even more involved in
the political process, there are numero~ activities appropriate for them as
concerned citizens. For example, as election time draws near, politicians
look for volunteers to assist in door-to-door canvasing, sign waving, con-
ducting telephone polls, and preparing pOSition papers. Raising campaign
funds for the legislator's reelection is always helpful. Often, the amount
actually raised is not as important as the fact that a number of constitutents
have contributed. Once a potential voter contributes even a dollar, he or
she is much more likely to vote for the candidate. When legislators have
public fund raisers, there is no question that they do want to raise funds.
More important is the appearance of raising money and of having a room
filled with people that look like they are enjoying themselves. All too often,
psychologists only make their presence known to their elected officials
when they have specific guild concerns that are not readily resolvable.
There are a host of societal issues upon which psychologists could have a
Significant impact. As concerned citizens and as members of a learned
profession, it behooves us to become involved in these nonguild issues, if
only to avoid the image of being solely concerned with self-serving matters.
If Dr. Doe looks out for her supportive legislator, he or she in turn will
look out for her interests. If the legislator does not make a policy of doing
this, he or she will not be reelected.
The particular bill that we focused upon in this chapter was generally
a noncontroversal one. Yet, as psychologists become more actively involvetl
in the political process, we will undoubtedly eventually seek to implement
some rather major and thus, by definition, highly controversial legislative
changes. The underlying process remains the same, only the stakes and the
concurrent emotional involvement increase proportionately. In this
regard, a number of our larger states have found it especially useful to
develop a systematic statewide "legislative network" through which their
state association legislative committees can be assured that every elected offi-
cial will receive direct communications from psychologists in his or her own
THE CHANGING AND CREATING OF LEGISLATION 619
district whenever a statewide alert becomes necessary. But again, the basic
legislative process is the same, regardless of how large a state may be or
how complex an issue may appear at first glance.
CONCLUSIONS
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A sourcebook. Washington, D.C.: American Psychological Association, 1979.
McGinn, P. Psychologists and the legislative process. SPAA Newsletter, 1978, 9, 1-2.
Metsky, M. Getting our feet wet in national politics. Clinical Psychologist, 1978, 31, 10.
Pallak, M. Psychology in the public forum (Editorial), American Psychologist, 1982, 37, 475.
Saks, M. Social psychological contributions to a legislative subcommittee on organ and tissue
transplants. American Psychologist, 1978, 33, 680-690.
IX
APPENDIXES
APPENDIX A
623
624 ApPENDIX A
any time and in any setting, whether public the mentally ill." ordered by the U.S. District
or private, profit or nonprofit, are required to Court in Alabama (Wyatt v. Stickney, 1972). In
observe these standards of practice in order concert with other APA committees, the Task
to promote the best interests and welfare of Force also represented the Association in
the users of such services. It is to be under- national-level deliberations with govemmental
stood that fulfillment of the requirements to groups and insurance carriers that defmed the
meet these Standards shaH be judged by qualifications necessary for psychologists in-
peers in relation to the capabilities for evalua- volved in providing health services.
tion and the circumstances that prevail in the These interim outcomes in vo Ived infl uence
setting at the time the program or service is by the Association on actions by groups of
evaluated. nonpsychologists that directly affected the
manner in. which psychological services were
Standards covering other psychological ser- employed, particularly in health and rehabilita-
vice functions may be added from time to time tion settings. However, these measures did not
to those already listed. However, functions and relieve the Association from exercising its re-
activities related to the teaching of psychology, sponsibility to speak out directly and authorita-
the writing or editing of scholarly or scientific tivelyon what standards for psychological prac-
manuscripts, and the conduct of scientific re- tice should be throughout a broad range of
search do not fall within the purview of the human service settings. It was also the respon-
present Standards. sibility of the Association to determine how
psychologists would be held accountable
should their practice fail to meet quality stan-
dards.
Historical Background In September 1974, after more than 4 years
of study and broad consultations, the Task
Early in 1970, acting at the direction ofthe As- Force proposed a set of standards, which the
sociation's Council of Representatives, the Association's Council of Representatives a-
Board of Professional Affairs appointed a Task dopted and voted td publish in order to meet
Force composed of practicing psychologists urgent needs of the public and the profession.
with specialized knowledge in at least one of Members of Council had various reservations
every major class of human service facility and about the scope and wording of the Standards as
with experience relevant to the setting of stan- initially adopted. By establishing a continuing
dards. Its charge was to develop a set of stan- Committee on Standards, Council took the first
dards for psychological practice. S;)on thereaf- step in what would be an ongoing process of
ter, partial support for this activity was obtained review and revision.
through a grant from the National Institute of The task of collecting, analyzing, and syn-
Mental Health. 3 thesizing reactions to the original Standards fell
First, the Task Force established liaison with to two successive committees. They were
national groups already active in standard set- charged similarly to review and revise the Stan-
ting and accreditation. It was therefore able to dards and to suggest means to implement them,
influence the adoption of certain basic princi- including their acceptance by relevant gov-
ples and wording contained in standards for emmental and private accreditation groups.
psychological services published by the loint The dedicated wolk of the psychologists who
Commission on Accreditation of Hospitals served on both those committees is gratefully
(lCAH) Accreditation Council for Facilities acknowledged. Also recognized with thanks
for the MentaHy Retarded (1971) and by the are the several hundred comments received
Accreditation Council for Psychiatric Fa- from scores of interested persons representing
cilities (lCAH, 1972). It also contributed professional, academic, and scientific psychol-
substantially to the "constitutionally required ogy, consumer groups, administrators of fa-
minimum standards for adequate treatment of cilities, and others. This input from those di-
STANDARDS FOR PROVIDERS OF PSYCHOLOGICAL SERVICES 625
rectly affected by the original Standards pro- under the law for those receiving privately de-
vided the major stimulus and much of the con- livered psychological services. On the other
tent for the changes that appear in this revision. hand, those receiving privately delivered
psychological services currently lack many of
the safeguards that are available in gov-
ernmental settings; these include peer review,
Principles and Implications consultation, record review, and staff supervi-
of Standards sion.
5. While assuring the user of the psycholo-
A few basic principles have guided the de- gist's accountability for the nature and quality
velopment of these Standards: of services rendered, standards must not con-
I. There should be a single set of standards strain the psychologist from employing new
that governs psychological service functions methods or making flexible use of support per-
offered by psychologists, regardless of their sonnel in staffmg the delivery of services.
specialty, setting, or form of remuneration. All
psychologists in professional practice should be
guided by a uniform set of standards just as they The Standards here presented have broad
are guided by a common code of ethics. implications both for the public who use
2. Standards should clearly establish mini- psychological services and for providers of
mally acceptable levels of quality for covered such services:
psychological service functions, regardless of I. Standards provide a firmer basis for a
the character of the users, purchasers, or mutual understanding between provider and
sanctioners of such covered services. user and facilitate more effective evaluation of
3. All persons providing psychological ser- services provided and outcomes achieved.
vices shall meet minimally acceptable levels of 2. Standards are an important step toward
training and experience, which are consistent greater uniformity in legislative and regulatory
and appropriate with the functions they per- actions involving providers of psychological
form. However, final responsibility and ac- services, and Standards provide the basis for
countability for services provided must rest the development of accreditation procedures
with psychologists who have earned a doctoral for service facilities.
degree in a program that is primarily psycholog- 3. Standards give specific content to the pro-
ical at a regionally accredited university or pro- fession's concept of ethical practice.
fessional school. Those providing psychologi- 4. Standards have significant impact on to-
cal services who have lesser (or other) levels of morrow's training models for both professional
training shall be supervised by a psychologist and support personnel in psychology.
with the above training. This level of qualifica- 5. Standards for the provision of psycholog-
tion is necessary to assure that the public re- ical services in human service facilities influ-
ceives services of high quality. ence what is considered acceptable structure,
4. There should be a uniform set of stan- budgeting, and staffing patterns in these
dards governing the quality of services to all facilities.
users of psychological services in both the pri- 6. Standards are living documents that re-
vate and public sectors. There is no justification quire continual review and revision.
for maintaining the double standard presently
embedded in most state legislation whereby
providers of private fee-based psychological The Standards .illuminate weaknesses in the
services are subject to statutory regulation, delivery of psychological services and point to
while those providing similar psychological their correction. Some settings are known to re-
services under governmental auspices are usu- quire additional and/or higher standards for
ally exempt from such regulations. This cir- specific areas of service delivery than those
cumstance tends to afford greater protection herein proposed. There is no intent to diminish
626 ApPENDIX A
User includes:
Definitions A. Direct users or recipients of psychologi-
cal services.
Providers of psychological services refers to B. Public and private institutions, facilities,
the following persons: or organizations receiving psychological ser-
A. Professional psychologists. 4 Profes- vices.
sional psychologists have a doctoral degree C. Third-party purchasers-those who pay
from a regionally accredited university or pro- for the delivery of services but who are not the
fessional school in a program that is primarily recipients of services.
psychological S and appropriate training and
experience in the area of service offered. 6 Sanctioners refers to those users and nonus-
B. All other persons who offer psychologi- ers who have a legitimate concern with the ac-
cal services under the supervision of a profes- cessibility, timeliness, efficacy, and standards
sional psychologist. of quality attending the provision of psycholog-
ical services. In addition to the users, sanction-
Psychological services refers to one or more ers may include members of the user's family,
of the following: 7 the court, the probation officer, the school ad-
A. Evaluation, diagnosis, and assessment ministrator, the employer, the union represen-
of the functioning of individuals and groups in a tative, the facility director, etc. Another class
variety of settings and activities. of sanctioners is represented by various gov-
B. Interventions to facilitate the functioning ernmental, peer review, and accreditation
of individuals and groups. Such interventions bodies concerned with the assurance of quality .
may include psychological counseling, psycho-
therapy, and process consultation.
C. Consultation relating to A and B above.
D. Program development services in the
Standard 1. Providers
areas of A, B, and C above."
E. Supervision of psychological services.
1.1 Each psychological service unit offering
psychological services shall hal'e ami/-
A psychological service unit is the functional
able at least one professional psychologist
unit through which psychological services are
and as many more professional psycholo-
provided:
gists as are necessary to assure the quality
A. A psychological service unit is a unit that
of services offered.
provides predominantly psychological services
and is composed of one or more professional
psychologists and supporting staff. INTERPRETATION: The intent of this Stan-
B. A psychological service unit may operate dard is that one or more providers of psycho log-
as a professional service or as a functional or ical services in any psychological service unit
STANDARDS FOR PROVIDERS OF PSYCHOLOGICAL SERVICES 627
shall meet the levels of training and experience porting personnel whose qualifications and
of the professional psychologist as specified in skills (e,g .. language, cultural and experiential
the preceding definitions}O background, race, and sex) are directly relevant
When a professional psychologist is not to the needs and characteristics of the users
available on a full-time basis, the facility shall served.
retain the services of one or more professional
psychologists on a regular part-time basis to 1.4 When functioning as part of an organi;:a-
supervise the psychological services provided. tiona I setting, professional psychologists
The psychologist(s) so retained shall have au- shall bring their background and skills to
thority and participate sufficiently to enable bear whenel'er appropriate upon the goals
him or her to assess the needs for services, re- of the organi;:ation by participating in the
view the content of services provided, and as- planning and'development of overall ser-
sume professional responsibility and account- l'ices. 11
ability for them.
INTERPRETATION: Professional psycholo-
1.2 Prol'iders of psychological services who gists shall participate in the maintenance of
do not meet the requirements for the pro- high professional standards by representation
fessional psychologist shall be supervised on committees concerned with service deliv-
by a professional psychologist who shall ery,
assume professional responsibility and ac- As appropriate to the setting, these activities
countabilityfor the services provided, The may include active participation, as voting and
lel'el and extent of supervision may I'al}' as office-holding members on the facility's ex-
from task to task so long as the supervising ecutive, planning, and evaluation boards and
psychologist retains a sufficiently close committees.
supervisol}' relationship to meet this stan-
dard, 1.5 Psychologists shall maintain current
1.3 Wherever a psychological service unit knowledge of scientific and professional
exists, a professional psychologist shall be developments that are directly related to
responsible for planning, directing, and the services they render.
reviewing the provision of psychological
sen'ices. INTERPRET ATION: Methods through which
knowledge of scientific and professional de-
INTERPRET ATlON: This psychologist shall velopment may be gained include, but are not
coordinate the activities of the psychological limited to, continuing education, attendance at
service unit with other professional, adminis- workshops, participation in staff development,
trative, and technical groups, both within and and reading scienti fic publications. 12
outside the facility. This psychologist, who The psychologist shall have ready access to
may be the director, chief, or coordinator of the reference material related to the provision of
psychological service unit, has related respon- psychological services.
sibilities including, but not limited to, recruit- Psychologists must be prepared to show evi-
ing qualified staff, directing training and re- dence periodically that they are staying abreast
search activities of the service, maintaining a of current knowledge and practices through
high level of professional and ethical practice, continuing education.
and assuring (hat staff members function only
within the areas of their competency. 1.6 Psychologisis shall limit their practice to
In order to facilitate the effectiveness of ser- their demonstrated areas of professional
vices by increasing the level of staff sensitivity competence.
and professional skills, the psychologist desig-
nated as director shall be responsible for par- INTERPRETATION: Psychological services
ticipating in the selection of the staff and sup- will be offered in accordance with the provid-
628 ApPENDIX A
er's areas of competence as defined by verifi- example, a psychological service unit serving a
able training and experience. When extending predominantly low-income, ethnic, or racial
services beyond the range of their usual prac- minority group should have a staffing pattern
tice, psychologists shall obtain pertinent train- and service program that is adapted to the lin-
ing or appropriate professional supervision. guistic, experiential, and attitudinal charac-
teristics of the users.
1.7 Psychologists who wish to change their
service specialty or to add an additional 2.1.2 A description of the organization of
area of applied specialization must meet the psychological service unit and
the same requirements with respect to sub- its lines of responsibility and ac-
ject matter and professional skills that countability for the delivery of
apply to doctoral training in the new spe- psychological services shall be
cialty.13 available in written form to staff of
the unit and to users and sanction-
.INTERPRETATION: Training of doctoral- ers upon request.
level psychologists to qualify them for change
in specialty will be under the auspices of ac- INTERPRETATION: The description should
credited university departments or professional include lines of responsibility, supervisory rela-
schools that offer the doctoral degree in that tionships, and the level and extent of account-
specialty. Such training should be individual- ability for each person who provides psycho-
ized, due credit being given for relevant logical services.
coursework or requirements that have previous-
ly been satisfied. Merely taking an internship or 2.1.3 A psychological service unit shall
acquiring experience in a practicum setting is include sufficient numbers of pro-
not considered adequate preparation for becom- fessional and support personnel to
ing a clinical, counseling, industrial-organiza- achieve its goals, objectives, and
tional, or school psychologist when prior train- purposes.
ing has not been in the relevant area. Fulfill-
ment of such an individualized training pro- INTERPRETATION: The workload and
gram is attested to by the award of a certificate diversity of psychological services required and
by the supervising department or professional the specific goals and objectives of the setting
school indicating the successful completion of will determine the numbers and qualifications
preparation in the particular specialty. of professional and support personnel in the
psychological service unit. Where shortages in
personnel exist so that psychological services
cannot be rendered in a professional manner,
the director of the psychological service unit
Standard 2. Programs shall initiate action to modify appropriately the
specific goals and objectives of the service.
2.1 Composition and organization of a
psychological service unit: 2.2 Policies:
2.1.1 The composition and programs ofa 2.2.1 When the psychological service unit
psychological service unit shall be is composed of more than one per-
responsive to the needs of the per- son wherein a supervisory relation-
sons or settings served. ship exists or is a component of a
larger organization, a written
INTERPRETATION: A psychological service statement of its objectives and scope
unit shall be so structured as to facilitate effec- of services shall be developed and
tive and economical delivery of services. For maintained.
STANDARDS FOR PROVIDERS OF PSYCHOLOGICAL SERVICES 629
2.2.2. All providers within a psychologi- 2.2.4 All providers within a psychologi-
cal service. unit shall support the cal service unit shall conform to rel-
legal and civil rights of the user. 14 evant statutes established by fed-
eral, state, and local governments.
INTERPRET ATlON: Providers of psycholog-
ical services shall safeguard the interests ofthe
user with regard to personal, legal, and civil INTE RPRET ATlON: All providers of psycho-
rights. They shall continually be sensitive to the logical services shall be familiar with appropri-
issue of confidentiality of information, the ate statutes regulating the practice of psycho-
short-term and long-term' impact of their deci- logy. They shall also be informed about agency
sions and recommendations, and other matters regUlations that have the force of law and that
pertaining to individual, legal, and civil rights. relate to the delivery of psychological services
Concerns regarding the safeguarding of in- (e.g., evaluation for disability retirement and
dividual rights of users include, but are not lim- special education placements). In addition, all
ited to, problems of self-incrimination in judi- providers shall be cognizant that federal agen-
cial proceedings, involuntary commitment to cies such as the Veterans Administration and
hospitals, protection of minors or legal incom- the Department of Health, Education, and
petents, discriminatory practices in employ- Welfare have policy statements regarding psy-
ment selection procedures, recommendations chological services. Providers of psychological
for special education provisions, information services shall be familiar with other statutes and
relative to adverse personnel actions in the regUlations, including those addressed to the
anned services, and the adjudication of domes- civii and legal rights of users (e.g., those prom-
tic relations disputes in divorce and custodial ulgated by the federal Equal Employment Op-
proceedings. Providers of psychological ser- portunity Commission) that are pertinent to
vices should take affirmative action by making their scope of practice.
themselves available for local committees, re- It shall be the responsibility of the American
view boards, and similar advisory groups estab- Psychological Association to publish periodi-
lished to safeguard the human, civil, and legal cally those federal policies, statutes, and regu-
rights of service users. lations relating to this section. The state
psychological associations are similarly urged
to publish and distribute periodically appropri-
2.2.3 All providers within a psychologi- ate state statutes and regulations.
cal service unit shall be familiar
with and adhere to the American
Psychological Association's Ethi- 2.2.5 All providers within a psycholog-
cal Standards of Psychologists, ical service unit shall, where ap-
Psychology as a Profession, Stan- propriate, inform themfelves
dards for Educational and Psycho- about and use the network of
logical Tests, and other official pol- human services in their com-
630 ApPENDIX A
Psychologists are responsible for making eliminate discriminatory practices instituted for
their services readily accessible to users in a self-serving purposes that are not in the interest
manner that facilitates the user's freedom of of the user (e.g., arbitrary requirements for re-
choice. ferral and supervision by another profession).
Psychologists shall be mindful of their ac- They shall be cognizant of their responsibilities
countability to the sanctioners of psychological for the development of the profession, partici-
services and to the general public, provided that pate where possible in the training and career
appropriate steps are taken to protect the confi- development of students and other providers,
dentiality of the service relationship. In the pur- participate as appropriate in the training of
suit of their professional activities they shall aid paraprofessionals, and integrate and supervise
in the conservation of human, material, and fi- their contributions within the structure estab-
nancial resources. lished for delivering psychological services.
The psychological service unit will not with- Where appropriate, they shall facilitate the de-
hold services to a potential client on the basis of velopment of, and participate in, professional
that user's race, color, religion, sex, age, orna- standards review mechanisms. 22
tionalorigin. Recognition is given, however, to Psychologists shall seek to work with other
the following considerations: The professional professionals in a cooperative manner for the
right of psychologists to limit their practice to a good of the user and the benefit of the general
specific category of user (e.g., children, ado- pUblic. Psychologists associated with multidis-
lescents, women); the right and responsibility ciplinary settings shall support the principle
of psychologists to withhold an assessment that members of each participating profession
procedure when not validly applicable; the right shall have equal rights and opportunities to
and responsibility of psychologists to withhold share all privileges and responsibilities of full
evaluative, psychotherapeutic, counseling, or membership in the human service facility, and
other services in specific instances where con- to administer service programs in their respec-
siderations of race, religion, color, sex, or any tive areas of competence.
other difference between psychologist and
client might impair the effectiveness of the rela- 3.3 There shall be periodic, systematic, and
tionship.19 effective evaluations of psychological
Psychologists who find that psychological services. 23
services are being provided in a manner that is
discriminatory or exploitative to users and/or INTERPRETATION: When the psychological
contrary to these Standards or to state or federal service unit is a component of a larger organiza-
statutes shall take appropriate corrective action, tion, regular assessment of progress in achiev-
which may include the refusal to provide ser- ing goals shall be provided in the service deliv-
vices. When conflicts of interest ari'se, the psy- ery plan, including consideration of the effec-
chologist shall be guided in the resolution of tiveness of psychological services relative to
differences by the principles set forth in the costs in terms of time, money, and the availa-
Ethical Standards of Psychologists of the bility of professional and support personnel.
American Psychological Association and by Evaluation of the efficiency and effective·
the Guidelines for Conditions of Employment ness of the psychological service delivery sys-
of Psychologists (1972).20 tem should be conducted internally and, when
possible, under independent auspices.
3.2 Psychologists shall pursue their activities It is highly desirable that there be a periodic
as members of an independent, autonom- reexamination of review mechanisms to ensure
ous profession. 21 that these attempts at public safeguards are ef-
fective and cost efficient and do not place un-
INTERPRETATION: Psychologists shall be necessary encumbrances on the provider or un-
aware of the implications of their activities for necessary additional expense to users or
the profession as a whole. They shall seek to sanctioners for services rendered.
STANDARDS FOR PROVIDERS OF PSYCHOLOGICAL SERVICES 633
3.4 Psychologists are accountable for all as- As providers of services, psychologists have
pects of the services they provide and the responsibility to be concerned with the envi-
shall be responsive to those concerned ronment of their service unit, especially as it
with these services. 24 affects the quality of service, but also as it im-
pinges on human functioning in the larger unit
INTERPRETATION: In recognizing their re- or organization when the service unit is in-
sponsibilities to users, sanctioners, third-party cluded in such a larger context. Physical ar-
purchasers, and other providers, wherever ap- rangements and organizational policies and
propriate and consistent with the user's legal procedures should be conducive to the human
rights and privileged communications, psy- dignity, self-respect, and optimal functioning
chologists shall make available information of users, and to the effective delivery of ser-
about, and opportunity to participate in, deci- vice. The atmosphere in which psychological
sions concerning such issues as initiation, ter- services are rendered should be appropriate to
mination, continuation, modification, and the service and to the users, whether in office,
evaluation of psychological services. Ad- clinic, school, or industrial organization.
ditional copies of these Standardsfor Providers
of Psychological Services can be ordered from
the American Psychological Association. NOTES
Depending upon the settings, accurate and
full information shall be made available to pro- 2 The footnotes appended to these Standards rep-
spective individual or organization users re- resent an attempt to provide a coherent context of
other policy statements of the Association regarding
garding the qualifications of providers, the na- professional practice. The Standards extend these
ture and extent of services offered, and, where previous policy statements where necessary to reflect
appropriate, fmancial and social costs. current concerns ofthe public and the profession.
Where appropriate, psychologists shall in-
3 NIMH Grant MH 21696.
form users of their payment policies and their
willingness to assist in obtaining reimburse- • For the purpose of transition, persons who met
ment. Those who accept reimbursement from a the following criteria on or before the date of adoption
third party should be acquainted with the ap- ofthe original Standards on September 4, 1974, shall
propriate statutes and regulations and should also be considered professional psychologists: (a) a
master's degree from a program primarily psycholog-
instruct their users on proper procedures for ical in content from a regionally accredited university
submitting claims and limits on confidentiality or professional school; (b) appropriate education,
of claims information, in accordance with per- training, and experience in the area of service offered;
tinent statutes. (c) a license or certificate in the state in which they
practice, conferred by a state board of psychological
examiners. or the endorsement of the state psycholog-
ical association through voluntary certifICation, or,
for practice in primary and secondary schools, a state
Standard 4. Environment department of education certificate as a school psy-
chologist provided that the certificate required at least
two graduate years.
4.1 Providers of psychological services shall
promote the development in the service 5 Minutes of the Board of Professional Affairs
setting ofa physical, organizational, and meeting, Washington, D.C., March S-9, 1974.
social environment that facilitates opti-
6 This definition is less restrictive than Recom-
mal human functioning. mendation40fthe APA (1967) policy statement set-
ting forth model state legislation affecting the prac-
INTERPRETATION: Federal, state, and local tice of psychology (hereinafter referred to as State
requirements for safety, health, and sanitation Guidelines), proposing one level for state license or
certificate and "requiring the doctoral degree from an
must be observed. Attention shall be given to accredited university or college in a program that is
the comfort and, where relevant, to the privacy primarily psychological, and no less than 2 years of
of providers and users. supervised experience, one of which is subsequent to
634 ApPENDIX A
the granting of the doctoral degree. This level should The application of said princ iples and methods
be designated by the title of 'psychologist' .. (p. includes but is not restricted to: diagnosis, preven-
1099). tion, and amelioration of adjustment problems
The 1972 APA "Guidelines for Conditions of and emotional and mental disorders of individuals
Employment of Psychologists" (hereinafter referred and groups; hypnosis; educational and vocational
to as CEP Guidelines) introduces slightly different counseling; personnel selection and management;
shadings of meaning in its section on "Standards for the evaluation and planning for effective work and
Entry into the Profession" as follows: learning situations; advertising and market re-
search; and the resolution of interpersonal and so-
Persons are properly identified as psychologists cial conflicts.
when they have completed the training and experi- Psychotherapy within the meaning of this act
ence recognized as necessary to perform functions means the use of learning, conditioning methods.
consistent with one of the several levels in a career and emotional reactions, in a professional relation-
in psychology. This training includes possession ship, to assist a person or persons to modify feel-
of a degree earned in a program primarily ings, attitudes, and behavior which are intellectu-
psychological in content. In the case of psycholog- ally. socially. or emotionally maladjustive or inef-
ical practice. it involves services for a fee. appro- fectual.
priate registration. certification. or licensing as The practice of psychology shall be as defined
provided by laws of the state in which the practices above. any existing statute in the state of _ _ __
will apply. (APA. 1972. p. 331) to the contrary notwithstanding. (APA, 1967, pp.
109S-I099)
In some situations. specialty designations and
standards may be relevant. The National Register of
Health Service Providers in Psychology. which • The relation of a psychological service unit to a
larger facility or institution is also addressed indi-
based its criteria on this standard. identifies qualified
psychologists in the health services field. rectly in the CEP Guidelines. which emphasize the
roles. responsibilities. and prerogatives of the psy-
chologist when he or she is employed by or provides
7 As noted in the opening section of these Stan- services for another agency. institution. or business.
dards. functions and activities of psychologists relat-
ing to the teaching of psychology. the writing or edit-
ing of scholarly or scientific manuscripts. and the 10 This Standard replaces earlier recommen-
conduct of scientific research do not fall within the dations in the 1967 State Guidelines concerning
purview of these Standards. exemption of psychologists from licensure. Recom-
mendations 8 and 9 of those Guidelines read as fol-
lows:
8 These definitions should be compared to the
State Guidelines. which include definitions of psy- 8. Persons employed as psychologists by ac-
chologist and the practice of psychology as follows: credited academic institutions. governmental
agencies. research laboratories. and business cor-
A person represents himself to be a psychologist porations should be exempted. provided such
when he holds himself out to the public by any title employees are performing those duties for which
or description of services incorporating the words they are employed by such organizations. and
"psychology." "psychological," "psycholo- within the confines of such organizations.
gist •.• andlor offers to render or renders services as 9. Persons employed as psychologists by ac-
defined below to individuals. groups. organiza- credited academic institutions. governmental
tions. or the public for a fee. monetary or other- agencies. research laboratories. and business cor-
wise.
porations consulting or offering their researc h find-
The practice of psychology within the meaning ings or providing scientific information to like or-
of this act is defined as rendering to individuals,
ganizations for a fee should be exempted. (APA.
groups or organizations, or the public any psycho-
1967. p. 1100)
logical service involving the application of princi-
ples. methods. and procedures of understanding, On the other hand. the 1967 State Guidelines spe-
predicting. and influencing behavior. such as the cifically denied exemptions under certain conditions.
principles pertaining to learning. perception. as noted in Recommendations 10 and II:
motivation, thinking, emotions. and interpersonal
relationships; the methods and procedures of inter-
viewing. counseling. and psychotherapy; of con- 10. Persons employed as psychologists who
structing. administering. and interpreting tests of offer or provide psychological services to the pub-
mental abilities. aptitudes. interests. attitudes. per- lic for a fee. over and above the salary that they
sonality characteristics. emotion. and motivation; receive for the performance of their regular duties.
and of assessing public opinion. should not be exempted.
STANDARDS FOR PROVIDERS OF PSYCHOLOGICAL SERVICES 635
II. Persons employed as psychologists by or- IS Support for this position is found in the section
ganizations that sell psychological services to the in Psychology as a Profession on relations with other
public should not be exempted. (APA, 1967, pp. professions:
1100(1101)
Professional persons have an obligation to know
The present APA policy, as reflected in this Stan- and take into account the traditions and practices of
dard, establishes a single code of practice for psy- other professional groups with whom they work
chologists providing covered services to users in any and to cooperate fully with members of such
setting. The present minimum requirement is that a groups with whom research, service, and other
psychologist providing any covered service must functions are shared. (APA, 1968, p. 5)
meet local statutory requirements for licensure or cer-
tification. See the section Principles and Implications '6 One example of a specific application of this
of the Standards for an elaboration of this position. principle is found in Guideline 2 in APA's (1973b)
"Guidelines for Psychologists Conducting Growth
Groups":
" A closely related principle is found in the AP A
(1972) CEP Guidelines:
The following information should be made avail-
able in writing [italics added] to all prospective partic-
It is the policy of APA that psychology as an
ipants:
independent profession is entitled to parity with
(a) An explicit statement of the purpose of the
other health and human service professions in in-
group;
stitutional practices and before the law. Psycholo-
(b) Types of techniques that may be employed;
gists in interdisciplinary settings such as colleges
(c) The education, training, and experience of the
and universities, medical schools, clinics, private
leader or leaders;
practice groups, and other agencies expect parity
(d) The fee and any additional expense that may
with other professions in such matters as academic
be incurred;
rank, board status, salaries, fringe benefits, fees,
(e) A statem~nt as to whether or not a follow-up
participation in administrative decisions, and all
service is included in the fee;
other conditions of employment, private contrac-
(f) Goals of the group experience and techniques
tual arrangements, and status before the law and
to he used;
legal institutions. (APA, 1972, p. 333)
(g) Amounts and kinds of responsibility to he as:
sumed by the leader and by the participants. For
12 See CEP Guidelines (section entitled "Career example, (i) the degree to which a participant is free
Development") for a closely related statement: not to follow suggestions and prescr;ptions of the
group leader and other group memhers; (ii) any re-
Psychologists are expected to encourage institu- strictions on a participant's freedom to leave the
tions and agencies which employ them to sponsor group at any time; and.
or conduct career development programs. The (h) Issues of confidentiality. (p. 933)
purpose of these programs would be to enable psy-
chologists to engage in study for professional ad- 17 See again Principle 5 (Confidentiality) in Ethi-
vancement and to keep abreast of developments in cal Standards of Psychologists (APA, 1977).
their field. (APA, 1972, p. 332)
18 Support for the principle of privileged com-
I' This Standard follows closely the statement re- munication is found in at least two policy statements
of the Association:
garding "Policy on Training for Psychologists Wish-
ing to Change Their Specialty" adopted by the APA
In the interest of both the public and the client
Council of Representatives in January 1976. In-
and in accordance with the requirements of good
cluded therein was the implementing provision that
professional practice. the profession of psychology
"this policy statement shall be incorporated in the
seeks recognition of the privileged nature of confi-
guidelines of the Committee on Accreditation so that
dential communications with clients. preferably
appropriate sanctions can be brought to bear on uni-
through statutory enactment or by administrative
versity and internship training programs which vio-
policy where more appropriate. (APA, 1968. p. 8)
late [it]."
25. Wherever possible, a clause protecting the
14 See also APA's (1977) Ethical Standards of privileged nature of the psychologist-client rela-
Psychologists. especially Principles 5 (Confidential- tionship be included.
ity), 6 (Welfare of the Consumer), and 9 (Pursuit of 26. When appropriate, psychologists assist in
Research Activities); and see Ethical Principles in obtaining general "across the board" legislation
the Conduct of Research with Human Participants fo"uch privileged communications. (APA, 1967,
(APA.1973a). p. 1103)
636 ApPENDIX A
19 This paragraph is drawn directly from the CEP Z3 This Standard on program evaluation is based
Guidelines (APA,.1972, p. 333). directly on the following excerpts of two APA posi-
tion papers:
20 "It is recognized that under certain cir-
cumstances, the interests and goals of a particular The quality and availability of health services
community or segment of interest in the population should be evaluated continuously by hoth consum-
may be in conflict with the general welfare. Under ers and health professionals. Research into the ef-
such circumstances, the psychologist's professional ftciency and effectiveness of the system should be
activity must be primarily guided by the principle of conducted both internally and under independent
promoting human welfare." (APA, 1972, p. 334) auspices. (APA, 1971, p. 1025)
21 Support for the principle ofthe independence of The comprehensive community mental health
psychology as a professinn is found in the following: center should devote an explicit portion of its
budget to program evaluation. All centers should
As a member of a~ autonomous profession, a inculcate in their staff attention to and respect for
psychologist rejects limitations upon his freedom research findings; the larger centers have an obliga-
of thought and action other than those imposed by tion to set a high priority on basic research and to
his moral, legal, and social responsibilities. The give formal recognition to research as a legitimate
Association is always prepared to provide appro- part of the duties of staff members.
priate assistance to any responsible member who . . . Only through explicit appraisal of program
becomes subjected to unreasonable limitations effects can worthy approaches be retained and re-
upon his opportunity to function as a practitioner, fined, ineffective ones dropped. Evaluative
teacher , researcher, administrator, or consultant. monitoring of program achievements may vary, of
The Association is always prepared to cooperate course, from the relatively informal to the system-
with any responsible professional organization in atic and quantitative, depending on the importance
opposing any unreasonable limitations on the pro- of the issue, the availability of resources, and the
fessional functions of the members of that organi- willingness of those responsible to take the risks of
zation. substituting informed judgment for evidence.
This insistence upon professional autonomy has (Smith & Hobbs, 1966, pp. 21-22)
been upheld over the years by the afftrmative ac-
tions of the courts and other public and private 24 See also the CEP Guidelines for the following
bodies in support of the right of the psycho- statement: • A psychologist recognizes that . . . he
logist-and other professionals-to pursue those alone is accountable for the consequences and effects
functions for which he is trained and qualified to of his services, whether as teacher, researcher, or
perform. (APA, 1968, p. 9) practitioner. This responsibility cannot be shared,
delegated, or reduced" (APA, 1972, p. 334).
Organized psychology has the responsibility to
define and develop its own profession, consistent
with the general canons of science and with the
public welfare.
Psychologists recognize that other professions REFERENCES
and other groups will, from time to time, seek to
define the roles and responsibilities of psycholo- Accreditation Council for Facilities for the Mentally
gists. The APA opposes such developments on the Retarded. Standards for residential facilities for
same principles that it is opposed to the psycholog- the mentally retarded. Chicago, 111.: Joint Com-
ical profession taking positions which would de- mission on Accreditation of Hospitals, 1971.
fine the work and scope of responsibility of other American Psychological Association, Committee on
duly recognized professions. . . . (AP A, 1972, Legislation. A model for state legislation affecting
p.333) the practice of psychology 1967. American Psy-
chologist, 1967,22, 1095-1103.
22 AP A support for peer review is detailed in the American Psychological Association. Psychology as
following excerpt from the APA (1971) statement en- a profession. Washington, D.C.: Author, 1968.
titled "Psychology and National Health Care": American Psychological Association. Psychology
and national health care. American Psychologist,
All professions participating in a national health 1971,26,1025-1026.
plan should be directed to establish review American Psychological Association. Guidelines for
mechanisms (or performance evaluations) that in- conditions of employment of psychologists.
clude not only peer review but active participation American Psychologist, 1972.27, 331-334.
by persons representing the consumer. In situa- American Psychological Association. Ethical prin-
tions where there are fiscal agents, they should also ciples in the conduct of research with human par-
have representation when appropriate. (p. 1026) ticipants. Washington. D.C.: Author, 1973. (a)
STANDARDS FOR PROVIDERS OF PSYCHOLOGICAL SERVICES 637
Specialty Guidelines
for the Delivery of Services
I The current members of the Committee on Professional Standards are Murphy Thomas (Chair),
Juanita Braddock, Lorraine Eyde, Morris Goodman, Judy Han, John H. Jackson, and Milton Schwebel.
APA staff liaisons are Sharon A. Shueman and Pam Arnold.
The following persons also served on the committee during the time the Specialty Guidelines were
being revised, Gilfred Tanabe (1980 Chair), Dave Mills (Partial 1981 Chair), Nadine Lambert, and Joy
Burke (APA staff liaison).
639
640 ApPENDIXB
clinical psychology by specifying important areas of 8. These Guidelines, while assuring the user of the
quality assurance and performance that contribute to the clinical psychologist's accountability for the nature and
goal of facilitating more effective human functioning. quality of services speciSed in this document, do not
preclude the clinical psychologist from using new meth-
ods or developing innovative procedures in the delivery
Princlple. and Implications of the Spectattl/ of clinical services.
Gvlclellnes
These Specialty Guidelines have broad implications
These Specialty Guidelines have emerged from and re- both for usen of clinical psychological services and for
affirm the same basic principles that guided the devel- providers of such services:
opment of the generic Standards for proo/den of Psy- 1. Guidelines for clinical psychological services pro-
chological Seroice. (APA, 1977b): vide a foundation for mutual understanding between
1. These Guidelines recognize that admission to the provider and user and facilitate more effective evalua-
practice of psychology is regulated by state statute. tion of services provided and outcomes achieved.
2. It is the intention of the APA that the generic Stan- 2. Guidelines for clinical psychologists are essential for
dartJa provide appropriate guidelines for statutory licens- uniformity in specialty credentialing of clinical psy-
ing of psychologists. In addition, although it is the p0- chologists.
sition of the APA that licensing he generic and not in 3. Guidelines give speciSc content to the professioo's
specialty areas, these Specialty Guidelines in clinical psy- concept of ethical practice as it applies to the functions
chology provide an authoritative reference for use in of clinical psychologists.
credentialing specialty providen of clinical psychological 4. Guidelines for cliuical psychological services may
services by such groups as divisions of the APA and state have signiScant impact on tomorrow's education aod
associations and by boards and agencies that Snd such training models for both professional and support per-
criteria useful for quality assurance. sonnel in clinical psychology.
3. A uniform set of Specialty Guidelines governs the 5. Guidelines for the provision of clinical psycholog-
quality of services to all usen of clinical psychological ical services in human service facilities inluence the
services in both the private and the puhlic seeton. Those determination of acceptable structure, budgeting. and
receiving clinical psychological services are protected by stafSng patterns in these facilities.
the same kinds of safeguards, irrespective of sector; these 6. Guidelines for clinical psychological services re-
include constitutional guarantees. statutory regulation, quire continual review and revision.
peer review, consultation, record review, and supervi-
sion. The Specialty Guidelines here presented are Intended
4. A uniform set of Specialty Guidelines governs clin- to improve the quality and delivery of clinical psycho-
ical psychological service functions offered by clinical logical services by specifying criteria for key aspects of
psychologists, regardless of setting or form of remuner- the practice setting. Some settings may require additional
ation. All clinical psychologists in professional practice andlor more stringent criteria for speciSc areas of service
recognize and are responsive to a uniform set of Specialty delivery.
Guidelines, just as they are guided hy a common code Systematically applied, these Guidelines serve to es-
of ethics. tablish a more effective and consistent basis for evalu-
5. Clinical psychology Guidelines establish clearly ar- ating the performance of individual service providen as
ticulated levels of quality for covered clinical psycho- well as to guide the organization of clinical psychological
logical service functions, regardless of the nature of the service units in human service settings.
usen, purchasen, or sanctionen of such covered services.
6. All penons providing clinical psychological services
meet specified levels of training and ex.perience that are Definition.
consistent with, and appropriate to, the functions they
perform. Clinical psychological services provided by per- ProokJeto. of c/lnfc<l/ psycho/op;c/ .eroIce.
refen to two
sons who do not meet the APA qualiScations for a profes- categories of persons who provide clinical psychological
sional clinical psychologist (see De&nitions) are super- services:
vised by a professional clinical psychologist. Final A. Professional clinical psychologists.' Professional
responsibility and accountability for services provide!! clinical psychologists have a doctoral degree from a re-
rest with professional clinical psychologists. gionally accredited university or professional school pro-
7. When providing any of the covered clinical psy- viding an organized, sequential clinical psychology pro-
chological service functions at any time and in any set- gram in a department of psychology in a university or
ting. whether public or private, proSt or nonproSt, clin- college, or in an appropriate department or unit of a
ical psychologists observe these Guidelines in order to professional school. Clinical psychology programs that
promote the best interests and welfare of the usen of are accredited by the American Psychological Associa-
such services. The extent to which clinical psychologists tion are recognized as meeting the deSnition of a clinical
observe these Guidelines is judged by peen. psychology program. Clinical psychology programs that
642 ApPENDIXB
are not accredited by the American Psychological As- B. Interventions directed at identifying and correct-
sociation meet .the definition of a clinical psychology ing the emotional conBicts, personality disturbances, and
program if they satisfy the following criteria: skill deficits underlying a person's distress and/or dys-
1. The program is primarily psychological in nature function. Interventions may reBect a variety of theoret-
and stands as a recognizable, coherent organizational ical orientations, techniques, and modalities. These may
entity within the institution. include, but are not limited to, psychotherapy, psych<>-
2. The program provides an integrated, organized analysis, behavior therapy, marital and family therapy,
sequence of study. group psychotherapy, hypnotherapy, social-learning ap-
3. The program has an identifiable body of students proaches, biofeedback techniques, and environmental
who are matriculated in that program for a degree. consultation and design.
4. There is a clear authority with primary respon- C. Professional consultation in relation to A and B
sibility for the core and specialty areas, whether or not above.
the program cuts across administrative lines. D. Program development services in the areas of A,
5. There is an identifiable psychology faculty, and B, and C ahove.
a psychologist is responsible for the program. E. Supervision of clinical psychological services.
In addition to a doctoral education, clinical psychol- F. Evaluation of all services noted in A through E
ogists acquire doctoral and postdoctoral training. Pat- above.
terns of education and training in clinical psychology'
are consistent with the functions to he performed and
the services to he provided, in accordance with the ages, A clinical rnychological service unit is the functional
populations, and problems encountered in various set- unit through which clinical psychological services are
tings. provided; such a unit may be part of a larger psych<>-
B. All other persons who are not professional clinical logical service organization comprising psychologists of
psychologists and who participate in the delivery of clin- more than one specialty and headed by a professional
ical psychological services under the supervision of a psychologist:
professional clinical psychologist. Although there may he A. A clinical psychological service unit provides pre-
variations in the titles of such persons, they are not re- dominantly clinical psychological services and is com-
ferred to as clinical psychologists. Their functions may posed of one or more professional clinical psychologists
be indicated by use of the adjective rnychological pre- and supporting staff.
ceding the noun, for example, rnychological4BsocIale, B. A clinical psychological service unit may operate
rnychological4Bsislanl, rnych%gicallechn/c1an, or rny- as a professional service or as a functional or geographic
chologica/ aide. Their services are rendered under the component of a larger multipsychological service unit
supervision of a professional clinical psychologist, who or of a governmental, educational, correctional, health,
is responsible for the designation given them and for training, industrial, or commercial organizational unit."
quality control. To he assigned such a designation, a C. One or more clinical psychologists providing
person has the background, training, or experience that professional services in a multidisciplinary setting con-
is appropriate to the functions performed. stitute a clinical psychological service unit.
D. A clinical psychological service unit may also be
one or more clinical psychologists in a private practice
Clinical P8l/Choiog/cQl 8ero/Ces refers to the applica- or a psychologicai consulting firm.
tion of principles, methods, and procedures for under-
standing, predicting, and alleviating intellectual, em<>-
tional, psychological, and bebavioral disability and U.er. of clinical rnychological .eroIce8 include:
discomfort. Direct services are provided in a variety of A. Direct users or recipients of clinical psychological
health settings, and direct and supportive services are services.
provided in the entire range of social, organizational, B. Public and private institutions, facilities, or orga-
and academic institutions and agencies.' Clinical psy- nizations receiving clinical psychological services.
chological services include the follOWing:' C. Third-party purchasers-those who pay for the
A. Assessment directed toward diagnosing the nature delivery of services but who are not the recipients of
and causes, and predicting the effects, of subjective dis- services.
tress; of personal, social, and work dysfunction; and of D. Sanctioners-those who have a legitimate concern
the psychological and emotional factors involved in, and with the accessibility, timeliness, efficacy, and standards
consequent to, pbysical disease and disability. Procedures of quality attending the provision of clinical psycholog-
may include, but are not limited to, interviewing, and. ical services. Sanctioners may include members of the
administering and interpreting tests of intellectual abil- user's family, the court, the probation officer, the schooi
ities, attitudes, emotions, motivations. personality char- administrator, the employer, the union representative,
acteristics, psychoneurological status, and other aspects the facility director, and so on. Sanctioners may also in-
of buman experience and behavior relevant to the dis- clude various governmental, peer review, and accredi-
turbance. tation bodies concerned with the assurance of quality.
SPECIALTY GUIDELINES FOR THE DELIVERY OF SERVICES 643
dards by representation on committees concerned with qui red. Merely taking an internship in clinical psychol-
service delivery. ogy or acquiring experience in a practicum setting is not
As appropriate to the setting, their activities may in- adequate preparation for becoming a clinical psychol<>-
clude active participation, as voting and as office-holding gist when prior education has not been in that area. Ful-
members, on the professional staffs of hospitals and other fillment of such an individualized educational program
facilities and on other executive, planning, and evalua- is attested to by the awarding of a certificate by the
tion hoards and committees. supervising department or professional school that in-
dicates the successful completion of preparation in clin·
ical psychology.
1.5 Clinical psychologists maintain current knowledge
of scientific and professional developments to preserve
and enhonce their professional competence. 9 1.8 ProfeSSional clinical psycholOgists are encouraged
to develop Innovative theorle$ and procedures and to
INTERPRETATION Methods through which knowledge of provide appropriate theoretical and/or empirical sup-
scientific and profeSSional developments may be gained port for their innovations.
include, but are not limited to, reading scientific and
professional publications, attendance at workshops, par- INTERPRETATION, A specialty of a profession rooted in
ticipation in staff development programs, and other a science intends continually to explore and experiment
forms of continuing education. The clinical psychologist with a view to developing and verifying new and im-
has ready access to reference material related to the pro- proved methods of serving the public in ways that can
vision of psychological services. Clinical psychologists are be documented.
prepared to show evidence periodically that they are
staying abreast of current knowledge and practices in
the field of clinical psychology through continuing ed-
ucation. Guideline 2
PROGRAMS
1.6 Clinical psychologists limit their practice to their
demonstrated areas of professional competence. 2_1 Composition and organization of a clinical psycho-
logical seroice unit:
INTERPRETATION Clinical psychological services are of-
fered in accordance with the proViders' areas of com- 2_1.1 The composition and programs of a clinical
petence as defined by verifiable training and experience. psycholOgical seroice unit are responsive to the nee.u
When extending services beyond the range of their usual of the persons or settings served.
practice, psychologists obtain pertinent training or ap-
propriate professional supervision. Such training or su- INTERPRETATION A clinical psychological service unit is
pervision is consistent with the extension of functions structured so as to facilitate effective and economical
performed and services provided. An extension of ser- delivery of services. For example, Ii clinical psychological
vices may involve a change in the theoretical orientation service unit serving predominantly a low-income, ethnic,
of the clinical psychologist, a change in modality or tech- or racial minority group has a staffing pattern and service
nique, or a change in the type of client and/or the kinds programs that are adapted to the linguistic, experiential.
of problems or disorders for which services are to be and attitudinal characteristics of the users.
provided (e.g., children, elderly persons, mental retar-
dation, neurological impairment). 2.1.2 A description of the organization of the clinical
psycholOgical service unit and its lines of responsi-
1.7 ProfeSSional psychologists who wish to qualify as bility and accountability for the delivery of psycho-
clinical psychologists meet the same requirements with logical services is available in written form to staff
respect to subject matter and professional skills thot of the unit and to users and sanctioners upon request.
apply to doctoral and postdoctoral education and train-
ing in clinical psychology. 10 INTEIU'RETATION The description includes lines of re-
sponsibility, supervisory relationships, and the level and
INTERPRETATION Education of doctoral-level psycholo- extent of accountability for each person who provides
gists to qualify them for specialty practice in clinical psychological services.
psychology is under the auspices of a department in a
regionally accredited university or of a professional 2_1.3 A clinical psycholOgical seroice unit includes
school that offers the doctoral degree in clinical psy- sufficient numbers of professional and support per-
chology. Such education is individualized, with due sonnelto achieve its goals, objectives, and purposes.
credit being given for relevant course work and other
requirements that have previously been satisfied. In ad- INTERPRETATION The work load and diversity of psy-
dition, doctoral-level training plus I year of postdoctoral chological services required and the specific goals and
experience supervised by a clinical psychologist is re- objectives of the setting determine the numbers and qual-
SPECIALTY GUIDELINES FOR THE DELIVERY OF SERVICES 645
ifications of professional and support personnel in the INTERPRETATION Providers of clinical psychological ser-
clinical psychological service unit. Where shortages in vices maintain up-to-date knowledge of the relevant
personnel exist. so that psychological services cannot he standards of the American Psychological Association.
rendered in a professional manner. the director of the
clinical psychological service unit initiates action to rem- 2.2.4 All providers within a clinical psychological ser-
edy such shortages. When this fails. the director appro- vice unit conform to relevant statutes established by
priately modifies the scope or work load of the unit to federal. state. and local governments.
maintain the quality of the services rendered.
I~TERPRETATION All providers 01 clinical psychological
services are familiar with appropriate statutes regulating
2.2 Policies:
the practice of psychology. They observe agency regu-
2.2. I When the clinical psycholOgical service unit is lations that have the force of law and that relate to the
composed of more than one person or is a component delivery of psychological services (e.g .. evaluation for
of a larger organization, a written statement of its disability retirement and special education placements).
objectives and scope of services is developed, main- In addition, all provlders are cognizant that federal
agencies such as the Veterans Administration, the De-
tained. and reviewed.
partment of Education. and the Department of Health
INTERPRETATION The clinical psychological service unit and Human Services have policy statements regarding
reviews its objectives and scope of services annually and psychological services, and where relevant, providers
revises them as necessary to ensure that the psychological conform to them. Providers of clinical psychological ser-
services offered are consistent with staff competencies vices are also familiar with other statutes and regulations.
and current psychological knowledge and practice. This including those addressed to the civil and legal rights of
statement is discussed with staff, reviewed with the ap- users (e.g .• those promulgated by the federal Equal Em-
propriate administrator, and distributed to users and ployment Opportunity Commission), that are pertinent
sanctioners upon request, whenever appropriate. to their scope of practice.
It is the responsibility of the American Psychological
2.2.2 All providers within a clinical psychological ser- Association to maintain current files of those federal pol-
vice unit support the legal and civil rights of the icies, statutes, and regulations relating to this section and
users.11 to assist its members in obtaining them. The state psy-
chological associations and the state licensing boards pe-
INTERPRETATION Providers of clinical psychological ser-
vices safeguard the interests of the users with regard to
riodically publish and distribute appropriate state stat-
utes and regulations.
personal. legal. and civil rights. They are continually
sensitive to the issut' of confidentiality of information.
2.2.5 All providers within a clinical psycholOgical ser-
the short-term and long-term impacts of their decisions
vice unit inform themselves about and use the net-
and recommendations, and other matters pertaining to
work of human services in their communities in order
individual, legal. and civil rights. Concerns regarding the
to link users with relevant services and resources.
safeguarding of individual rights of users include, but
are not limited to, problems of self-incrimination in ju- lNTEHI'HET-\.TION Clinical psychologists and support staff
dicial proceedings, involuntary commitment to hospitals, are sensitive to the broader context of human needs. In
protection of minors or legal incompetents, discrimina- recognizing the matrix of personal and societal problems,
tory practices in employment selection procedures, rec- providers make available to users information regarding
ommendation for special education provisions, infor- human services such as legal aid societies, social services,
mation relative to adverse personnel actions in the armed employment agencies, health resources, and educational
services, and adjudication of domestic relations disputes and recreational facilities. Providers of clinical psycho-
in divorce and custodial proceedings. Providers of clin- logical st"fvices refer to such community resources and,
ical psychological services take affirmative action by when indicated, actively intervent" on behalf of the users.
making themselves available to local committees, review Community resources include the private as well as
boards, and similar advisory groups established to safe- the public sectors. Private resources include private
guard the human, civil, and legal rights of service users. agencies and centers and psychologists in independent
private practice. Consultation is sought or referral made
2.2.3 All providers within a clinical psychological ser- within the public or private network of services when-
vice unit are familiar with and adhere to the Amer- ever required in the best interest of the users. Clinical
ican Psychological Association's Standards for Pro- psychologists. in either the private or the public setting.
viders of Psychological Services. Ethical Principles of utilize other resources in the community whenever in-
Psychologists. Standards for Educational and Psycho- dicated because of limitations within the psychological
logical Tests. Ethical Principles in the Conduct of Re- serviCt" unit providing the services. Professional clinical
search With Human Participants. and other official psychologists in private practice are familiar with the
policy statements relevant to standards for profes- types of services offered through local community men-
sional services issued by the ASSociation. tal health clinics and centers. including alternatives to
646 ApPENDIXB
hospitalization, and know the costs and eligibility re- 2.3.4 Each clinical psychological service unit follows
quirements for those services. an established record retention and disposition
policy.
S.2.6 In the delivery of clinical psychological seroices, INTERPRETATION. The policy on record retention and
the "..oviders maintain a Caope1'dtioe relationship disposition conforms to federal or state statutes or ad-
with colleagues and co-workers in the best interest ministrative regulations wbere such are applicable. In
of the users. I! the absence of such regulations, the policy is (a) that the
INTERPRETATION. Clinical psychologists recognize the full record be retained intact for 3 years after the com-
areas of special competence of other professional psy- pletion of planned services or after the date of last contact
chologists and of professionals in other fields for either with the user, whicbever is later; (b) that a full record
consultation or referral purposes. Providers of clinical or summary of the record be maintained for an addi-
psychological services make appropriate use of other tional 12 years; and (c) that the record may be disposed
professional, research, technical, and administrative re- of no sooner than 15 years after the completion of
sources to serve the best interests of users and establish planned services or after the date of the last contact.
and maintain cooperative arrangements with such other whichever is later. These temporal gUides are consistent
resources as required to meet the needs of users. with procedures currently in use by federal record cen-
ters.
2.3 Procedures: In the event of the death or incapacity of a clinical
psychologist in independent practice, special procedures
2.3.1 Each clinical psychofogical service unit follows are necessary to ensure the continuity of active services
a set of procedural guidelines for the delivery of psy- to users and the proper safeguarding of inactive records
chological .eroices. being retained to meet this Guideline. Following ap-
proval by the affected user, it is appropriate for another
INTERPRETATION. Providers are prepared to provide a clinical psychologist, acting under the auspices of the
statement of procedural gUidelines, in either oral or writ- local professional standards review committee (PSRC),
ten form, in terms that can be understood by users, in- to review the records with the user and recommend a
cluding sanctioners and local administrators. This state- course of action for continuing professional service, if
ment describes the current methods, forms, procedures, needed. Depending on local circumstances, the review-
and techniques being used to achieve the objectives and ing psychologist may also recommend appropriate ar-
goals for psychological services. rangements for the halance of the record retention and
disposition period.
2.3.2 Providers of clinical psychological services de- This Guideline has been designed to meet a variety
oelop plans awoprlate to the JIf'OI'Itlers' professional of circumstances that may arise, often years after a set
pract1ces and to the "..ob/ems presented by the users. of psychological services has been completed. More and
more records are being used in forensic matters, for peer
INTERPRETATION. A clinical psychologist develops a plan review, and in response to requests from users. other
that describes the psychological services, their objectives, professionals, or other legitimate parties requiring ac-
and the manner in which they wiD be provided.I:l.I< This curate information ahout the exact dates, nature, course,
plan is in written form; it serves as a basis for obtaining and outcome of a set of psychological services. These
understanding and concurrence from the user and pro- record retention procedures also provide valuable base-
vides a mechanism for subsequent peer review. This plan line data for the original psychologist-provider when a
is, of course, modified as new needs or information de- previous user retlllTlS for additiona1 services.
velops.
A clinical psychologist who provides services as one
2.3.5 Providers of clinical psychological services
member of a collaborative effort participates in the de- maintain a system to "..otect confidentiality of the/r
velopment and implementation of the overall service records. IS
plan and provides for its periodic review.
INTERPRETATION· Clinical psychologists are responsible
2.3.3 Accurate, current, and pertinent documenta- for maintaining tbe confidentiality of information about
tion of essential clinical psychological serolces pro- users of services, from whatever source derived. All per-
oided is maintained. sons supervised by clinical psychologists, including non-
professional personnel and students, who have access to
INTERPRETATION. Records kept of clinical psychological records of psychological services are required to maintain
services may include, but are not limited to, identifying this confidentiality as a condition of employment.
data, dates of services, types of services, Significant ac- The clinical psychologist does not release con6~ential
tions taken. and outcome at termination. Providers of information, except with the written consent of the user
clinical psychological services ensure t\lat essential in- directly involved or his or ber legal representative. Even
formation concerning services rendered is recorded after consent for release has been ohtained, the clinical
within a reasonable time following their completion. psychologist clearly identifies such information as con-
SPECIALTY GUIDELINES FOR THE DELIVERY OF SERVICES 647
lidential to the recipient of the information.'b II directed INTERPIIETATION Clinical psychologists provide services
otherwise by statute or regulations with the force of law to users in a manner that is considerate. effective. eco-
or by court order, the psychologist may seek a resolution nomical, and humane. Clinical psychologists make their
to the conflict that is both ethically and legally feasible services readily accessible to users in a manner that fa-
and appropriate. cilitates the users' freedom of choice.
Users 8ff" informed in advance of any limits in the Clinical psychologists are mindful of their account-
setting for maintenance of confidentiality of psycholog- ability to the sanctioners of clinical psychological services
ical information. For instanct>', clinical psychologists in and to the general public, provided that appropriate steps
hospital, clinic, or agency settings inform their patients are taken to protect the conlidel)tiality of the service
that psychological information in a patient's clinical rec- relationship. In the pursuit of their professional activities,
ord may be available without the patient's written con- they aid in the conservation of human, material, and
sent to other members of the professional staff associated financial resource-so
with the patient's treatment or rehabilitation. Similar The clinical psychological service unit does not with-
limitations on conlidentiality of psychological informa- hold services to a potential client on the basis of that
tion may be present in certain school, industrial, military, user's race, color, religion. gender, sexual orientation,
or other institutional settings, or in instances in which age, or national origin. Recognition is given, however.
the user has waived conlidentiality for purposes of third- to the follOWing considerations: the profeSSional right of
party payment. clinical psychologists to limit their practice to a specilic
Users have the right to obtain information from their category of users (e.g., children. adolescents, women);
psychological records. However, the records are the the right and responsibility of clinical psychologists to
property of the psychologist or the facility in which the withhold an assessment procedure when not validly ap-
psychologist works and are, therefore, the responsibility plicable; and the right and responsibility of clinical psy-
of the psychologist and subject to his or her control. chologists to withhold evaluative. psychotherapeutic.
When the user's intention to waive conlidentiality is counseling, or other services in specific instances in which
judged by the professional clinical psychologist to be their own limitations or client characteristics might im-
contrary to the user's best interests or to be in conflict pair the effectiveness of the relationship."·18 Clinical
with tbe user's civil and legal rights, it is the responsibility psychologists seek to ameliorate through peer review,
of the clinical psychologist to discuss the implications of consultation, or other personal therapeutic procedures
releasing psychological information and to assist the user those factors that inhibit the proviSion of services to par-
in limiting disclosure only to information required by ticular users. When indicated services are not available,
the present circumstance. clinical psychologists take whatever action is appropriate
Raw psychological data (e.g., questionnaire returns or 10 inform responsible persons and agencies of the lack
test protocols) in which a user is identified are released of such services.
only with the written consent of the user or his or her Clinical psychologists who lind that psychological ser-
legal representative and released only to a person rec- vices are being provided in a manner that is discrimi-
ognized by the clinical psychologist as qualilied and com- natory or exploitative to users and/or contrary to these
petent to use the data. Guidelines or to state or federal statutes take appropriate
Any use made of psychological reports, records, or corrective action, which may include the refusal to pro-
data for research or training purposes is consistent with vide services. When conBicts of interest arise, the clinical
this Guideline. Additionally, providers of clinical psy- psychologist is guided In the resolution of differences by
chological services comply with statutory conlidentiality the principles set forth in the American Psychological
requirements and those embodied in the American Psy- Association's Ethical PnflClples of Psychologists (APA,
chological Association's Ethictll PnflClples of Psycholo- 1981b) and "Guidelines for Conditions of Employment
gists (APA, 1981b). of Psychologists" (APA, 1972).
Providers of clinical psychological services remain sen-
sitive to both the benelits and the possible misuse of 3.2 Clinical psychologists pu,sue thei, activities as
information regarding individuals that is stored in large membe,s of the independent, autonomous profession
computerized data banks. Providers use their influence of psychology.'·
to ensure that such information is "used in a socially re-
sponsible manner. INTERPRETATION. Clinical psychologists, as members of
an independent profession. are responsible hoth to the
public and to their peers through established review
mechanisms. Clinical psychologists are aware of the im-
Guideline 3 plications of their activities for the profession as a whole.
ACCOUNTABILITY They seek to eliminate discriminatory practices insti-
tuted for self-serVing purposes that are not in the interest
3.1 The clinictll psychologist's pt'ofessWnalllCuvuy Is of the users (e.g., arbitrary reqUirements for referral and
guided pnmanly by the pnflClple of pt'OTROUng human supervision by another profession). They are cognizant
welfare. of their responsibilities for the development of the profes-
648 ApPENDIXB
sion. They participate where possible in the training and modi6cation, and evaluation of clinical psychological
career development of students and other providers, par- services.
ticipate as appropriate in the training of paraprofession- Depending on the settings, accurate and full infor-
als or other professionals, and integrate and supervise the mation is made available to prospective individual or
implementation of their contributions within the struc- organizational users regarding the quali6cations of pro-
ture established for delivering psychological services. viders, the nature and extent of services offered, and
Clinical psychologists facilitate the development of, and where appropriate, financial and social costs.
participate in, professional standards review mecha- Where appropriate, clinical psychologists inform users
nisms. 20 of their payment policies and their willingness to assist
Clinical psychologists seek to work with other profes- in obtaining reimbursement. Those who accept reim-
sionals in a cooperative manner for the good of the users bursement from a third party are acquainted with the
and the benefit of the general public. Clinical psychol- appropriate statutes and regulations and assist their users
ogists associated with multidisciplinary settings support in understanding procedures for submitting claims and
the principle that members of each participating profes- limits on con6dentiality of claims information, in ac-
sion have equal rights and opportunities to share all priv- cordance with pertinent statutes.
ileges and responsibilities of full membership in hospital
facilities or other human service facilities and to admin-
ister service programs in their respective areas of com-
petence. Guideline 4
ENVIRONMENT
3,3 There are periodic, systematic, and effective eool-
uatlDns of clinical psychological .eroIces. 21
4,1 Providers of clinical psychological serolce. promote
the development In the serolce setting of a physical,
INTERPRETATION, When the clinical psychological ser- organizational, and social enVIronment that facilitate.
vice unit is a component of a larger organi7.ation, regular opt/mal human functioning.
evaluation of progress in achieving goals is provided for
INTERPRETATION· Federal, state, and local requirements
in the service delivery plan, including consideration of
for safety, health, and sanitation are observed.
the effectiveness of clinical psychological services rela-
As providers of services, clinical psychologists are con-
tive to costs in terms of use of time and money and the
cerned with the environment of their service unit, es-
availability of professional and support personnel.
pecially as it affects the quality of service, but also as
Evaluation of the clinical psychological service deliv-
it impinges on human functioning when the service unit
ery system is conducted internally and, when possible,
is included in a larger context. Physical arrangements
under independent auspices as well. This evaluation in-
and organizational poliCies and procedures are condu-
cludes an assessment of effectiveness (to determine what
cive to the human dignity, self-respect, and optimal func-
the service unit accomplished), efficiency (to determine
tioning of users and to the effective delivery of service.
the total costs of providing the services), continuity (to
Attention is given to the comfort and the privacy of users.
ensure that the services are appropriately linked to other
The atmosphere in which clinical psychological services
human services), availability (to determine appropriate
are rendered is appropriate to the service and to tbe
levels and distribution of services and personnel), acces- users, whether in an office. cliniC, school. industrial or-
sibility (to ensure that the services are barrier free to
ganization, or other institutional setting.
users), and adequacy (to determine whether the services
meet the identi6ed needs for such services).
There is a periodic reexamination of review mecha- FOOTNOTES
nisms to ensure that these attempts at public safeguards I The footnotes appended to these Specialty Guidelines rep-
are effective and cost ef6cient and do not place unnec- resent an attempt to provide a coherent context of other policy
essary encumbrances on the providers or impose unnec- statements of the Association regarding professional practice.
The Guidelines extend these previow policy statements where
essary additional expenses on users or sanctioners for ser-
necessary to re8ect current concerns of the public and the
vices rendered. profession.
3.4 Clinical psychologists are accountable for all as- • The following two categories 01 professional psychologists
who met the criteria indicated below on or before the adoption
pects of the services they provide and are responsive to of these Specialty Guidelines on January 31, 1980, are also con-
those concerned w/th the.e .ervlce.... sidered clinical psychologists: Category I-persons who com-
pleted (a) a doctoral degree program primarily psychological
INTERPRETATION, In recognizing their responsibilities to in content at a regionally accredited university or professional
users, and where appropriate and consistent with the school and (b) 3 postdoctoral yean of appropriate education,
users' legal rights and privileged communications, clin- training. and experience in providing clinical psychological ser-
vices as de&ned herein, including a minimum of 1 year in a
ical psychologists make available information ahout, and clinical setting; Category 2-persons who on or before Septem-
provide opportunity to participate in, decisions concern- ber 4, 1974, <a) completed a master's degree from a program
ing such issues as initiation, termination, continuation, primarily psychological in content at a regionally accredited
SPECIALTY GUIDELINES FOR THE DELIVERY OF SERVICES 649
university or professional school and (b) held a license or cer- Uons, in a professional relationship. to assist a person or per·
tificate in the state in which they practiced. conferred by a state sons to modify feelings, attitudes, and behavior which are
board of psychological examiners, or the endorsement of the intellectually, socially. or emotionally maladjustive or inef~
state psychological association through voluntary certification, fectual.
and who, in addition, prior to January 31, 1980, (c) obtained The practice 01 psychology shall be as defined above, any
5 post-master's years of appropriate education, training, and existing statute in the state of _ _ to the contrary notwith~
experience in providing clinical psychological services as de- standing. (APA, 1967, pp. 1098-1(99)
fined herein, including a minimum of 2 years in a clinical set-
ting. 6 The relation of a psychological service unit to a larger fa~
After January 31, 1980. professional psychologists who wish cility or institution is also addressed indirectly in the APA (1972)
to be recognized as professional clinical psychologists are re· "Guidelines lor Conditions 01 Employment 01 Psychologists"
rerred to Guideline 1.7. (hereinafter referred to as CEP Guidelines), which emphasizes
The definition of the professional clinical psychologist in these the roles, responsibilities. and prerogatives of the psychologist
Guidelines does not contradict or supersede in any way the when he or she is employed by or provides services for another
broader definition accorded the term clinical psycholOgist in agency, institution, or business.
the Federal Employees Health Benefits Program (see Access to
Psychologists and Optometrists Under Federal Health Bene~ 7 This Guideline replaces earlier recommendations in the
fits Program, u.s. Senate Report No. 93-961, June 25, 1974). 1967 state guidelines concerning exemption of psychologists
from licensure. Recommendations 8 and 9 of those guidelines
:3 The areas of knowledge and training that are a part of the
read as follows:
educational program for all professional psychologists have been
presented in two APA documents, Educati01l and Credential· Persons employed as psychologists by accredited academic
ing in Psychology II (APA, 1977a) and Criterla for Accredi- institutions, governmental agencies. research laboratories. and
tation of Doctoral Training Programs and Internships In business corporations should be exempted, provided such em~
Professional Psychology (APA, 1979). There is consistency in ployees are performing those duties for which they are em·
the presentation of core areas in the education and training of ployed by such organizations, and within the confines of such
all professional psychologists. The description of education and organizations.
training in these Guidelines is based primarily on the document Persons employed as psychologists by accredited academic
Education and Credentlaltng in Psychology l/. It is intended institutions, governmental agencies, research laboratories, and
to indicate broad areas of required curriculum, with the ex~ business corporations consulting or offering their research
peetation that training programs will undoubtedly want to in~ findings or providing scientific information to like organi~
terpret the specific content of these areas in different ways zations lor a lee should be exempted. (APA, 1967, p. 11(0)
depending on the nature, philosophy. and intent of the pro-
grams. On the other hand, the 1967 state gUidelines specifically de-
nied exemptions under certain conditions, as noted in Recom-
~ Functions and activities of psychologists relating to the mendations 10 and 11:
teaching of psychology, the writing or editing of scholarly or
scientific manuscripts, and the conduct of scientific research do Persons employed as psychologists who offer or provide
not fall within the purview of these Guidelines. psychological services to the public for a fee. over and above
the salary that they receive for the performance of their reg~
5 The definitions should be compared with the APA (1967) ular duties, should not be exempted.
guidelines for state legislation (hereinafter referred to as state Persons employed as psychologists by organizations that
guidelines), which define psychologist and the practice of psy~ sell psychological services to the public should not be ex-
chology as follows: empted. (APA, 1967, pp. 1100(1101)
A person represents himself (or herself] to be a psychologist
The present APA policy. as reHected in this Guideline, es-
when he [or she1 holds himself (or herself] out to the public
tablishes a single code 01 practice lor psychologists providing
by any title or description of services incorporating the words
covered services to users in any setting. The present position
.. psychology," .. psychological," "psychologist, ,. and/or offers
is that a psychologist providing any covered service meets local
to render or renders services as defined below to individuals.
statutory requirements for licensure or certi6cation. See the
groups, organizations, or the public for a fee, monetary or
section entitled Principles and Implications of the Specialty
otherwise.
Guidelines for an elaboration of this position.
The practice of psychology within the meaning of this act
is defined as rendering to individuals, groups, organizations,
, A closely related principle is lound in the APA (1972) CEP
or the public any psychological servi.ce involving the appli.
cation of principles. methods, and procedures of understand·
Guidelines:
ing, predicting, and inHuendng behavior, such as the prin- It is the policy of APA that psychology as an independent
ciples pertaining to learning, perception, motivation, thinking, profession is entitled to parity with other health and human
emotions and interpersonal relationships; the methods and service professions in institutional practices and before the
procedures of interviewing, counseling, and psychotherapy; law. Psychologists in interdisciplinary seHinp such as colleges
of constructing, administering, and interpreting tests of men· and universities, medical schools, clinics. private practice
tal abilities, aptitudes, interests, attitudes, personality char· groups, and other agencies expect parity with other profes-
acteristics, emotion, and motivation; and of assessing public sions in such matters as academic rank, board status, salaries,
opinion. fringe benefits. fees. participation in administrative decisions.
The application of said principles and methods includes. and all other conditions of employment, private contractual
but is not restricted to: diagnosis, prevention, and ameliora~ arrangements. and status before the law and legal institutions.
hon of adjustment problems and emotional and mental dis- (APA, 1972, p. 333)
orders of individuals and groups; hypnosis; educational and
vocational counseling; personnel selection and management; • See CEP Guidelines (section entitled Career Development)
the evaluation and planning for effective work and learning for a closely related statement:
situations; advertising and market research; and the resolution
of interpersonal and social conHicts. Psychologists are expected. to encourage institutions and
Psychotherapy within the meaning of this act means the agencies which employ them to sponsor or conduct career
use of learning, condiUoning methods, and emotional reac~ development programs. The purpose to these programa; would
650 ApPENDIXB
be to enable psychologists to engage in study for professional "across the board" legislation for such privileged communi-
advancement and to keep abreast of developments in their cations. (APA, 1987, p. 11(0)
field. (APA, 1972, p. 332)
,; This paragraph is directly adapted from the CEP Guide-
10 This Guideline follows closely the statement regarding line. (APA, 1972, p. 333).
"Policy on Training for Psychologists Wishing to Change Their
Specialty" adopted by the APA Council of Repr_ntatives in .. The CEP Guidelines also include the following:
January 1976. Included therein was the implementing provision
that "this policy statement shan be incorporated in the guide-. It is recognized that under certain circumstances, the in-
lines of the Committee on Accreditation so that appropriate terests and goals of a particular community or segment of
sanctions can be brought to bear on university and internship interest in the population may be in con8iet with the general
training programs that violate [It]" (Conger, 1976, p. 424). welfare. Under such circumstances, the psychologist's profes-
sional activity must be primarily guided by the principle of
"See also APA's (198lb) Eth/cG1 Principle. of P.ycholog/8ts, "promoting human welfare." (APA, 1972, p. 334)
especially Principles 5 (Confidentiality), 6 (Welfare of the Con·
sumer), and 9 (Research with Human Participants); and see 19 Support for the principle of the independence of psychol..
Eth/cG1 Principle. In the Conduct of R••••rch With Hu"",n ogy as a profession is found in the following:
P.rticipants (APA, 1973&). Also, in 1978 Division 17 approved
in principle a statement on "Principles for Counseling and Psy. As a member of an autonomous profession, a psychologist
chotherapy With Women," which was designed to protect the rejects limitations upon his lor her] freedom of thought and
interests of female users of clinical psychological' services. action other than those imposed by his [or her] moral, legal,
and social responsibilities. The Association is always prepared
1.2 Support for this position is found in Psychology as tJ Profes- to provide appropriate assistance to any responsible member
sion in the section on relations with other professions: who becomes subjected to unreasonable limitations upon his
[or her1 opportunity to function as a practitioner, teacher,
Professional persons have an obligation to know and take researcher, administrator, or consultant. The Association is
into account the traditions and practices of other professional always prepared to cooperate with any responsible profes-
groups with whom they work and to cooperate fully with sional organization in opposing any unreasonable limitations
members of such groups with whom research, service, and on the professional funetions of the members of that orga-
other functions are shared. (APA, 1968, p. 5) nization.
This insistence upon profeSSional autonomy has been up-
11 One example of a specific application of this principle is
held over the years by the affirmative actions of the courts
found in Guideline 2 in APA·s (1973b) '·Guidelines for Psy·
and other public and private bodies in support of the right
chologists Conducting Growth Groups":
of the psychologist-and other professionals-to pursue those
The following information should be made available in functions for which he [or she] is trained and qualified to
wrlting [italics added] to all prospective participant" perform. (APA. 1968, p. 9)
(0) An explicit statement of the purpose of the group: Organized psychology has the responsibility to define and
(b) Types of techniques that may he employed; develop its own profession, consistent with the general canons
(c) The education, training, and experience of the leader of science and with the public welfare.
or leaders: Psychologists recognize that other professions and other
(d) The fee and any additional expense that may he in· groups will, from time to time, seek to define the roles and
curred; responsibilities of psychologist. The APA opposes such de·
(e) A statement as to whether or not a follow-up service velopments on the same principle that it is opposed to the
is included in the fee: psychological profession taking positions which would define
(j) Goals of the group experience and techniques to he the work and scope of responsibility of other duly recognized
used; professions. (APA, 1972, p. 333)
(g) Amounts and kinds of responsibility to be assumed by
the leader and by the participants. For example, (I) the degree
lIO APA support for peer review is detailed in the following
to which a participant is free not to follow suggestions and
excerpt from the APA (l971) statement entitled "Psychology
prescriptions of the group leader and other group members; and National Health Care It:
(ii) any restrictions on a participant's freedom to leave the
group at any time; and All professions participating in a national health plan
(h) Issues 01 confidentiality. (p. 933) should be directed to establish review mechanisms (or per·
fonnance evaluations) that include not only peer review but
"See APA's (198la) APA/CHAMPUS Outpatient Psycho· active participation by persons representing the consumer.
10gictJl Provider Manual. In situations where there are fiscal agents, they should also
have representation when appropriate. (p. 1026)
"See Principle 5 (Confidentiality) in Ethlc.1 Prtnciples of
P.ycholog/8t, (APA, 1981b). 21 This Guideline on program evaluation is based directly on
the follOWing excerpts from two APA position papers:
Support for the principle of privileged communication is
If.
give formal recognition to research as a legitimate part of the conduct of research with humnn parH~pants. Washington,
duties of staff members. D.C., Author. 1973. (a)
. Only through explicit appraisal of program effects can American Psychological ~ssociation. Guidelines for psycholo-
worthy approaches be retained and refined, ineffective ones gists conducting growth groups. American PsycholOgist,
dropped. Evaluative monitoring of program achievements 1973.28. 933. (b)
may vary, of course, from the relatively informal to the sys- American Psychological Association. Standards for educational
tematic and quantitative, depending on the importance of and psycholOgical tests. Washington, n.G: Author, 1974.
the issue, the availablity of resources, and the willin~ness of (a)
those responsible to take risks of substituting informed. judg- American Psychological Association. Standards for providers
ment for evidence. (Smith & Hobbs. 1966. pp. 21-22) of psychological services. Washington. D.C., Author. 1974.
(b)
22 See also the CEP Guidelines for the following statement: American Psychological Association. Educatton and creden-
"A psychologist recognizes that. . he [or she1 alone is ac- Haling in psychology 11. Report of a meeting, June 4-5, 1977.
countable for the' consequences and effects of his [or herl ser- Washington. D.C., Author. 1977. (a)
vices, whether as teacher, researcher, or practitioner. This re- American Psychological Association. Standards for providers
sponsibility cannot be shared. delegated. or reduced" (APA. of psychological services (Rev. ed.). Washington. D.L Au-
1972. p. 334). thor. 1977. (b)
American Psychological Association. Criteria for accreditatton
of doctoral training programs and internships in profes-
REFERENCES sIoTull psf/Chology. Washington. D.C., Author. 1979 (amended
1980).
American Psychological Association. APAjCHAMPUS outpa-
American Psychological Association, CommiHee on Legislation. tient psf/Chological provider manual (Rev. ed.). Washington.
A model for state legislation affecting the practice of psy- D.C., Author. 1981. (a)
chology. Amencan PSf/ChoIogist. 1967.22. 1095-1100. American Psychological Association. Ethical princtples of psy-
American Psychological Association. Psychology as a profes- chologists (Rev. ed.). Washington. D.L Author. 1981. (b)
sion. Washington, D.G: Author, 1968. Conger, J. J. Proceedings of the American Psychological As-
American Psychological Association. Psychology and national sociation, Incorporated, for the year 1975: Minutes of the
health care. American PSf/Chologist. 1971.26. 1025-1026. annual meeting of the Council of Representatives. American
American Psychological Association. Guidelines for conditions Psychologist. 1976. 31. 406-434.
of employment of psychologists. American P'f/Chologist. Smith, M. 8., & Hobbs, N. The communHy and the community
1972. 27. 331-334. mental health center. Washington, D.G: American Psycho-
American Psychological Association. Etlrical prindples in the logical Association, 1966.
652 ApPENDIXB
tice of counseling psychology by specifying important of such services. The extent to which counseling psy-
areas of quality assurance and performance that con- chologists observe these Guidelines is judged by peers.
tribute to the goal of facilitating more effective human 8. These GUidelines, while assuring the user of the
functioning. counseling psychologist's accountability for the nature
and quality of services specified in this document, do not
Principles and Implications of the Specialty preclude the counseling psychologist from using new
GUidelines methods or developing innovative procedures in the de-
livery of counseling services.
These Specialty Guidelines emerged from and reaffirm
the same basic principles that gUided the development These Specialty Guidelines have broad implications
of the generic Standards for Provider. of Psychological both for users of counseling psychological services and
Serolces (APA, I977b): for providers of such services:
I. These Guidelines recognize that admission to the 1. Guidelines for counseling psychological services
practice of psychology is regulated by state statute. provide a foundation for mutual understanding between
2. It is the intention of the APA that the generic Stan- provider and user and facilitate more effective evalua-
dards provide appropriate guidelines for statutory li- tion of services provided and outcomes achieved.
censing of psychologists. In addition, although it is the 2. Guidelines for counseling psychologists are essential
position of the APA that licensing be generic and not in for uniformity in specialty credentialing of counseling
specialty areas, these Specialty Guidelines in counseling psychologists.
psychology provide an authoritative reference for use in 3. Guidelines give specific content to the profession's
credentialing specialty providers of counseling psycho- concept of ethical practice as it applies to the functions
logical services by such groups as divisions of the APA of counseling psychologiSts.
anll state associations and by boards and agencies that 4. Guidelines for counseling psychological services
find such criteria useful for quality assurance. may have siguificant impact on tomorrow's education
3. A uniform set of Specialty Guidelines governs the and training models for both professional and support
quality of services to all users of counseling psychological personnel In counseling psychology.
services in both the private and the public sectors. Those 5. Guidelines for the provision of counseling psycho-
receiving counseling psychological services are protected. logical services in human service facilities inBuence tbe
by the same kinds of safeguards, irrespective of sector; determination of acceptable structure, budgeting, and
these include constitutional guarantees, statutory regu- staffing patterns in these facilities.
lation. peer review. consultation. record review. and su- 6. Guidelines for counseling psychological services
pervision. require continual review and revision.
4. A uniform set of Specialty Guidelines governs coun-
seling psychological service funrtions offered by coun- The Specialty Guidelines here presented are Intended
seling psychologists, regardless of setting or form of re- to improve the quality and delivery of counseling psy-
muneration. All counseling psychologists in professional chological services by specifying criteria for key aspects
practice recognize and are responsive to a uniform set of the practice setting. Some settings may require ad-
of Specialty Guidelines, just as they are guided by a ditional and/or more stringent criteria for specific areas
common code of ethics. of service delivery.
5. Counseling psychology Guidelines establish clear, Systematically applied, these Guidelines serve to es-
minimally acceptable levels of quality for covered coun- tablish a more effective and consistent hasis for evalu-
seling psychological service functions, regardless of the ating the performance of individual service providers as
nature of the users, purchasers, or sanctioners of such well as to gUide the organization of counseling psycho-
covered services. logical service units in human service settings.
6. All persons providing counseling psychological ser-
vices meet specified levels of training and experience Definitions
that are consistent with. and appropriate to, the functions
they perform. Counseling psychological services pro- Providers of counseling psychological serolces refers to
vided by persons who do not meet the APA qualifications two categories of persons who provide counseling psy-
for a professional counseling psychologist (see Defini- chological services:
tions) are supervised by a professional counseling psy. A. Professional counseling psychologists.' Professional
chologist. Final responsibility and accountability for counseling psychologists have a doctoral degree from a
services provided rest with professional. counseling regionally accredited university or professional school
psychologists. providing an organized, sequential counseling psycbol-
7. When providing any of the covered counseling ogy program In an appropriate academic department in
psychological service functions at any time and in any a university or college, or in an appropriate department
setting, whether public or private, profit or nonprofit, or unit of a professional school. Counseling psychology
counseling psychologists observe these Guidelines in or- programs that are accredited by the American Psycho-
der to promote the best interests and welfare of the users logical Association are recognized as meeting the de6-
654 ApPENDIXB
nition of a counseling psychology program. Counseling A. Assessment, evaluation, and diagnosis. Procedures
psychology programs that are not accredited by the may include, but are not limited to, behavioral obser-
American Psychological Association meet the definition vation, interviewing, and administering and interpreting
of a counseling psychology program if they satisfy the instruments for tbe assessment of educational achieve-
following criteria: ment, academic skills, aptitudes, interests, cognitive
1. The program is primarily psychological in nature abilities, attitudes, emotions, motivations, psychoneuro-
and stands as a recognizable, coherent organizational logical status, personality characteristics, or any other
entity within the institution. aspect of human experience and behavior that may con-
2. The program provides an integrated, organized tribute to understanding and helping the user.
sequence of study. B. Interventions witb individuals and groups. Pr0ce-
3. The program has an identifiable body of students dures include individual and group psychological coun-
who are matriculated in that program for a degree. seling (e.g., education, career, couples, and family coun-
4. There is a clear authority with primary respon- seling) and may use a therapeutic, group process, or
sibility for the core and specialty areas, whether or not social-learning approach, or any other deemed to be ap-
the program cuts across administrative lines. propriate. Interventions are used for purposes of pre-
5. There is an identifiable psychology faculty, and vention, remediation, and rehabilitation; they may in-
a psychologist is responsible for the program. corporate a variety of psychological modalities, such as
The professional counseling psychologist's doctoral psychotherapy, behavior therapy, marital and family
education and training experience' is defined by the in- therapy, biofeedback techniques, and environmental
stitution offering the program. Only counseling psy- design.
chologists, that is, those who meet the appropriate ed- C. Professional consultation relating to A and B above,
ucation and training requirements, have the minimum for example, in connection with developing in-service
professional qualifications to provide unsupervised coun- training for staff or assisting an educational institution
seling psychological services. A professional counseling or organization to design a plan to cope with persistent
psychologist and others providing counseling psycholog- problems of its students.
ical services under supervision (described below) form
D. Program development services in the areas of A,
an integral part of a multilevel counseling psychological B, and C above, such as assisting a rehabilitation center
service delivery system. to design a career-counseling program.
B. All other persons who proVide counseling psycho-
E. Supervision of all counseling psychological services,
logical services under the supervision of a professional
such as the review of assessment and intervention activ-
counseling psychologist. Although there may be varia-
ities of staff.
tions in tbe ,titles of such persons, tbey are not referred
to as counseling psychologists. Their functions may be F. Evaluation of all services noted in A through E
indicated by use of the adjective psychological preceding above and research for the purpose of their improve-
ment.
the noun, for example, psychological IJ8soclate, psycho-
logical assistant, psychological technfc/4n, or psycho-
logical aide. A coumeljng psycholOgical service unit is the func-
tional unit through which counseling psychological ser-
Counseling psychologkal seroice& refers to services vices are provided; such a unit may be part of a larger
provided by counseling psychologists that apply princi- psychological service organization comprising psychol-
ples, methods, and procedures for facilitating effective ogists of more than one specialty and headed by a profes-
functioning during the life-span developmental pro- sional psychologist:
cess. <.. In providing such services, counseling psychol- A. A counseling psychological service unit provides
ogists approach practice with a Significant emphasis on predominantly counseling psychological services and is
positive aspects of growth and adjustment and with a composed of one or more professional counseling psy-
developmental orientation. These services are intended chologists and supporting staff.
to help persons acquire or alter personal-social skills, B. A counseling psychological service unit may op-
improve adaptability to changing life demands, enhance erate as a functional or geographic component of a larger
environmental coping skills, and develop a variety of multipsychological service unit or of a governmental,
problem-solving and decision-making capabilities. Coun- educational, correctional, health, training, industrial, or
seling psychological services are used by individuals, cou- commercial organizational unit, or it may operate as an
ples, and families of all age groups to cope with problems independent professional service.·
connected with education, career choice, work, sex, mar- C. A counseling psychological service unit may take
riage, family, other social relations, health, aging, and the form of one or more counseling psychologists pr0-
handicaps of a social or physical nature. The services are viding professional servil'e5 in a multidisciplinary setting.
offered in such organizations as educational, rehabilita- D. A counseling psychological service unit may also
tion, and health institutions and in a variety of other take the form of a private practice, composed of one or
publiC and private agencies committed to service in one more counseling psychologists serving individuals or
or more of the problem areas cited above. Counseling groups, or the form of a psychological consulting firm
psychological services include the following: serving organizations and institutions.
SPECIALTY GUIDELINES FOR THE DELIVERY OF SERVICES 655
Users of counseling psychological sermces include: gist of another specialty or by a professional from an-
A. Direct users or recipients of counseling psycholog- other discipline whose competence in the given area
ical services. has been demonst<ated by premous training and ex-
B. Public and private institutions, facilities, or orga- perience.
nizations receiving counseling psychological services.
C. Third-party purchasers-those who pay for the INTERPRETATION In each counseling psychological ser-
delivery of services but who are not the recipients of vice unit there may be varying levels of responsibility
services. with respect to the nature and quality of services pro-
D. Sanctioners-those who have a legitimate concern vided. Support personnel are considered to be responsible
with the accessibility, timeliness, efficacy, and standards for their functions and behavior when assisting in the
of quality attending the provision of counseling psycho- provision of counseling psychological services and are
logical services. Sanctioners may include members of the accountable to the professional counseling psychologist.
user's family, the court, the probation officer, the school Ultimate professional responsibility and accountability
administrator, the employer, the union representative. for the services provided require that the supervisor re-
the facility director, and so on. Sanctioners may also in- view reports and test protocols, and review and discuss
clude various governmental, peer review, and accredi- intervention plans, strategies, and outcomes. Therefore,
tation bodies concerned with the assurance of quality. the supervision of all counseling psychological services
is provided directly by a profeSSional counseling psy-
chologist in a face-to-face arrangement involving indi-
vidual and/or group supervision. The extent of super-
vision is determined by the needs of the providers, but
Guideline 1
in no event is it less than 1 hour per week for each
PROVIDERS
support staff member providing counseling psychologi-
cal services.
1.1 Each counseling psycholOgical semce unit offering To facilitate the effectiveness of the psychological ser-
psychological semces has available at least one profes- vice unit, the nature of the supervisory relationship is
sional counseling psychologist and as many more communicated to support personnel in writing. Such
professional counseling psychologists as are necessary communications delineate the duties of the employees,
to assure the adequacy and quality of SeTmees offered. describing the range and type of services to be provided.
The limits of independent action and decision making
INTERPRETATION, The intent of this Guideline is that one
are defined. The description of responsibility specifies
or more providers of psychological services in any coun-
the means by which the employee will contact the profes-
seling psychological service unit meet the levels of train-
sional counseling psychologist in the event of emergency
ing and experience of the profeSSional counseling psy-
or crisis situations.
chologist as specified in the preceding definitions.'
When a professional counseling psychologist is not
available on a full-time basis, the facility retains the ser- 1.3 WhereVeT a counseling psychological sermee unit
vices of one or more professional counseling psychologists exists, a professional counseling psychologist is respon-
on a regular part-time basis. The counseling psychologist sible for planning, directing, and reviewing the prom-
so retained directs the psychological services, including sion of counseling psychological sermces. Whenever the
supervision of the support staff, has the authority and counseling plf1Jchological semce unit Is part of a larger
participates sufficiently to assess the need for services, professional psychological sermee encompassing various
reviews the content of services provided, and assumes psychological specialties, a professional psychologist
professional responsibility and accountability for them. shall be the administrative head of the serlJice.
The psychologist directing the service unit is respon-
sible for determining and justifying appropriate ratios INTERPRETATION, The counseling psychologist who di-
of psychologists to users and psychologists to support rects or coordinates the unit is expected to maintain an
staff, in order to ensure proper scope, accessibility, and ongoing or periodic review of the adequacy of services
quality of services provided in that setting. and to formulate plans in accordance with the results 01
such evaluation. He or she coordinates the activities of
1.2 P<OtJiIkrs of counseling psycholOgical services who the counseling psychology unit with other professional,
do not meet the requirements for the professional coun- administrative, and technical groups, both within and
seling psychologist are supemsed directly by a profes- outside the institution or agency. The counseling psy-
sional counseling psychologist who assumes p<ofes- chologist has related responsibilities including, but not
sional responsunlity and accountability for the ser1Jices limited to, directing the training and research activities
prOtJilkd. The level and extent of supemsion may vary of the service, maintaining a high level of professional
from task to task so long as the supervising psychologist and ethical practice, and ensuring that staff members
retains a sufficiently close supervisory relationship to function only within the areas of their competency.
meet this Guideline. Special proficiency training or 8U- To facilitate the effectiveness of counseling services
perlJision may be promded by a profeSSional psycho/o- by raising the level of staff sensitivity and professional
656 ApPENDIXB
skills. the counseling psychologist designated as director with respect to .ubJect matter and profelSlonal .kll"
is responsible for participating in the selection of staff thot apply to doctoral edlJC(Jtion and Iraining in coun·
and support personnel whose quali6cations and skills sellng PlliChology.10
(e.g.• language. cultural and experiential background.
INTERPRETATION, Education of doctoral· level psycholo-
race. sex. and age) are relevant to the needs and cbar-
acteristics of the users served. gists to qualify them for specialty practice in counseling
psychology is under the auspices of a department in a
regionally accredited university or of a professional
1.4 When funclloning tJ8 part of an organizational set·
school that offers the doctoral degree in counseling psy.
ling. professional counseling PI""hologists bring their
backgrounds and .kll" to bear on the goa"
of the or·
chology. Such education is individualized. with due
credit being given for relevant course work and other
ganlzation, whene1ler appropriate. by parljcjpation In
requirements tbat bave previously been satis6ed. In ad·
the planning and development of overaU sertJlces.·
dition. doctoral-level training supervised by a counseling
INTERPRETATION, Professional counseling psychologists psychologist is required. Merely taking an internship In
participate In the maintenance of high professional.tan· counseling psychology or acquiring experience in a prac-
dards by representation on committees Concerned with ticum setting is not adequate preparation for becoming
service deliVery. a counseling psychologist wben prior education has not
As appropriate to the setting. their activities may in· been In tbat area. Ful6l1ment of such an individualized
c1ude active participation. as voting and as of6ee-holding educational program is attested to by tbe awarding of
members. on the facility's professional staff and on other a certificate by the supervising department or profes-
executive. planning. and evaluation boards and com· sional school that indicates the successful completion of
mittees. preparation In counseling psychology.
I.S Counseling PI""hologist. maintain current knowl· I.S ProfelSional counseling psychologist. are encour-
edge of scientific and professional developments to pre. aged to develop innooatlve theories and procedure. and
serve and enhance their professional competence. to provlde appropriate theoretictJI and/or emp/rictJlsup-
port for their Innooatlons.
INTERPRETATION, Methods through which knowledge of
scienti6c and professional developments may be gained INTERPRETATION, A specialty of a profession rooted in
include, but are not limited to, reading scIenti6c and a science intends continually to explore and experiment
professional publications, attendance at professional with a view to developing and verifying new and im-
workshops and meetings, participation in staff devel· proved ways of serving the public and documents tbe
opment programs, and other forms of continuing edu· innovations.
cation.' The counseling psychologist bas ready access to
reference material related to the provision of psycholog·
ical services. Counseling psychologists are prepared to
show evidence periodically that they are staying abreast
of current knowledge and practices in the 6eld of coun· Guideline 2
seling psychology through continuing education. PROGRAMS
1.8 Counseling PI""hologist. limit their pracllce to 1.1 Compoaition and organization of a counseling PI"-
their demonstrated areas of profes_al competence. chologictJI.ervice unit:
INTERPRETATION, Counseling psychological services are
2.1.1 The compoaition and programs of a counseling
offered in accordance with tbe providers' areas of com- PlychoiogictJl seroIce unit are responsive to the need.
petence as de6ned by veri6able training and experience. of the per.ons or settings served.
When extending services beyond the range of their usual
practice, counseling psychologists obtain pertinent train· INTERPRETATION, A counseling psychological service unit
ing or appropriate professional supervision. Such training is structured so as to facilitate effective and economical
or supervision is consistent with the extension of functions delivery of services. For example, a counseling psycho-
performed and services prOVided. An extension of ser- logical service unit serving predominantly a low-income,
vices may involve a cbange in the theoretical orientation ethnic, or racial minority group bas a staf6ng pattern
of the counseling psychologist, in the modality or tech· and service programs that are adapted to the linguistic.
niques used. in the type of client. or In tbe kinds of experiential. and attitudinal characteristics of the users.
problems or disorders for which services are to be pro-
vided.
I.U A description of lhe organization of lhe coun-
.ellng PI""hologictJI service unit and III lines of re-
1.7 Profe._al PI""hologists who WlBh to qualif" III sponsibility and GCCOUntabUit" for the delivery of
counseling Plychologisll meet the lllme requirement. PI!JCh%gic4l.ertJlces ill available in written form to
SPECIALTY GUIDELINES FOR THE DELIVERY OF SERVICES 657
.taff of the unit and 10 users and sanctioners upon pitals, protection of minors or legal incompetents, dis-
request. criminatory practices in employment selection pr0ce-
dures, recommendation for special education provisions,
INTERPRETATION, The description includes lines of re-
information relative to adverse personnel actions in the
sponsibility, supervisory relationships, and the level and armed services, and adjudication of domestic relations
extent of accountability for each penon who provides disputes in divorce and custodial proceedings. Providers
psychological services. of counseling psychological services take affirmative ac-
tion by making themselves available to local committees
2.1.3 A counseling psychological .ervice unit In- review boards, and similar advisory groups establisheci
cludes suffictent numbers of profe.stonaland support to safeguard the human, civil, and legal rights of service
personnel to achfeoe It. goo/8, obJectllle8, and pur- users.
poses.
INTERPRETATION, The work load and diversity of psy- 2.2.3 All prootders wllhln a counseling psychological
chological services required and the specific goals and service unit are familiar with dnd adhere to the
objectives of the setting determine the numbers and qual- Amerlcan P.ychologlcal Assoctatlon's Standards for
ifications of professional and support personnel in the Providers of Psychological Services, Ethical Principles
counseling psychological service unit. Where shortages of Psychologists, Standards for Educational and Psy-
in personnel exist, so that psychological services cannot chological Tests, Ethical Principles In the Conduct of
he rendered in a professional manner, the director of the Research With Human Participants, and olher offictal
counseling psychological service unit initiates action to policy statement. relet>ant to standards for profes-
remedy such shortages. When this fails, the director ap- stonal.erv1ce8 issued by the AsBOClatlon.
propriately modifies the scope or work load of the unit
INTERPRETATION, Providers of counseling psychological
to maintain the quality of the services rendered and, at
services maintain current knowledge of relevant stan-
the same time, makes continued efforts to devise alter-
dards of the American Psychological Association.
native systems for delivery of services.
network of human services in their communities in slanal pract1ces and to the problems presented by the
order to link users with relevant services and re- users.
sources.
INTERPRETATION, A counseling psychologist, alter initial
INTERPRETATION, Counseling psychologists and support assessment, develops a plan describing the objectives of
staff are sensitive to the broader context of human needs. the psycholOgical services and the manner in which they
In recognizing the matrix of personal and social prob- will be provided." To illustrate, the agreement spells out
lems, providers make available to clients information the objective (e.g., a career decision), the method (e.g.,
regarding human services such as legal aid societies, s0- short-term counseling), the roles (e.g., active participa-
cial services, employment agencies, health resources, and tion by the user as well as the provider), and the cost.
educational and recreational facilities. Providers of coun- This plan is in written form. It serves as a basis for ob-
seling psychological services refer to such community taining understanding and concurrence from the user
resources and. when indicated, actively intervene on and for establishing accountability and provides a mech-
behalf of the users. anism for subsequent peer review. This plan is, 01 course,
Community resources include the private as well as modified as changing needs dictate.
the public sectors. Consultation is sought or referral made A counseling psychologist who provides services as one
within the public or private network of services when- member 01 a collaborative effort participates in the de-
ever required in the best interest of the users. Counseling velopment, modification (if needed), and implementa-
psychologists, in either the private or the public setting, tion of the overall service plan and provides for its pe-
utilize other resources in the community whenever in- riodic review.
dicated because of limitations within the psychological
service unit providing the services. Professional coun-
seling psychologists in private practice know the types 2.3.3 Accurate, current, and perUnent documenta-
of services offered through local community mental tion of essentw.l counseling psychological services
health clinics and centers, through family-service, career, prot>kled is maintained.
and placement agencies, and through reading and other
educational improvement centers and know the costs and INTERPRETATION, Records kept of counseling psycholog-
the eligibility requirements for those services. ical services include, but are not limited to, identifying
data, dates of services, types of services, significant ac-
2-2.6 In the delivery of counseling psychologicalser- tions taken. and outcome at termination. Providers of
vice., the providers maintain a cooperative relation- counseling psychological services ensure that essential
ship with colleagues and co-workers in the best in- information concerning services rendered is recorded
terest of the users." within a reasonable time following their completion.
course of action for continuing professional service, if property of the psychologist or the facility in which the
needed. Depending on local circumstances, appropriate psychologist works and are, therefore, the responsibility
arrangements for record retention and disposition may of the psychologist and subject to his or her control.
also be recommended by the reviewing psychologist. When the user's intention to waive confidentiality is
This Guideline has been designed to meet a variety judged by the professional counseling psychologist to be
of circumstances that may arise, often years after a set contrary to the user's best interests or to be in conflict
of psychological services has been completed. Increas- with the user's civil and legal rights, it is the responsibility
ingly, psychological records are being used in forensic of the counseling psychologist to discuss the implications
matters, for peer review, and in response to requests from of releasing psychological information and to assist the
users, other professionals. and other legitimate parties user in limiting disclosure only to information required
requiring accurate information about the exact dates, by the present circumstance.
nature. course, and outcome of a set of psychological Raw psychological data (e.g., questionnaire returns or
services. The 4-year period for retention of the full record test protocols) in which a user is identified are released
covers the period of either undergraduate or graduate only with the written consent of the user or his or her
study of most students in postsecondary educational in- legal representative and released only to a person rec-
stitutions, and the 7-year period for retention of at least ognized by the counseling psychologist as qualified and
a summary of the record covers the period during which competent to use the data.
a previous user is most likely to return for counseling Any use made of psychological reports, records, or
psychological services in an educational institution or data for research or training purposes is consistent with
other organization or agency. this Guideline. Additionally, providers of counseling psy-
chological services comply with statutory confidentiality
2.3.5 Providers of coonseling psycholOgical services requirements and those embodied in the American Psy-
maintain a system to protect confidentiality of their chological Association's Ethical Principles of Psycholo-
records. 14 gists (APA, 1981b).
Providers of counseling psychological services who use
INTERPRETATION. Counseling psychologists are respon- information about individuals that is stored in large com-
sible for maintaining the confidentiality of information puterized data banks are aware of the possible misuse
about users of services, from whatever source derived, of such data as well as the benefits and take necessary
All persons supervised by counseling psychologists, in- measures to ensure that such information is used in a
cluding nonprofessional personnel and students, who socially responsible manner.
have access to records of psychological services maintain
this confidentiality as a condition of employment and/
or supervision.
The counseling psychologist does not release confi-
dential information, except with the written consent of Guideline 3
the user directly involved or his or her legal represen- ACCOUNTABILITY
tative. The only deviation from this rule is in the event
of clear and imminent danger to. or involving, the user. 3.1 The promotion of human welfare Is the primary
Even after consent for release has been obtained, the prine/pie guiding the professional octiotty of the COUn-
counseling psychologist clearly identifies such informa- seling psychologist and the counseling psychological
tion as confidential to the recipient of the information. 15 service unit.
If directed otherwise by statute or regulations with the
force of law or by court order, the psychologist seeks a INTERPRETATION, Counseling psychologists provide ser-
resolution to the conflict that is both ethically and legally vices to users in a manner that is considerate, effective,
feasible and appropriate. economical, and humane. Counseling psychologists are
Users are informed in advance of any limits in the responsible for making their services readily accessible
setting for maintenance of confidentiality of psycholog- to users in a manner that facilitates the users' freedom
ical information. For instance, counseling psychologists of choice.
in agency clinic, or hospital settings inform their clients
I Counseling psychologists are mindful of their account-
that psychological information in a client's record may ability to the sanctioners of counseling psycbological ser-
be available without the client's written consent to other vices and to the general public, provided that appropriate
members of the professional staff associated with service steps are taken to protect the confidentiality of the service
to the client. Similar limitations on confidentiality of relationship. In the pursuit of their professional activities,
psychological information may be present in certain ed- they aid in the conservation of human, material, and
ucational, industrial. military, or other institutional set- financial resources.
tings, or in instances in which the user has waived con- The counseling psychological service unit does not
fidentiality for purposes of third-party payment. withhold services to a potential client on tbe basis of that
Users have the right to obtain information from their user's race, color, religion, gender. sexual orientation,
psychological records. However, the records are the age, or national origin; nor does it provide services in a
660 ApPENDIXB
discriminatory or exploitative fashion. Counseling psy- support the principle that members of each participating
chologists who find that psychological services are being profeSSion have equal rights and opportunities to share
provided in a manner that is discriminatory or exploit- all privileges and responsibilities of full membership in
ative to users and/or contrary to these Guidelines or to human service facilities and to administer service pro-
state or federal statutes take appropriate corrective ac- grams in their respective areas of competence.
tion, which may include the refusal to provide services.
When conllicts of interest arise, the counseling psychol-
ogist is guided in the resolution of differences by the 3.3 There are periodic, systematic, and effective eval-
principles set forth in the American Psychological As- uations of counseling psychological servfces."
sociation's Ethical Principles of Psychologist. (APA,
INTERPRETATION, When the counseling psychological ser-
1981b) and "Guidelines for Conditions of Employment
vice unit is a component of a larger organization, regular
of Psychologists" (APA, 1972).16
evaluation of progress in achieving goals is provided for
Recognition is given to the following considerations
in the service delivery plan, including consideration of
in regard to the withholding of service: (a) the profes-
the effectiveness of counseling psychological services rel-
sional right of counseling psychologists to limit their
ative to costs in terms of use of time and money and the
practice to a specific category of users with whom they
availability of profeSSional and support personnel.
have achieved demonstrated competence (e.g., adoles-
Evaluation of the counseling psychological service de-
cents or families); (b) the right and responsibility of coun-
livery system is conducted internally and, when possible,
seling psychologists to withhold an assessment procedure
under independent auspices as well. This evaluation in-
when not validly applicable; (c) the right and responsi-
cludes an assessment of effectiveness (to determine what
bility of counseling psychologists to withhold services in
the service unit accomplished), effiCiency (to determine
specific instances in which their own limitations or client
the total costs of providing the services), continuity (to
characteristics might impair the quality of the services;
ensure that the services are appropriately linked to other
(d) the obligation of counseling psychologists to seek to
human services), availability (to determine appropriate
ameliorate through peer review, consultation, or other
levels and distribution of services and personnel), acces-
personal therapeutic procedures those factors that inhibit
sibility (to ensure that the services are barrier free to
the provision of services to particular individuals; and
users), and adequacy (to determine whether the services
(e) the obligation of counseling psychologists who with-
meet the identified needs for such services).
hold services to assist c1ients in obtaining services from
There is a periodic reexamination of review mecha·
other sources,li
nisms to ensure that these attempts at public safeguards
are effective and cost efficient and do not place unnec-
3,2 Counseling psycholOgists pursue their activities as essary encumbrances on the providers or impose unnec-
members of the independent, autonomous profession essary additional expenses on users or sanctioners for ser·
of psychology. ,. vices rendered.
INTERPREHTION· Counseling psychologists, as members
of an independent profession, are responsible both to the 3,4 Counseling psychologists are accountable for all
public and to their peers through established review aspects of the servfces they provide and are responsive
mechanisms. Counseling psychologists are aware of the to those concerned with these services"
implications of their activities for the profession as a
whole. They seek to eliminate discriminatory practices INTERPRETATION· In recognizing their responsibilities to
instituted for self-serving purposes that are nol in the users, sanctioners, third-party purchasers, and other pro-
interest of the users (e.g., arbitrary requirements for re- viders, and where appropriate and consistent with the
ferral and supervision by another profession). They are users' legal rights and privileged communications, coun-
cognizant of their responsibilities for the development seling psychologists make available information about,
of the profession, partiCipate where possible in the train- and provide opportunity to partiCipate in, decisions con·
ing and career development of students and other pro- cerning such issues as initiation, termination, continua·
viders, participate as appropriate in the training of para· tion, modification, and evaluation of counseling psycho-
professionals or other professionals, and integrate and logical services.
supervise the implementation of their contributions Depending on the settings, accurate and full infor-
within the structure established for delivering psycho- mation is made available to prospective individual or
logical services. Counseling psychologists facilitale the organizational users regarding the qualifications of pro-
development of, and participate in, professional stan- viders, the nature and extent of services offered, and
dards review mechanisms,I9 where appropriate, financial and social costs.
Counseling psychologists seek to work with other Where appropriate, counseling psychologists inform
professionals in a cooperative manner for the good of the users of their payment policies and tbeir willingness to
users and the benefit of the general public. Counseling assist in obtaining reimbursement. To assist their users,
psychologists associated with multidisciplinary settings those who accept reimbursement from a third party are
SPECIALTY GUIDELINES FOR THE DELIVERY OF SERVICES 661
acquainted with the appropriate statutes and regulations, After January 31. 1980. profeSSional psychologists who wish
the procedures for submitting claims, and the limits on to be recognized as professional counseling psychologists are
confidentiality of claims information, in accordance with referred to Cuideline 1.7.
pertinent statutes. .1 The areas of knowledge and training that are a part of the
educational program for all professional psychologists have been
presented in two APA documents, Education and Credential-
ing in Psychology II (APA. 1977a) and Criteria for Accredi-
tation of Doctoral Training Programs and Internships in
Guideline 4 Pro!es:.ional Psychology (APA, 1979). There is conSistency in
the prewntation of core areas in the education and training of
ENVIRONMENT all profeSSional p!oychologists. The description of education and
training in these Guidelines is based primarily on the document
Education and Credenttaling in Psychology 11. It is intended
4.1 Providers of counseling psychological services pro- to indicate broad areas of required curriculum, with the ex-
mote the development in the service setting of a phys- pt>.(·tation that training programs will undoubtedly want to in-
ical, organizational, and social environment that facil- terpret the spt"cific content of theSt" areas in diHerent ways
itates optimal human functioning. dt'pending on the nature. philosophy. and intent of the pro-
~rams.
years in a counseling setting. cilityor institution is also addressed indirectly in the APA (1972)
662 ApPENDIXB
"Guidelines for Conditions of Employment of Psychologists" that "this policy statement shan be incorporated in the guide-
(hereinafter referred to as CEP Guidelines). which emphasize lines of the Committee on Accreditation so that appropriate
the roles. responsibilities. and prerogatives of the psychologist sanctions can be brought to bear on university and internship
when he or she is employed by or provides services for another training programs that violate [it]" (Conger. 1976. p. 424).
agency, institution, or business.
"See also APA's (1981bj Ethlcol Principle. of P.ycIw/ogl<ts.
1This Guideline replaces earlier recommendations in the especially Principles 5 (Con6dentiality). 6 (Welfare of the Con-
sumer), and 9 (Research With Human Participants); and see
1967 state guidelines ooncerning exemption of psychologists
from licensure. Recommendations 8 and 9 of those guidelines Ethlcol Principles In lhe Conducl of Re.e4rch Wllh Humsn
read as follows: Parlicl""nt. (APA. 1973a). Also, in 1978 Division 17 approved
in principle a statement on "Principles for Counseli~g and Psy-
Persons employed as psychologists by accredited academic chotherapy With Women," which was designed to protect the
institutions. governmental agencies, research laboratories, and interests of female users of counseling psychological services.
business corporations shoold be exempted. provided such em-
ployees are performing those duties for which they are em- U'Support for this position is found in the section on.relations
ployed by such organizations. and within the confines of such with other professions in Psychology as a ProJeul.on:
organizations.
Persons employed as psychologists by accredited academic Professional persons have an obligation to know and take
institutions, governmental agencies, research laboratories, and into account the traditions and practices of other professional
bwiness corporations consulting or offering their research groups with whom they work and to cooperate fully with
6ndings or providing scientific information to Iflee organi- members of such groups with whom research. service, and
.ations for a fee should be exempted. (APA. 1967. p. 11(0) other functions are shased. (APA. 1968. p. 5)
On the other hand. the 1967 state guidelines speci6cally de- 13 One example of a specific application of this principle is
nied exemptions under certain conditions, as noted in Recom- found in APA's (198la) revised APA/CHAMPUS OutpGtient
mendations 10 and 11: P.yclwlog1c4/ Provider Manual. "'nother example. quoted be-
Persons employed as psychologists who offer or provide low. is found in Guideline 2 in APA', (1973b) "Guidelines for
psychological services to the public for a fee. over and above Psychologists Conducting Growth Groups":
the salary that they receive for the performance of their reg- The following information should be made available In
ular duties. should not be exempted. writing [italics added] to all prospective partiCipants:
Persons employed as psychologists by organizations that (a) An explicit statement of the purpose of the group;
sell psychological services to the public should not be ex- (b) Types of techniques that may be employed;
empted. (AP.... 1967. pp. 1100(1101) (c) The education. training. and experience of the leader
or leaders;
The present AP... policy. as reHected in this Guideline. es-
(d) The fee and any additional expense that may be in-
tablishes a single code of practice for psychologists proViding
curred;
covered services to users in any setting. The present position
(e) A statement as to whether or not a follow-up service
is that a psychologist providing any covered service meets local
statutory requirements for licensure or certification. See the is included in the fee;
(f) Goals of the group experience and techniques to be
section entitled Principles and ImplicatiOns of the Specialty
Guidelines for further elaboration of this point.
used;
(g) ... mounts and kinds of responsibility to be assumed by
.... closely related principle is found in the APA (1972) CEP the leader and by the participants. For example. (I) the degree
to which a participant is free not to follow suggestions and
Guidelines:
prescriptions of the group leader and other group members;
It is the policy of AP... that psychology as an independent (It) any restrictions on a participant's freedom to leave the
profession is entitled to parity with other health and human group at any time; and
service professions in institutional practices and before the (h) Issues of con6dentiality. (p. 933)
law. Psychologists in interdisciplinary settings such as colleges
and universities, medical schools. clinics, private practice "See Principle 5 (Confidentiality) in Elh/col Principle. of
groups, and other agencies expect parity with other profes- Psychologl<ts ("'PA. 198Ib).
sions in such matters as academic rank, board status, salaries,
fringe beneSts., fees. partiCipation in administrative decisions. IS Support for the principles of privileged communication is
and all other conditions of employment, private contractual found in at least two policy statements of the Association:
arrangements. and status before the law and legal institutions.
(AP.... 1972, p. 333) In tbe interest of hoth the public and the client and in
accordance with the requirements of good professional prac-
9 See CEP Guidelines (section entitled Career Development) tice, the profession of psychology seeks recognition of the
for a closely related statement: privileged nature of con6dential communications with clients.
preferably through statutory enactment or by adminbtrative
Psychologists are expected to encourage institutions and polley wbere more appropriate. ("'PA. 1968. p. 8)
agencies which employ them to sponsor or conduct career Wherever possible. a clause protecting the privileged na-
development program. The purpose of these programs would ture of the psychologist-client relationship be included.
be to enable psychologists to engage in study for professional Wben appropriate. psychologists assist in obtsining general
advancement and to keep abreast of developments in their "across the board" legislation for such privileged communi-
6eld. (AP.... 1972. p. 332) cations. (APA. 1967. p. 1103)
11.1 This Guideline follows closely the statement regarding .. The CEP Guidelines include tbe following;
"Policy on Training for Psychologists Wishing to Change Their
Specialty" adopted by the APA Council of Representatives in It is recognized that under certain circumstances, the in-
January 1976. Included therein was the implementing provision terests and goals of a particular community or segment of
SPECIALTY GUIDELINES FOR THE DELIVERY OF SERVICES 663
interest in the population may be in con8ict with the general give formal recognition to research as a legitimate part of the
welfare. Under such circumstances, the psychologist's profes-- duties of staff members.
sional activity must be primarily guided by the principle of . Only through explicit appraisal of program effects can
"promoting human welfare," (APA. 1972, p. 334) worthy approaches be retained and refined, ineffective ones
dropped. Evaluative monitoring of program achievements
11 This paragraph is adapted in part from the CEP Guidelines may vary, of course, from the relatively informal to the sys-
(APA, 1972, p. 333). tematic and quantitative, depending on the importance of
the issue, the availability of resources, and the willingness of
"Support lor the principle of the independence of psychol- those responsible to take risks of substitlJting informed judg-
ogy as a profession is found in the following: ment for evidence. (Smith & Hobbs, 1966, pp. 21-22)
As a member of an autonomous profession, a psychologist 21 See also the CEP Guidelines for the following statement:
rejects limitations upon his [or her] freedom of thought and .. A psychologist recognizes that . . . he [or she] alone is ac-
action other than those imposed by his [or her] moral, legal, countable for the consequences and effects of his [or her] ser-
and social responsibilities. The Association is always prepared vices, whether as teacher, researcher, or practitioner. This re-
to provide appropriate assistance to any responsible member sponsibility cannot be shared, delegated, or reduced" (APA,
who becomes subjected to unreasonable limitations upon his 1972, p. 334).
[or her) opportunity to function as a practitioner, teacher,
researcher, administrator, or consultant. The Association is
REFERENCES
always prepared to cooperate with any responsible profes-
sional organization in opposing any unreasonable limitatiON American Psychological Association, Committee on Legislation.
on the professional functions of the members of that orga- A model for state legislation affecting the practice of psy-
nization. chology. American P.ychologisl, 1967, 22, 1095-1103.
This insistence upon professional autonomy has been u~ American Psychological Association. Psychology as a profes-
held over the years by rhe affirmative actions of the courts .Jon. Washington, D.C., Author, 1968.
and other public and private bodies in support of the right American Psychological Association. Psychology and national
of the psychologist-and other professionals-to pursue those health care. American P.ychologisl, 1971,26, 1025-1026.
functions for which he [or she] is trained and qualified to American Psychological Association. Guidelines for conditions
perform. (APA, 1968, p. 9) of employment of psychologists. American P.ychologisl,
Organized psychology has the responsibility to define and 1972,27,331-334.
develop its own profession, consistent with the general canons American Psychological Association. Ethical prlndples in the
of science and with the public welfare. conduct of research with hUr1UJn participants. Washington,
Psychologists recognize that other professions and other D.C., Author, 1973. (a)
groups will, from time to time, seek to define the roles and American Psychological Association. Guidelines for psycholo-
responsibilities of psychologists. The APA opposes such de- gists conducting growth groups. American Psychologisl,
velopments on the same principle that it is opposed to the 1973, 28,933. (b)
psychological profession taking positions which would define American Psychological Association. Standards for educatwnal
the work and scope of responsibility of other duly recognized and ".ychologlcal lesl•. Washington, D.C., Author, 1974.
profession. (APA, 1972, p. 333) (a)
American Psychological Association. Standarch Jor provtden
19 APA support for peer review is detailed in the following of ".ychologlcfJl ..me... Washington, D.C., Author, 1974.
excerpt from the APA (1971) statement entitled "Psychology (b)
and National Health Care": American psychological Association. Education and creden-
llallng In psychology 11. Report of a meeting, June 4-5, 1977.
All professions participating in a national health plan Washington, D.C., Author, 1977. (a)
should be directed to establish 'review mechanisms (or per- American Psychological Association. Standards for providen
formance evaluations) that include not only peer review but of psychologlcal service. (Rev. ed.). Washington, D.L Au-
active participation by persons representing the consumer. thor, 1977. (b)
In situations where there are fiscal agents. they should also American Psychological Association. Criteria for accreditation
have representation when appropriate. (p. 1026) of doctoral Iralnlng p1'ograms and Inlernshlps In profes-
sional psychology. Washington, D.C., Author, 1979 (amended
:zo This Guideline on program evaluation is based directly on 1980).
the following excerpts from two APA position papers: American Psychological Association. APAjCHAMPUS oul"..-
t;enl psychologlcfJl p1'outder manual (Rev. ed.). Washington,
The quality and availability of health services should be D.C., Author, 1981. (a)
evaluated continuoU5ly by both consumers and health profes- American Psychological Association. Ethical pnnctples of psy-
sionals. Research into the efficiency and effectiveness of the chologists (Rev. ed.). Washington, D.C., Author, 1981. (b)
system should be conducted both internally and under in-
Conger, J. 1- Proceedings of the American Psychological As-
dependent auspices. (APA, 1971, p. 1025)
sociation, Incorporated, for the year 1975: Minutes of the
The comprehensive community mental health center annual meeting of the Council of Representativ~. Americdn
should devote an explicit portion of its budget to program P.ychologist, 1976,31, 406-434.
evaluation. All centers should inculcate in their staff attention Smith, M. B., 6: Hobbs, N. The community and thecommunUy
to and respect for research findings; the larger centers have mental health center. Washington, D.C.: American Psycho-
an obligation to set a high priority on basic research and to logical Association, 1966.
664 ApPENDIXB
Specialty Guidelines
for the Delivery of Services by
Industrial/ Organizational Psychologists
The Specialty Guidelines that follow are supplements to vices they are not trained to render. It is the intent of
the generic Standards f{JT Providers of Psychological these Guidelines, however, that after the grandparenting
Services, originally adopted by the American Psycho- period, psychologists not put themselves forward as spe-
logical Association (APA) in September 1974·and revised cialists in a given area of practice unless they meet the
in January 1977 (APA, 1974b, 1977). Admission to the qualifications noted in the Guidelines (see Definitions).
practice of psychology is regulated hy state statute. It is Therefore, these Guidelines are meant to apply only to
the position of the Association that licensing be based on those psychologists who voluntarily wish to be designated
generic, and not on specialty, qualifications. Specialty as Industrial / {JTganlzatlonal psychologist•. They do not
guidelines serve the additional purpose of providing p0- apply to other psychologists.
tential users and other interested groups with essential These Guidelines represent the profession's best judg-
information about particular services available from the ment of the conditions, credentials, and experience that
several specialties in professional psychology. Although contribute to competent professional practice. The APA
the original APA Standards were designed to fill the strongly encourages, and plans to participate in, efforts
needs of several classes of psychological practitioners and to identify professional practitioner behaviors and job
a wide variety of users, the diversity of professional prac- functions and to validate the relation between these and
tice and the use of psychological services require spe- desired client outcomes. Thus, future revisions of these
cialty gUidelines to clarify the special nature of both Guidelines will increasingly reflect the results of such
practitioners and users. These Specialty Guidelines for efforts.
the Delivery of Services by Industrial/Organizational Like the APA generic Standards, the I/O Specialty
(I/O) Psychologists are designed to define the roles of Guidelines are concerned with improving the quality,
I/O psychologists and the particular needs of users of 1/ effectiveness, and accessibility of psychological services
o psychological services. for all who require benefit from them. These Specialty
Professional psychology specialties have evolved from Guidelines are intended to clarify questions of interpre-
generic practice in psychology and are supported hy tation of the APA generic Standards as they are applied
university training programs. There are now at least four to I/O psychology.
recognized professional specialties-clinical. counseling, This document presents the APA's position on I/O
school, and industrial! organizational psychology. practice. Ethical standards applicable to I/O psycholo-
The knowledge base in each of these specialty areas gists are already in effect, I as are other documents that
has increased, refining the state of the art to the point provide guidance to I/O practitioners in specific appli-
that a set of uniform specialty guidelines is now possible cations of I/O psychology.' (Note; Footnotes appear at
and desirable. The present Guidelines are intended to the end of the Specialty Guidelines. See p. 669.)
educate the public, the profession, and other interested The Committee on Professional Standards established
parties regarding specialty professional practices. They by the APA in January 1980 is charged with keeping the
are also intended to facilitate the continued systematic generic Standards and the Specialty Guidelines respon-
development of the profession. sive to the needs of the public and the profession. It is
The content of each specialty guideline reflects a con- also charged with continually reviewing, modifying, and
sensus of university faculty and public and private prac-
titioners regarding the knowledge base, services pro-
vided, problems addressed, and clients served. These Specialty Guidelines were prepared through the coop-
Traditionally, all learned disciplines have treated the erative efforts of the APA Committee on Standards for Providers
designation of specialty practice as a reflection of prep- of Psychological Services (COSPOPS), chaired by Durand F.
Jacobs, and the APA Division of Industrial and Organizational
aration in greater depth in a particular subject matter, Psychology (DiviSion 14). Virginia Ellen Schein and Frank
together with a voluntary limiting of focus to a more Friedlander served as the 1/0 representatives on COSPOPS,
restricted area of practice by the professional. Lack of and Arthur Centor and Richard Kilburg served as the Central
specialty designation does not preclude general providers Office liaisons to the committee. Thomas E. Tice and C. J.
Bartlett were the key liaison persons from the Division 14
of psychological services from using the methods or deal- ProfeSSional Affairs Committee. Drafts of these Guidelines were
ing with the populations of any specialty, except insofar reviewed and commented on by members of the Division 14
as psychologists voluntarily refrain from proViding ser- Executive Committee.
SPECIALTY GUIDEUNES FOR THE DEUVERY OF SERVICES 665
extending them progressively as the profession and the eration the capabilities for evaluation and the circum-
science of psychology develop new knowledge, improved stances that prevail in the setting at the time the program
methods, and additional modes of psychological services. or service is evaluated.
The Specialty Guidelines for the Delivery of Services 8. These Guidelines, while assuring the user of the
by Industrial/Organizational Psychologists that follow I/O psychologist's accountability for the nature and qual-
have been established by the APA as a means of self- ity of services rendered, do not preclude the providers
regulation to protect the public interest. They gUide the of I/O psychological services from using new methods
specialty practice of I/O psychology by specifying im- or developing innovative procedures in the delivery of
portant areas of quality assurance and performance that such services.
contribute to the goal of facilitating more effective hu-
man functioning. These Specialty GUipelines have broad implications
both for users of I/O psychological services and for pro-
viders of such services:
Principles and Implications of the Specialty I. Guidelines for I/O psychological services provide
Guidelines a basis for a mutual understanding between provider and
These Specialty Guidelines have emerged from and re- user and facilitate effective evaluation of services pro-
affirm the same basic principles that guided the devel- vided and outcomes achieved.
opment of the generic Standards for PrOlJklers of Psy- 2. Guidelines for I/O psychological services make an
chological Services (APA, 1977): important contribution toward greater uniformity in leg-
I. These Guidelines recognize that where the practice islative and regulatory actions involving I/O psycholo-
of I/O psychology is regulated by federal, state, or local gists. Guidelines for providers of I/O psychological ser-
statutes, all providers of I/O psychological services con- vices may be useful for uniformity in specialty
form to such statutes. credentialing of I/O psychologists, if such specialty cre-
2. A uniform set of Specialty Guidelines governs I/O dentialing is required.
psychological service functions offered by I/O psychol- 3. Although guidelines for I/O psychological services
ogists, regardless of setting or form of remuneration. All may have an impact on tomorrow's training models for
I/O psychologists in professional practice recognize and hoth professional and support personnel in I/O psy-
are responsive to a uniform set of Specialty Guidelines, chology, tbey are not intended to interfere with inno-
just as they are gUided by a common code of ethics. vations in the training of I/O psychologists.
3. The I/O Specialty Guidelines establish clearly ar- 4. Guidelines for I/O psychological services require
ticulated levels of quality for covered I/O psychological continual review and revision.
service functions, regardless of the nature of the users,
purchasers, or sanctioners of such covered services. The Specialty Guidelines bere presented are intended
4. All persons providing I/O psychological services to improve tbe quality and delivery of I/O psychological
meet specified levels of training and experience that are services by specifying criteria for key aspects of tbe prac-
consistent with, and appropriate to, the functions they tice setting. Some settings may require additional and/
perform. Persons providing such services who do not or more stringent criteria for specific areas of service
meet the APA qualifications for a professional I/O psy- delivery.
cholOgist (see Definitions) are supervised by a psychol-
ogist with the requisite training. This level of qualifi- Definitions
cation is necessary to ensure that the public receives
services of high quality. Final responsibility and ac- A fully qualified I/O psychologist has a doctoral degree
countability for services provided rest with professional earned in a program primarily psycholOgical in nature.
I/O psychologists. This degree may be from a department of psychology
5. These Specialty Guidelines for I/O psychologists or from a school of business, management, or adminb-
are intended to present the APA's position on levels for trative science in a regionally accredited university. Con-
training and professional practice and to provide clari- sistent with the commitment of I/O psychology to the
fication of the APA generic Standards. scientist-professional modeL I/O psychologists are thor-
6. A uniform set of Specialty Guidelines governs the oughly prepared in basic scientific methods as well as in
quality of I/O psychological services in both the private psychological science; therefore, programs that do not
and the public sectors. Those receiving I/O psychological include training in basic scientific methods and research
services are protected by the same kinds of safeguards, are not considered appropriate educational and training
irrespective of sector. models for I/O psychologists. The I/O psychology doc-
7. All persons representing themselves as I/O psy- toral program provides training in (a) scientific and
chologists at any time and in any setting. whether public professional ethics, (b) general psychological science, (c)
or private, profit or nonprofit, observe these Guidelines research design and methodology, (d) quantitative and
in order to promote the interests and welfare of the users qualitative methodology, and (e) psychological measure-
of I/O psychological services. Judgment of the degree ment, as well as (f) a supervised practicum or laboratory
to which these Guidelines are observed take into consid- experience in an area of I/O psychology, (g) a field ex-
666 APPENDIxB
perience in the application and delivery of I/O services, F. Design and optimization of work environments.
(h) practice in the conduct of applied research, (i) train- Services include designing work environments and op-
ing in other areas of psychology, in business, and in the timizing person-machine effectiveness.
social and behavioral sciences, as appropriate, and (j)
preparation of a doctoral research dissertation'
Although persons who do not meet all of the above
quali6cations may provide I/O psychological services, Guideline I
such services are performed under the supervision of a PROVIDERS
fully quali6ed I/O psychologist. The supervising I/O
psychologist may he a full-time member of the same
organization or may be retained on a part-time hasis. Staffing and Qualifications of Staff
Psychologists so retained have the authOrity and partic-
ipate suf6ciently to assess the need for services, to review 1.1 ProfeSSional 1/0 psychologist. maintain CIJ"ent
the services provided, and to ensure professional respon- knowledge of ~cientific and profeSSional developments
sibility and accountability for them. Special pro6ciency thot are related to the seraiee. they render.
training or supervision may be provided by professional INTERPRETATION, Methods through which knowledge of
psychologists of other specialties or by professionals of scienti6c and professional development may be gained
other disciplines whose competencies in the given area include, but are not limited to, continuing education,
have been demonstrated by previous training and ex- attendance at workshops, participation in staff devel-
perience. opment, and reading scienti6c publications.
The I/O psychologist has ready access to reference
IndustritJl/organlzational psycholOgical serotces in- material related to the provision of psychological ser-
volve the development and application of psychological vices.
theory and methodology to problems of organizations
and problems of individuals and groups in organizational
1.2 Professional 1/0 psycholOgists limit thelr practice
settings. The purpose of such applications to the assess-
to thelr demonstrated areas of professional competence.
ment, development, or evaluation of individuals, groups,
or organizations is to enhance the effectiveness of these INTERPRETATION· I/O psycholOgical services are offered
individuals, groups, or organizations. The following areas in accordance with the providers' areas of competence
represent some examples of such applications: as de6ned by veri6able training and experience.
A. Selection and placement of employees. Services When extending services beyond the range of their
include development of selection programs, optimal usual practice, professional I/O psychologists obtain per-
placement of key personnel, and early identi6cation of tinent training or appropriate professional supervision.
management potential.
B. Organization development. Services include ana- 1.3 ProfeSSional psycholOgists who wish to chonge thelr
lyzing organizational structure, formulating corporate speclalty to 1/0 areas meet the same requirements with
personnel strategies, maximizing the effectiveness and respect to ..wJect matter and professional skills thot
satisfaction of individuals and work groups, effecting apply to doc!oral training in the new speclalty.
organizationaJ change. and counseling employees for
INTERPRETATION, Education and training of doctoral-
purposes of improving employee relations, personal and
level psychologiSts, when prior preparation has not been
career development. and superior-subordinate relations.
in the I/O area, includes education and training in the
C. Training and development of employees. Services
content, methodology, and practice of I/O psychology.
include identifying training and development needs; for-
Such preparation is individualized and may be acquired
mulating and implementing programs for technical in a number of ways. Formal education in I/O psy-
training. management training. and organizational de-
chology under the auspices of univerSity departments
velopment; and evaluating the effectiveness of training
that offer the doctoral degree in I/O psychology, with
.and development programs in relation to productivity certification by the supervising department indicating
and satisfaction criteria.
competency in I/O psychology, is recommended. How-
D. Personnel research. Services include continuing ever, continuing education courses and workshops in
development of assessment tools for selection, placement, I/O psychology, combined with supervised experience
classi6cation, and promotion of employees; validating as an I/O psychologist. may also he acceptable.
test instruments; and measuring the effect of cultural
factors on test performance.
1.4 Professional 1/0 psychologists are encouraged to
E. Improving employee motivation. Services in-
develop innovative procedures and theory.
clude enhancing the productive output of employees,
identifying and improving factors associated with job INTERPRETATION, Although these Guidelines give ex-
satisfaction, and redesigning jobs to make them more amples of I/O psychologist activities, such activities are
meaningful. not limited to those provided. I/O psychologists are en-
SPECIALTY GUIDELINES FOR THE DELIVERY OF SERVICES 667
couraged to develop innovative ways of approaching structional or personnel screening uses; interviews, such
problems. as employment or curriculum advisory interviews, that
do not involve the assessment of individual personality
characteristics; the design, administration, and interpre-
tation of opinion surveys; the design and evaluation of
Guideline It person-machine systems; the conduct of employee de-
PROFESSIONAL CONSIDERATIONS velopment programs; the counseling of employees by
supervisors regarding job performance and working re-
lationships; and the teaching of psychological principles
Protecting the User
or techniques that do not involve ameliorative services
2.l 1/0 psychologlcol practice supports the legal and to individuals or groups.
ciml rights of the user.
role as that of a collaborator, a technical advisor, a sci- quirements and those embodied in the American Psy-
entific monitor, or an informed layperson. The purchaser chological Association's Ethical Princtples of Psy-
clearly de6nes its anticipated role, speci6es the extent clwlogists (APA, 1981).
to which it wishes to be involved in various aspects of Providers of I/O psychological services remain sensi-
program planning and work definition, and describes tive to both the hene6ts and the possible misuse of in-
how differences of opinion on technical and scientific formation regarding individuals that is stored in com-
matters are to be resolved. Members of the staff of both puterized data banks. Providers use their influence to
the unit purchasing services and the unit providing ser- ensure that such information is used in a socially re-
vices are made fully aware of the various role definitions. sponsible manner.
Deferring all major project decisions to the purchaser is
not necessarily considered appropriate in scientific de-
velopment.
Guideline 3
2,7 Proo/ders of I/O psyclwloglcalseroices establish a ACCOUNTABILITY
system to protect confident/lJljjy of their records.
INTERPRETATION· I/O psychologists are responsible for Evaluating I/O PsycholOgical Services
maintaining the confidentiality of information about
users of services, whether obtained by themselves or by 3.1 The professIonal activities of providers of I/O psy-
those they supervise. All persons supervised by I/O psy- clwlOgicalsemces are guIded primarily by the princtple
chologists, including nonprofessional personnel and stu- of promoting human welfare.
dents, who have access to records of psycholOgical ser-
vices are required to maintain this confidentiality as a INTERPRETATION: I/O psychologists do not withhold ser-
condition of employment. vices to a potential client on the basis of race, color,
The I/O psychologist does not release confidential in- religion, sex, age, handicap, or national origin. Recog-
formation, except with the written consent of the user nition is given, however. to the following considerations:
directly involved or the user's legal representative. Even the professional right of I/O psychologists to limit their
after the consent for release has been obtained, the I/O practice to avoid potential conflict of interest (e.g., as
psychologist clearly identifies such information as con- between union and management, plaintiff and defen-
fidential to the recipient of the information. If directed dant, or business competitors); the right and responsi-
otherwise by statute or regulations with the force of law bility of psychologists to withhold a procedure when it
or by court order, the psychologist seeks a resolution to is not validly applicable; the right and responsibility of
the conflict that is both ethically and legally feasible and I/O psychologists to withhold evaluative, diagnostic, or
appropriate. change procedures or other services where they might
Users are informed in advance of any limits in the be ineffective or detrimental to the.achievement of goals
setting for maintenance of confidentiality of psycholog- and fulfillment of needs of individuals or organizations.
ical information. I/O psychologists who find that psychological services
When the user intends to waive confidentiality, the are being provided in a manner that is discriminatory
psychologist discusses the implications of releasing psy- or exploitative to users and/or contrary to these Guide-
chological information and assists the user in limiting lines or to state or federal statutes take appropriate cor-
disclosure only to information required by the present rective action, which may include the refusal to provide
circumstances. services. When conflicts of interest arise, the I/O psy-
Raw psychological data (e.g., test protocols, interview chologist is guided in the resolution of differences by the
notes, or questionnaire returns) in which a user is iden- principles set forth by the American Psychological As-
tified are released only with the written consent of the sociation in the Ethical Princtples of Psyclwlogisfs (APA,
user or the user's legal representative and released only 1981) and the "Guidelines for Conditions of Employ-
to a person recognized by the I/O psychologist as qual- ment of Psychologists" (APA, 1972).
ified and competent to use the data. (Note: The user may
be an individual receiving career counseling, in which 3.2 There are per/odIc, systemaUc, and effect/ve eool-
case individual confidentiality must be maintained, or uat/ons of psychological services.
the user may be an organization, in which case individual
data may be shared with others within the organization. INTERPRETATION Regular assessment of progress in
When individual information is to be shared with others, achieving goals and meeting needs is provided in all
e.g., managers, the individual supplying the information I/O psychological service units. Such assessment includes
is made aware of how this information is to be used.) both the validation of psychological services designed to
Any use made of psychological reports, records, or predict outcomes and the evaluation of psychological
data for research or training purposes is consistent with services designed to induce organizational or individual
this Guideline. Additionally, providers of I/O psycho- change. This evaluation includes consideration of the
logical services comply with statutory confidentiality re- effectiveness of I/O psychological services relative to
SPECIALTY GUIDELINES FOR THE DELIVERY OF SERVICES 669
costs in terms of use of time and money and the avail- tion, including a minimum of 2 years in an organizational set-
ability of professional and support personnel. ting, and (c) received a license or certificate in the state in which
Evaluation of the efficiency and effectiveness of the they practiced, conferred by a state board of psychological ex-
aminers; Category 2-persons who completed <a) a doctoral
I/O psychological service delivery system is conducted degree from a program primarily psychological in content at
internally and. when possible. under independent aus- a regionally accredited university and (b) 3 postdoctoral years
pices as well. of appropriate education. training. and experience in providing
It is clearly explained to the user that evaluation of 1/0 services as defined herein in the Definitions section, in-
cluding a minimum of 1 year in an organizational setting.
services is a necessary part of providing I/O psycholog-
ical services and that the cost of such evaluation is jus- REFERENCES
tified as part of the cost of services.
American Psychological Association. Guidelines for conditions
of employment of psychologists. American Psyclwloglst.
1972,27.331-1334.
FOOTNOTES American Psychological Association. Standards for eduC6tWnaI
and psychological te.t•. Washington, D.C., Author, 1974.
I See Ethical Princlpl.. of P'ycholOglst. (APA. 1981). (a)
American Psychological Association. Standards for "rovk1ers
• See Principia for the Validation and V.e of Personnel of psychological .emce•. Washington, D.C., Author, 1974.
Selection Procedu... (APA Divi.ion of Industrial and Orga- (b)
nizational Psychology. 1980). American Psychological Association. Standards for ".,ooklers
of psychological .ervIces (Rev. ed.J. Washington, D.C., Au-
:I The following two categories of persons who met the criteria thor, 1977.
indicated below on or before the adoption of these Specialty American Psychological Association. Division of Industrial and
Guidelines on January 31,1980, shall also he considered profes- Organizational Psychology. Principles for the validation and
sional I/O psychologists: Category I-persons who on or before use of personnel ,election procedure. (2nd ed.). Berkeley,
September 4, 1974. (aJ completed a master's degree from a Cali£., Author, 1980. (Copies may he ordered from Lewis E.
program primarily psychological in content at a regionally ac- Albright, Kaiser Aluminum & Chemical Corporation. 300
credited university. (b) completed 5 post-master', yean of ap- Lakeside Drive-Room KB 2140, Oakland, California 94643.)
propriate education, training. and experience in providing I/O American Psychological Association. Elh/c61 principles of psy-
psychological services as defined herein in the Definitions sec- chologist, (Rev. ed.). Washington, D.C., Author, 1981.
670 APPENDIXB
sive to the needs of the public and the profession. It is quality of services specified in this document, do not
also charged with continually reviewing, modifying, and preclude the school psychologist from using new methods
extending them progressively as the profession and the or developing innovative procedures for the delivery of
science of psychology develop new knowledge, improved school psychological services.
methods. and additional modes of psychological services.
The Specialty Guidelines for the Delivery of Ser- These Specialty Guidelines for school psychology have
vices by School Psychologists ha ve been established by broad implications both for users of school psychological
the APA as a means of self-regulation to protect the services and for providers of such services:
public interest. They gUide the specialty practice of I. Guidelines for school psychological services provide
school psychology by specifying important areas of qual- a foundation for mutual understanding between provider
ity assurance and performance that contribute to the goal and user and facilitate more effective evaluation of ser-
of facilitating more effective human functioning. vices provided and outcomes achieved.
2. Guidelines for school psychological services are es-
sential for uniformity of regulation by state departments
Principles and Implications of the Specialty of education and other regulatory or legislative agencies
GUidelines concerned with the provision of school psychological ser-
vices. In addition, they provide the basis for state ap-
These Specialty Guidelines have emerged from and re- proval of training programs and for the development of
affirm the same basic principles that guided the devel- accreditation procedures for schools and other facilities
opment of the generic Standards for Providers of Psy- providing school psychological services.
cholOgical Services (APA, 1977b), 3. Guidelines give specific content to the profession's
I. These Guidelines recognize that admission to the concept of ethical practice as it applies to the functions
practice of school psychology is regulated by state statute. of school psychologists.
2. It is the intention of the APA that the generic Stan- 4. Guidelines for school psychological services have
dards provide appropriate guidelines for statutory li- significant impact on tomorrow's education and training
cenSing of psychologists. In addition, although it is the models for both professional and support personnel in
position of the APA that licensing be generic and not in school psychology.
specialty areas, these Specialty Guidelines in school psy- 5. Guidelines for the provision of school psychological
chology should provide an authoritative reference for use services influence the determination of acceptable struc-
in credentialing specialty providers of school psycholog- ture, budgeting, and staffing patterns in schools and other
ical services by such groups as divisions of the APA and facilities using these services.
state associations and by boards and agencies that find 6. Guidelines for school psychological services require
such criteria useful for quality assurance. continual review and revision.
3. A uniform set of Specialty Guidelines governs
school psychological service functions offered by school The Specialty Guidelines presented here are intended
psychologists, regardless of setting or source of remu- to improve the quality and the delivery of school psy-
neration. All school psychologists in professional practice chological services by specifying criteria for key aspects
recOgnize and are responsive to a uniform set of Specialty of the service setting. Some school settings may require
Guidelines, just as they are guided by a common code additional and/or more stringent criteria for specific
of ethics. areas of service delivery.
4. School psychology Guidelines establish clearly ar- Systematically applied, these Guidelines serve to es-
ticulated levels of training and experience that are con- tablish a more effective and consistent basis for evalu-
sistent with, and appropriate to, the functions performed, ating the performance of individual service providers as
School psychological services provided by persons who well as to guide the organization of school psychological
do not meet the APA qualifications for a professional service units.
school psychologist (see Definitions) are to be supervised
by a professional school psychologist. Final responsibility Definitions
and accountability for services provided rest with profes-
sional school psychologists. Providers of school psychological services refers to two
5. A uniform set of Specialty Guidelines governs the categories of persons who provide school psychological
quality of services to all users of school psychological services:
services in both the private and the public sectors. Those A. Professional school psychologists.'" Professional
receiving school psychological services are protected by school psychologists have a doctoral degree from a re-
the same kinds of safeguards, irrespective of sector; these gionally accredited university or professional school pro-
include constitutional guarantees, statutory regulation, viding an organized, sequential school psychology pro-
peer review, consultation, record review, and staff su- gram in a department of psychology in a university or
pervision. college, in an appropriate department of a school of ed-
6. These Guidelines, while assuring the user of the ucation or other similar administrative organization, or
school psychologist's accountability for the nature and in a unit of a professional school. School psychology pro-
672 ApPENDIXB
grams that are accredited by the American Psychological cation, for the protection and promotion of mental health
Association are recogoized as meeting the definition of and the facilitation of learning:'
a school psychology program. School psychology pro- A. Psychological and psychoeducational evaluation
grams that are not accredited by the American Psycho- and assessment of the school functioning of children and
logical Association meet the definition of a school psy- young persons. Procedures include screening, psycholog-
chology program if they satisfy the following criteria: ical and educational tests (particularly individual psy-
1. The program is primarily psychological in nature chological tests of intellectual functioning, cognitive de-
and stands as a recognizable, coherent organizational velopment, affective behavior, and neuropsychological
entity within the institution. status), interviews, observation, and behavioral evalua-
2. The program provides an integrated, organized tions, with explicit regard for the context and setting in
sequence of study. which the professional judgments based on assessment,
3. The program h.. an identifiable body of students diagnosis, and evaluation will be used.
who are matriculated in that program for a degree. B. Interventions to facilitate the functioning of indi-
4. There is a clear authority with primary respon- viduals or groups, with concern for how schooling influ-
sibility for the core and specialty areas, whether or not ences and is influenced by their cognitive, conative, af-
the program cuts across administrative lines. fective, and social development. Such interventions may
5. There is an identifiable psychology faculty, and include, but are not limited to, recommending, planning,
a psychologist is responsible for the program. and evaluating special education services; psychoedu-
Patterns of education and training in school psychol- cational therapy; counseling; affective educational pro-
ogy' are consistent with the functions to be performed grams; and training programs to improve coping skills·
and the services to be provided, in accordance with the C. Interventions to facilitate the educational services
ages, populations, and problems found in the various and child care functions of school personnel, parents, and
schools and other settings in which school psychologists community agencies. Such interventions may include,
are employed. The program of study includes a core of but are not limited to, in-service school-personnel edu-
academic experience, both didactic and experiential, in cation programs, parent education programs, and parent
basic areas of psychology, includes education related to counseling.
the practice of the specialty, and provides training in D. Consultation and collaboration with school person-
assessment, intervention, consultation, research, program nel and/or parents concerning specific school-related
development, and supervision, with special emphasis on problems of students and tbe professional problems of
school-related problems or school settings.' staff. Such services may include, but are not limited to,
Professional school psychologists who wish to represent assistance with the planning of educational programs
themselves as proficient in specific applications of school from a psychological perspective; consultation with
psychology that are not already part of their training are teachers and other school personnel to enhance their
required to have further academic training and super- understanding of the needs of particular pupils; modi-
vised experience in those areas of practice. fication of classroom instructional programs to facilitate
B. All other persons who offer school psychological children's learning; promotion of a positive climate for
services under the supervision of a school psychologist. learning and teaching; assistance to parents to enable
Although there may be variations in the titles and job them to contribute to their children's development and
descriptions of such persons, they are not called school school adjustment; and other staff development activi-
psychologists. Their functions may be indicated by use ties.
of the adjective psychological preceding the noun. E. Program development services to individual schools,
1. A speciali81 in school psychology has successfully to school administrative systems, and to community
completed at least 2 years of graduate education in school agencies in such areas as needs assessment and evaluation
psychology and a training program that includes at least of regular and special education programs; liaison with
1,000 hours of experience supervised by a professional community. state, and federal agencies concerning the
school psychologist, of which at least 500 hours must be mental health and educational needs of children; coor-
in school settings. A specialist in school psychology pro- dination, administration, and planning of specialized
vides psychological services under the supervision of a educational programs; the generation, collection. orga·
professional school psychologist.· nization, and dissemination of information from psycho-
2. Titles for others who provide school psycholog- logical research and theory to educate staff and parents.
ical services under the supervision of a professional school F. Supervision of school psychological services (see
psychologist may include school psychological examiner, Guideline 1.2, Interpretation).
school psychological lechnician, school psychological
assi8lanl, school psychomelri8I, or school psychomelric A school psychological service unil is the functional
assi8lanl. unit through which school psychological services are pro-
vided; any such unit has at least one profeSSional school
School psychological serotces refers to one or more of psychologist associated with it:
the following services offered to clients involved in ed- A. Such a unit provides school psychological services
ucational settings, from preschool through higher edu- to individuals, a school system, a district, a community
SPECIALTY GUIDELINES FOR THE DELIVERY OF SERVICES 673
agency, or a corporation, or to a consortium of school INTERPRETATION, The intent of this Guideline is that one
systems, districts. community agencies. or corporations or more proViders of psychological services in any school
that contract together to employ providers of school psy- psychological service unit meet the levels of training and
chological services. A school psychological service unit experience of the professional school psychologist spec-
is composed of one or more profeSSional school psy- ified in the preceding definitions.
chologists and, in most instances, supporting psycholog- When a professional school psychologist is not avail-
ical services staff. able on a full-time hasis to proVide school psychological
B. A school psychological service unit may operate as services, the school district obtains the services of a
an independent professional service to schools or as a profeSSional school psychologist on a regular part-time
functional component of an administrative organiza- hasis. Yearly contracts are desirable to ensure continuity
tional unit, such as a state department of education, a of services dUring a school year. The school psychologist
public or private school system, or a community mental so retained directs the psychological services, supervises
health agency. the psychological services provided by support personnel,
e. One or more professional school psychologists pro- and participates sufficiently to be able to assess the need
viding school psychological services in an interdisciplin- for services, review the content of services prOVided, and
ary or a multidisciplinary setting constitute a school psy- assume professional responsibility and accountability for
cholOgical service unit. them. A professional school psychologist supervises no
D. A school psychological service unit may also be one more than the equivalent of 15 full-time specialists in
or more professional psychologists offering services in school psychology and/or other school psychological per-
private practice, in a school psychological consulting sonnel.
firm, or in a college- or university-hased facility or pro- Districts that do not have easy access to professional
gram that contracts to offer school psychological services school psychologists because of geographic considera-
to individuals, groups, school systems, districts, or cor- tions, or because professional school psychologists do not
porations. live or work in the area employ at least one full-time
specialist in school psychology and as many more support
Users of school psycholOgical services include: personnel as are necessary to assure the adequacy and
A. Direct users or recipients of school psychological quality of services. The following strategies may be con-
services, such as pupils. instructional and administrative sidered to acquire the necessary supervisory services
school staff members, and parents. from a professional school psychologist:
B. Public and private institutions, facilities, or orga- A. Employment by a county, region, consortium of
nizations receiving school psychological services, such as schools, or state department of education of full-time
boards of education of public or private schools, mental supervisory personnel in school psychology who meet
health facilities, and other community agencies and ed- appropriate levels of training and experience, as speci-
ucational institutions for handicapped or exceptional fied in the definitions, to visit school districts regularly
children. for supervision of psychological services staff.
C. Third-party purchasers-those who pay for the B. Employment of profeSSional school psychologists
delivery of services but who are not the recipients of who engage in independent practice for the purpose of
services. providing supervision to school district psychological ser-
D. Sanctioners-such as those who have a legitimate vices staff.
concern with the accessibility, timeliness, efficacy, and e. Arrangements with nearby school districts that em-
standards of quality attending the provision of school ploy professional school psychologists for part-time em-
psychological services. Sanctioners may include members ployment of such personnel on a contract hasis specifi-
oj the useis family, the court, the prohation officer, the ca\ly for the purpose of supervision as described in
school administrator, the employer, the facility director, Guideline I.
and 50 on. Sanctioners may also include various govern- The school psychologist directing the school psycho-
mental, peer review, and accreditation bodies concerned. logical service unit, whether on a full- or part-time hasis,
with the assurance of quality. is responsible for determining and justifying appropriate
ratios of school psychol~gists to users, to specialists in
school psychology, and to support personnel, in order to
ensure proper scope, accessibility, and quality of services
Guideline I provided in that setting. The school psychologist reports
PROVIDERS to the appropriate school district representatives any
findings regarding the need to modify psychological ser-
1.1 Each school psycholOgiCal service unIt offering vices or staf6ng patterns to assure the adequacy and
school psychological services has avaIlable at least one quality of services offered.
professional school psychologist and as many additional
professlanalschool psychologists and support personnel
as are necessary 10 assure Ihe adequacy and quallly of 1.2 Providers of school psychologiCal services who do
services offered. nol meel the requirements for the professional school
674 ApPENDlxB
psychologist are supervised directly by a professional director or coordinator of the school psychological ser-
school psychologist who assumes professional respon- vices and is supervised by a professional school psy-
sibility and accountability for the serotces pracided. The chologist employed on a part-time basis, for a minimum
level and extent of superotsion may oary from task to of 2 hours per week.
task so long as the supervising psychologist retains a
sufficiently close supervisory relationship to meet this 1.4 When functioning as part of an organizationalset-
Guideline. Special proficiency training or supervision ting, professional school psychologists bring their back-
may be pracided by a professional psychologist of an- grounds and skills to bear on the goals of the organi-
other specialty or by a professional from another dis- zation, whenever appropriate, by participating in the
cipline whose competency in the given area has been planning and development of overall serotces.
demonstrated'
INTERPRETATION Professional school psychologists par-
INTERPRETATION: Professional responsibility and ac-
ticipate in the maintenance of high professional stan-
countability for the services provided require that the
dards by serving as representatives on, or consultants to,
supervisor review reports and test protocols; review and
committees and boards concerned with service delivery,
discuss intervention strategies, plans, and outcomes;
especially when such committees deal with special ed-
maintain a comprehensive view of the school's proce-
ucation, pupil personnel services, mental health aspects
dures and special concerns~ and have sufficient oppor-
of schooling, or other services that use or involve school
tunity to discuss discrepancies among the views of the
psychological knowledge and skills.
supervisor. the supervised, and other school personnel on
As appropriate to the setting, school psychologists' ac-
any problem or issue. In order to meet this Guideline,
tivities may include active participation, as voting and
an appropriate number of hours per week are devoted
as office-holding members, on the facility's executive,
to direct face-ta-face supervision of each full-time school
planning. and evaluation boards and committees.
psychological service staff member. In no event is this
supervision less than one hour per week for each staff
member. The more comprehensive the psychological ser- 1.5 School psychologists maintain current knowledge
vices are, the more supervision is needed. A plan or for- of scientific and professional developments to preserve
mula for relating increasing amounts of supervisory time and enhance their professional competence.
to the complexity of professional responsibilities is to be INTERPRETATION Methods through which knowledge of
developed. The amount and nature of supervision is spec-
scientific and professional developments may be gained
ified in writing to all parties concerned.
include, but are not limited to. (a) the reading or prep-
aration of scientific and professional publications and
1.3 Wherever a school psychological serotce unit exists, other materials, (b) attendance at workshops and pre-
a professional school psychologist is responsible for sentations at meetings and conventions, (c) participation
planning, directing, and remewing the provision of in on-the-job staff development programs, and (d) other
school psychological sermces. forms of continuing education. The school psychologist
INTERPRETATION, A school psychologist coordinates the and staff have available reference material and journals
activities of the school psychological service unit with related to the provision of school psychological services.
other professionals, administrators, and community School psychologists are prepared to show evidence pe-
groups, both within and outside the school. This school riodically that they are staying abreast of current knowl-
psychologist, who may be the director, coordinator, or edge in the Seld of school psychology and are also keep-
supervisor of the school psychological service unit, has ing their certification and licensing credentials up-to-
related responsibilities including, but not limited to, re- date.
cruiting qualified staff, directing training and research
activities of the service, maintaining a high level of 1.6 School psychologists limit their practice to thetr
professional and ethical practice, and ensuring that staff demonstrated areas of professional competence.
members function only within the areas of their com-
petency. INTERPRETATION: School psychological services are of·
To facilitate the effectiveness of services by raising the fered in accordance with the providers' areas of com·
level of staff sensitivity and professional skills, the psy- petence as defined by verifiable training and experience.
chologist deSignated as director is responsible for partic- When extending services beyond the range of their usual
ipating in the selection of staff and support personnel practice, school psychologists obtain pertinent training
whose qualifications are directly relevant to the needs or appropriate professional supervision. Such training or
and characteristics of the users served. supervision is consistent with the extension of functions
In the event that a professional school psychologist is performed and services provided. An extension of ser-
employed by the school psychological service unit on a vices may involve a change in the theoretical orientation
basis that affords him or her insufficient time to carry of the practitioner, in the techniques used, in the client
out full responsibility for coordinating or directing the age group (e.g., children, adolescents, or parents), or in
unit, a specialist in school psychology is designated as the kinds of problems addressed (e.g., mental retardation,
SPECIALTY GUIDELINES FOR THE DELIVERY OF SERVICES 675
neurological impairment, learning disabilities, family erence groups are utilized in the practice of school psy-
relationships). chology.
1.7 Psychologists who wish to qualify as school psy- 2,\.2 A description of the organiZl.ltion of the school
chologists meet the same requirements with respect to psychological service unit and its lines of responsi-
subject matter and professional skills that apply to doc- bility and accountability for the delivery of school
toral training in school psychology. I. psychologlcal services is available in written form to
instructional and administrative staff of the unit and
INTERPRETATION Education of psychologists to qualify to parents, students, and members of the community.
them for specialty practice in school psychology is under
INTERPRETATION The description includes lines of re-
the auspices of a department in a regionally accredited
sponsibility, supervisory relationships, and the level and
university or of a professional school that offers the doc-
extent of accountability for each person who provides
toral degree in school psychology, through campus- and/
school psychological services.
or field-based arrangements. Such education is individ-
ualized. with due credit being given for relevant course
2,1,3 A school psychologlcal service unit includes suf-
work and other requirements that have previously been
ficient numbers of professional and support person-
satisfied. In addition to the doctoral-level education spec-
nel to achieve its goals, objectives, and purposes.
ified above, appropriate doctoral-level training is re-
quired. An internship or experience in a school setting INTERPRETATION· A school psychological service unit in-
is not adequate preparation for becoming a school psy- cludes one or more professional school psychologists, spe-
chologist when prior education has not been in that area. cialists in school psychology, and other psychological ser-
Fulfillment of such an individualized training program vices support personnel. When a professional school
is attested to by the awarding of a certificate by the psychologist is not available to provide services on a full-
supervising department or professional school that in- or part-time baSis, the school psychological services are
dicates the successful completion of preparation in school conducted by a specialist in school psychology, super-
psychology. vised by a professional school psychologist (see
Guideline 1.2).
1.8 ProfeSSional school psychologists are encouraged to The work load and diversity of school psychological
services required and the specific goals and objectives of
develop innovative theories and procedures and to pro-
the setting determine the numbers and qualifications of
vide appropriate theoret/cal and/or empirical support
professional and support personnel in the school psycho-
for their innovations.
logical service unit. For example, the extent to which
INTERPRETATION, A specialty of a profession rooted in services involve case study, direct intervention, and/or
science intends continually to explore, study, and con- consultation will be significant in any service plan. Case
duct research with a view to developing and verifying study frequently involves teacher and/or parent confer-
new and improved methods of serving the school pop- ences, observations of pupils, and a multi-assessment re-
ulation in ways that can be documented. view, including student interviews. Similarly, the target
populations for services affect the range of services that
can be offered. One school psychologist, or one specialist
in school psychology under supervision, for every 2,000
pupils is considered appropriate. I I
Guideline 2 Where shortages in personnel exist, so that school psy-
PROGRAMS chological services cannot be rendered in a professional
manner, the director of the school psychological service
2.1 Composition and organization of a school psycho- unit informs the supervisor/administrator of the service
10glcal service unit: about the implications of the shortage and initiates action
to remedy the situation. When this fails, the director
2,1,1 The composition and programs of a school psy- appropriately modifies the scope or work load of the unit
chalOgiCal service unit are responsive to the needs of to maintain the quality of services rendered.
the school population that is served.
2,2 Policies:
INTERPRETATION: A school psychological service unit is
structured so as to facilitate effective and economical
2,2,1 When the school psycholOgiCal service unit is
delivery of services. For example, a school psychological
composed of more than one person or is a component
of a larger organization, a written statement of its
service unit serving predominantly low-income, ethnic,
objectives and scope of services is developed, main-
or racial minority children has a staffing pattern and
service programs that are adapted to the linguistic, ex- tained, and reviewed.
periential, and attitudinal characteristics of the users. INTERPRETATION, The school psychological service unit
Appropriate types of assessment materials and norm ref- reviews its objectives and scope of services annually and
676 APPENDlxB
revises them as necessary to ensure that the school psy- quirements and other agency regulations that have the
chological services offered are consistent with staff com- force 01 law and that relate to the delivery 01 school
petencies and current psychological knowledge and prac- psychological services (e.g.. certi6cation of. eligibility
tice. This statement is discussed with staff, reviewed by for, and placement in, special education programs). In
the appropriate administrators, distributed to instruc- addition, all providers are cognizant that lederal agencies
tional and administrative staff and school board mem- such as the Department of Education and the Depart-
bers, and when appropriate. made available to parents. ment of Health and Human Services have policy state-
students, and members 01 the community upon request. ments regarding psychological services. Providers of
school psychological services are familiar as well with
1l.1l.2 All providers within a school psychologiCal ser- other statutes and regulations, including those addressed
""'e unit support the legal and civil rights of the to the civil and legal rights of users (e.g., Public Law 94·
USets. lt 142, The Education for All Handicapped Children Act
of 1975). that are pertinent to their scope of practice.
INTERPRETATION, Providers of school psychological ser- It is the responsibility 01 the American Psychological
vices safeguard the interests 01 school personnel, students. Association to maintain 61es 01 those lederal policies,
and parents with regard to personal, legal. and civil statutes, and regulations relating to this section and to
rights. They are continually sensitive to the issue 01 con- assist its members in obtaining them. The state psycho-
6dentialityof inlormation. the short-term and long-term logical associations, school psychological associations, and
impacts of their decisions and recommendations. and state licensing boards periodically publish and distribute
other matters pertaining to individual, legal, and civil appropriate state statutes and regulations.
rights. Concerns regarding the saleguarding 01 individ-
ual rights 01 school personnel, students, and parents in- 2.2.5 All prOviders within a school psycholOgical ser-
clude, but are not limited to. due-process rights 01 parents vice unit inform themselves about and use the net-
and children, problems of sell-incrimination in judicial work of human services in their commun/ties in order
proceedings, involuntary commitment to hospitals. child to link users with relevant services and resources.
abuse, Ireedom 01 choice, protection 01 minors or legal
INTERPRETATION, School psychologists and support staff
incompetents, discriminatory practices in identi6cation
are sensitive to the broader context of human needs. In
and placement, recommendations lor special education
recognizing the matrix of personal and societal problems,
.provisions, and adjudication 01 domestic relations dis-
providen; make available to clients information regard-
putes in divorce and custodial proceedings. Providers 01
ing human services such as legal aid societies. social ser-
school psychological services take al6rmative action by
vices, health resources like mental health centers, private
making themselves available to local committees, review
practitioners, and educational and recreationallacilities.
boards, and similar advisory groups established to safe-
School psychological staff formulate and maintain a file
guard the human, civil. and legal rights of children and
of such resources for reference. The speci6c information
parents.
provided is such that users can easily make contact with
the services and freedom of choice can be honored. Pro-
2.2.3 All providers within a school psychological ser-
viders of school psychological services refer to such com-
oIce unit are familiar with and adhere to the Amer-
munity resources and, when indicated, actively intervene
ican PsychologiCal Association's Standards lor Pro-
on hehalf of the users. School psychologists seek oppor-
viders of Psychological Services. Ethical Principles of
tunities to serve on boards of community agencies in
Psychologists, Standards for Educational and Psycho-
order to represent the needs of the school population in
logical Tests. Ethical Principles in the Conduct of Re-
the community.
search With Human Participants, and other official
policy statements relevant to standards for profes- 2.2.6 In the delivery of school psychological services,
sionalserolces issued by the Association. providers maintain a cooperative relationship with
colleagues and co-workers in the best interest of the
INTERPRETATION A copy of each 01 these documents is mers.
maintained by providers of school psychological services
and is available upon request to all school personnel and INTERPRETATION. School psychologists recognize the
officials. parents. members of the community, and where areas of special competence of other psychologists and
applicable. students and other sanctioners. of other professionals in the school and in the community
for either consultation or referral purposes (e.g.• school
2.2.4 All providers within a school psycholOgical ser· social workers, speech therapists, remedial reading teach-
""'e unit conform to relevant statutes established by ers, special education teachers, pediatricians. neurolo-
federal, state, and local gooemments. gists, and public health nurses). Providers of school psy-
chological services make appropriate use of other
INTERPRETATION All providers of school psychological professional. research, technical, and administrative re-
services are lamiliar with and conlorm to appropriate sources whenever these serve the best interests of the
statutes regulating the practice of psychology. They also school staff, children. and parents and establish and
are inlormed about state department 01 education re- maintain cooperative and/or collaborative arrangements
SPECIALTY GUIDELINES FOR THE DELIVERY OF SERVICES 677
with such other resources as required to meet the needs are maintained separately from the child's cumulative
of users. record folder. Once a case study is completed and/or an
intervention begun, records are reviewed and updated
2.3 Procedures: at least monthly.
2.3.1 A school psychological sermce unit follows a set
of procedural guidelines for the delivery of school 2.3.4 Each school psychological seroices unit fol-
psychological sermces. lows an established record retention and disposition
policy.
INTERPRETATION. The school psychological service staff
is prepared to provide a statement of procedural guide- INTERPRETATION. The policy on maintenance and review
lines in written form in terms that can be understood by of psychological records (including the length of time
school staff, parents, school board members, interested that records not already part of school records are to be
members of the community, and when appropriate, stu· kept) is developed by the local school psychological ser-
dents and other sanctioners. The statement describes the vice unit. This policy is consistent with existing federal
current methods, forms, case study and assessment pr<r and state statutes and regulations.
cedures, estimated time lines, interventions, and evalu-
ation techniques being used to achieve the objectives and
2.3.5 Provjders of school psychological .ermce. main-
goals for school psychological services.
tain a system to protect confidentiality of their rec-
This statement is communicated to school staff and
ords.
personnel, school board members, parents, and when
appropriate, students or other sanctioners through what- INTERPRETATION. School psychologists are responsible for
ever means are feasible, including in-service activities, maintaining the confidentiality of information about
conferences, oral presentations, and dissemination of users of services, from whatever source derived. All per-
written materials. sons supervised by school psychologists, including non-
The school psychological service unit provides for the professional personnel and students, who have access to
annual review of its procedures for the delivery of school records of psychological services maintain this confiden-
psychological services. tiality as a condition of employment. All appropriate
staff receive training regarding the confidentiality of
2.3.2 Providers of school psycholOgical seroices de- records.
velop plans awroprlate to the providers' profesBional Users are informed in advance of any limits for main-
practices and to the' problems pre.ented by the users. tenance of confidentiality of psychological information.
There Is a mutually acceptable understandtng be- Procedures for obtaining informed consent are devel-
tween provjders and school staff, parents, and .tu- oped by the school psychological service unit. Written
dots or responsible agents regarding the goals and informed consent is obtained to conduct assessment or
the delivery of seroices. to carry out psychological intervention services. Inform-
INTERPRETATION. The school psychological service unit ing users of the manner in which requests for information
notifies the school unit in writing of the plan that is will be handled and of the school personnel who will
adopted for use and resolves any points of difference. share the results is part of tbe process of obtaining con-
The plan .includes written consent of guardians of stu- sent.
dents and, when appropriate, consent of students for the The school psychologist conforms to current laws and
services provided. Similarly, the nature of tbe assessment regulations with respect to the release of confidential
tools that are to be used and the reasons for their inclusion information. As a general rule. however, the school psy-
are spelled out. The objectives of intervention(s) of a chologist does not release confidential information, e.-
psychological nature as well as the procedures for im- cept with the written consent of the parent or, where
plementing the intervention(s) are specified. An estimate appropriate. the student directly involved or his or her
of time is noted where appropriate. Parents and/or stu- legal representative. Even after consent for release has
dents are made aware of the various decisions that can been obtained, the school psychologist clearly identifies
be made as a result of the service(s), participate in ac- such information as confidential to the recipient of the
counting for decisions that are made, and are ioformed information. When there is a connict with a statute, with
of how appeals may be instituted. regulations with the force of law, or with a court order,
the school psychologist seeks a resolution to the conBict
that is both ethically and legally feasible and appropriate.
2.3_3 Accurate, current, and pertinent documenta- Providers of school psychological services ensure that
tion of essential school psychological sermces pro-
psychological reports which will become part of the
vided Is maintained.
school records are reviewed carefully so that confiden-
INTERPRETATION. Records kept of psychological services tiality of pupils and parents is protected. When the
may include, but are not limited.. to, identifying data, guardian or student intends to waive confidentiality, the
dates of services, names of providers of services, types school psychologist discusses the implications of releasing
of services, and Significant actions taken. These records psychological information and assists the user in limiting
678 ApPENDIXB
disclosure to only that information required by the pres- that employers can make decisions regarding their em-
ent circumstance. ployment. assignment of their duties. and so on; (b) the
Raw psychological data (e.g.• test protocols, counseling right and responsibility of school psychologists to with-
or interview notes, or questionnaires) in which a user is hold an assessment procedure when not validly appli-
identified are released only with the written consent of cable; (c) the right and responsibility of school psy-
the user or his or her legal representative. or by court chologists to withhold evaluative. psychotherapeutic.
order when such material is not covered by legal con- counseling. or other services in specific instances in which
fidentiality. and are released only to a person recognized their own limitations or client characteristics might im-
by the school psychologist as competent to use the data. pair the effectiveness of the relationship; and (d) the
Any use made of psychological reports. records, or obligation of school psychologists to seek to ameliorate
data for research or training purposes is consistent with through peer review. consultation. or other personal ther-
this Guideline. Additionally. providers of school psycho- apeutic procedures those factors that inhibit the provision
logical services comply with statutory confidentiality re- of services to particular users. In such instances. it is
quirements and those embodied in the American Psy- incumbent on school psychologists to advise clients about
chological Association's Ethical Principles of Psy- appropriate alternative services. When appropriate ser-
chologists (APA. 1981). vices are not available. school psychologists inform the
Providers of school psychological services remain sen- school district administration and/or other sanctioners
sitive to both the benefits and the possible misuse of of the unmet needs of clients In all instances. school
information regarding individuals that is stored in large psychologists make available information. and provide
computerized data banks. Providers use their in8uence opportunity to participate in decisions. concerning such
to ensure that such information is managed in a socially issues as initiation. termination. continuation, modifica-
responsible manner. tion. and evaluation of psychological services. These
Guidelines are also made available upon request.
Accurate and full information is mad" available to
prospective individual or organizational users regarding
the qualifications of providers. the nature and extent of
Guideline 3 services offered. and where appropriate. the financial
ACCOUNTABILITY costs as well as the benefits and possible risks of the pro-
posed services.
3.1 The promotion of human welfaTe Is the primary Professional school psychologists offering services for
princjple guiding the professional acjlt1ity of the school a fee inform users of their payment policies, if applicable.
psychologist and the schoof psychoiog/cQl service unIt. and of their willingness to assist in obtaining reimburse-
ment when such services have been contracted for as an
INTERPRETATION, School psychological services staff pro- external resource.
vide services to school staff members. students. and par-
ents in a manner that is considerate and effective. 3.2 School psychologists pursue thetr acjlt>ltle. as mem-
School psychologists make their services readily ac- ber. of the Independent. autonomous profe83ion of psy-
cessible to users in a manner that facilitates the users' chology.'·
freedom of choice. Parents. students. and other users are
made aware that psychological services may be available INTERPRETATION, School psychologists are aware of the
through other public or private sources. and relevant implications of their activities for the profession of psy-
information for exercising such options is provided upon chology as a whole. They seek to eliminate discrimina-
request. tory practices instituted for self-serving purposes that are
School psychologists are mindful of their accountabil- not in the interest of the users (e.g.. arbitrary require-
ity to the administration. to the school board. and to the ments for referral and supervision by another profession)
general public. provided that appropriate steps are taken and to discourage misuse of psychological concepts and
to protect the confidentiality of the service relationship. tools (e.g.• use of psychological instruments for special
In the pursuit of their professional activities. they aid in education placement by school personnel or others who
the conservation of human. material. and financial re- lack relevant and adequate education and training).
sources. School psychologists are cognizant of their responsibilities
The school psychological service unit does not with- for the development of the profession and for the im-
hold services to children or parents on the basis of the provement of schools. They participate where possible
users' race. color. religion. gender. sexual orientation. in the training and career development of students and
age. or national origin. Recognition is' given. however. other providers; they participate as appropriate In the
to the follOWing considerations: (a) the professional right training of school administrators. teachers, and parapro-
of school psychologists. at the time of their employment. fessionals; and they integrate. and supervise the imple-
to state that they wish to limit their services to a specific mentation of. their contributions within the structure
category of users (e.g., elementary school children. ex- established for delivering school psychological services.
ceptional children. adolescents). noting their reasons so Where appropriate. they facilitate the development of.
SPECIALTY GUIDELINES FOR THE DELIVERY OF SERVICES 679
to be recognized as professional school psychologists are referred peetation that training programs will undoubtedly want to in-
to Guideline 1.7. terpret the speeific content of these areas in different ways
The APA Council of Representatives passed a "Resolution on depending on the nature, philosophy, and intent of the pro-
the Master's-Levellssue" in January 1977 containing the fol- grams.
lowing statement. which influenced the development of a third
category of professiooal school psychologist" S Although specialty education and training guidelines have
not yet been developed and approved by APA, the foDowing
The title "Professional Psychologist" has heen used so description of education and training components of school
widely and by persons with such a wide variety of training psychology programs represents a consensus regarding specialty
and experience that it does not provide the information the training in school psychology at this time.
public deserves, The edlJCtltlon of school psychologists encompasses the equiv-
As a consequence, the APA takes the position and makes alent of at least 3 rears of full-time graduate academic study.
it a part of its policy that the use of the title "Professional While instructiona formats and course titles may vary from
Psychologist," and its variations such as "Clinical Psycholo-- program to program, each program has didactic and experi-
gist," "Counseling Psychologist," "School Psychologist," and ential instruction (a) in scientific and professional areas com-
"Indwtrial Psychologist"· are reserved for those who have mon to all professional psychology programs, such as ethics and
completed 8 Doctoral Training Program in Psychology in a standards, research design and methodology, statistics, and psy-
university, college, or professional school of psychology that chometric methods, and (b) in such substantive areas as the
is APA or regionally accredited. In order to meet this stan- biological bases of behavior, the cognitive and affective bases
dard. a transition period will be acknowledged for the use of behavior, the social, cultural, ethnic, and sex role bases of
of the title "School Psychologist," so that ways may he sought behavior, and individual differences. Course work includes s0-
to increase opportunities for doctoral training and to improve cial and philosophical bases of education, curriculum theory
the level of educational codes pertaining to the title, (Conger, and practice, etiology of learning and behavior disorders, ex-
1977, p, 426) ceptional children, and special education. Organization theory
and administrative practice should also be included in the pro-
For the purpose of transition. then. there is still another cat- gram. This list is not intended to dictate specific courses or a
egory of persons who can he considered professional school sequence of instruction. It is the responsibility of programs to
psychologists for practice in elementary and secondary schools. determine how these areas are organized and presented to stu-
Category 3 consists of persons who meet the following criteria dents. Variations in educational format are to be expected.
on or before, but not beyond, January 31, 1985, (a) a master's The training of school psychologists includes practicum and
or higher degree, requiring at least 2 years of full-time graduate field experience in conjunction with the educational program.
stndy in school psychology, from a regionally accredited uni- In addition, the program includes a supervised internship ex-
venity or professional school; (b) at [east 3 additional yean of perience beyond practicum and 6eld work, equivalent to at
training and experience in school psychological services. in- least 1 academic school year, but in no event fewer than 1,200
cluding a minimum of 1,200 hours in school settings; and (c) hours, in schools or in a combination of schools and community
a license or certi6cate conferred by a state board of psycholog- agencies and centers. with at least 600 hours of the internship
ical examiners or a state educational agency for practice in in the school setting. An appropriate number of hours per week
elementary or secondary schools. should be devoted to direct face-to-face supervision of each
Preparation equivalent to that described. in Category 3 en- intern. In no event is there less than 1 hour per week of direct
tities an individual to use the title profe.sional school psychol- supervision. Overall professional supervision is provided by a
ogtst in school practice, but it does not exempt the Individual professional school psychologist. However, supervision in spe-
from meeting the requirements of licensure or other require- d6c procedures and techniques may be provided by others,
ments for which a doctoral degree is prerequisite. with the agreement of the supervising professional psychologist
and the supervisee. The training experiences provided and the
, A professional school psychologist who is licensed by a state
competencies developed occur in settings in which there are
or District of Columbia board of examiners of psychology for
opportunities to work with children, teachers, and parents and
the independent practice of psychology and who has 2 yean
to supervise others providing psychological services to children.
of supervised (or equivalent) experience in health services, of
which at least 1 year is postdoctoral, may be listed as a "Health 6 In order to implement these Specialty Guidelines, it will be
Service Provider in Psychology" in the National Hegg,n oj necessary to determine in each state which non-doctoral-level
Health Service Prouiderr in Psychology, school psychologists certified by the state department of edu-
cation are eligible to he considered profesalonal school psy-
A Health Service Provider in Psychology is de6ned as a
chologists for practice in elementary and secondary schools. A
psychologist, certified/licensed at the independent practice
national register of all professional school psychologists and spe-
level in his/her state, who is duly trained and experienced
cialists in school psychology would be a useful and efficient
in the delivery of direct, preventive, assessment and thera-
means by which to inform the public of the available school
peutic intervention services to individuals whose growth, ad-
psychological services personnel.
justment, or functioning is actually impaired or is demon-
strably at high risk of impairment. (Council for the National 1 Functions and activities of school psychologists relating to
Register of Health Service Providers in Psychology, 1980, the teaching of psychology, the writing or editing of scholarly
p, xi) or scientiDc manuscripts, and the conduct of scientific research
do not fall within the purview of these Guidelines.
4 The areas of knowledge and training that are a part of the
educational program for all professional psychologists have been 'Nothing in these Guidelines precludes the school psychol-
presented in two APA documents, EduC4tfon and Credentlal- ogist from being trained beyond the areas described herein {e.g.,
ing in Psychology 1/ (APA, 1977a) and CrlterltJ for Accredi- in psychotherapy for children, adolescents. and their families
tation of Doctoral Training Programs and Internships in in relation to school-related functioning and problems) and,
Professtonal Psychology (APA, 1979), There i. consistency in therefore, from providing services on the basis of this training
the presentation of core areas in the education and training of to clients as appropriate.
all professional psychologist' The description of education and
training in these Guidelines is based primarily on the document II In some states, a supervisor's certi6cate is required in order
EdlJCtltlon and Cretknttaling In Psychology 1/, It is intended to use the title 8Upervtsor in the public schools. Supervision of
to indicate broad areas of required curriculum, with the ex- providers of psychological services by a professional school psy~
SPECIALTY GUIDELINES FOR THE DELIVERY OF SERVICES 681
chologist does not mean that the school psychologist is thereby sional organization in opposing any unreasonable limitations
authorized or entitled to offer supervision to other school per- on the professional functions of the members of that orga-
sonnel. Supervision by the school psychologist is con6ned to nization.
those areas appropriate to his or her training and educational This insistence upon profeSSional autonomy has been up-
background and is viewed as part of the school psychologist's held over the years by the affirmative actions of the courts
professional responsibilities and duties and other public and private lxxlies in support of the right
The following guidellne for supervision has been written by of the psychologist-and other professionals-to pursue those
the Executive Committee of the Division of School Psychology: functions for which he [or she] is trained and qualified to
perform. (AP .... 1966. p. 9)
In addition to heing a professional school psychologist. the
person who supervises school psychological services and/or Organized psychology has the responsibility to define and
school psychological personnel shall have the following qual- develop its own profession, consistent with the general canons
m.cations: broad undentanding of diagnostic assessment. COR- of science and with the public welfare.
sultation, programming, and other intervention strategies; Psychologists recognize that other professions and other
skills In supervision; the ability to empathize with supervisee" groups will, from time to time, seek to define the roles and
and commitment to continuing educati.on. The supervising responsibilities of psychologists. The APA opposes such de-
school psychologist also sball have had the equivalent of at velopments on the same principle that it is opposed to the
least 2 years of satisfactory full-time. on-the-job experience psychological profession taking positions which would define
as a school psychOlogist practicing directly In the school or the work and scope of responsibility of other duly recognized
deallng with school-related problems in independent prac- professions. ("'PA. 1972. p. 333)
tice.
REFERENCES
,. This Guideline follows closely the statement regarding
"Policy on Training for Psychologists Wishing to Change Their American Psychological Association. Psychology .. a profeo-
Specialty" adopted by the APA Council of Representatives in lion. Washington. D.C.: "'uthor. 1968.
January 1976. Included therein was the implementing provision American Psychological Association. Guidelines for conditions
that "this polley statement shall he incorporated in the guide- of employment of psychologists. Amerlcan Psyclwlopl.
lines of the Committee on Accreditation 50 that appropriate 1972, 27. 331-334.
sanctions can be brought to bear on university and internship American Psychological Association. Ethical prindpks In the
training programs that violate [it)" (Conger. 1976. p. 424). conducl of ,o.eorch wllh humon pa,ljcjpanls. Washington.
D.C.: Author. 1973.
" Two surveys of school psychological practice provide a ra- ...merican Psychological ...ssociation. Standa,ds for educalional
tionale for the speci&catlon of this Guideline (Farling & Hoedt. and psychological lolls. Washington. D.G: ... uthor. 1974.
1971; Kicklighter. 1976). The median ratios of psychologists to (a)
pupils were 1 to 9.000 in 1966 and 1 to 4.000 in 1974. Those American Psychological Association. Standards for provUlers
responding to Klcklighter's survey projected that the ratio of of psyclwlog/cal ,ervIce•. Washington. D.C.: Author, 1974.
psychologists to pupils would he 1 to 2.500 in 1980. These data (b)
were collected before the passage of Public Law 94-142. the American Psychological Association. Education and creden-
Education for All Handicapped Children ...ct of 1975. The reg- llalingln psyclwlogy 11. Report 01 a meeting. June 4-5.1977.
ulations for implementing this act require extensive identifi- Washington. D.G: Author. 1977. (a)
cation. assessment, and evaluation services to children, and it American Psychological Association. Standards for prootder8
is reasonable in 1981 to set an acceptable ratio of psychologists of psyclwlog/cal.ervices (Rev. ed.). Washington. D.C.: "'u-
to pupils at 1 to 2.000. thor. 1977. (b)
American Psychological Association. Criteria for accreditation
"See also Elhlcal Pnnclples of P.yclwlopl. ("'PA. 1961). of docloral I,ainlng programs and Inlem.hlps in profe.-
especially Principles 5 (Con8dentiality), 6 (Welfare of the Con- aionaI psychology. Washington. D.C.: Author. 1979 (amended
sumer). and 9 (Research With Human Participants). and Elhlcal 1980).
Pnndp/es In lhe Conducl of lleBeorch With HUmBn Partjcj- American Psychological Association. Elhlcal pnndple. of psy-
panl. (APA. 1973). Also. in 1978 Division 17 approved in prin- elwlopts (Rev. ed.). Washington. D.C.: Author. 1961.
ciple a statement on "Principles for Counseling and Psycho- Conger. J. j. Proceedings of the American Psychological .....
therapy With Women." which was designed to protect the seciation. Incorporated, for the year 1975: Minutes of the
interests of female users of counseling psychological services. annual meeting of the Council of Representatives. American
Psycholopl. 1976. 31. 406-434.
13 Support for the principle of the independence of psychol- Conger, J. j. Proceedings of the American Psychological As-
ogy as a profession is found in the following: sociation, Incorporated, for the year 1976: Minutes of the
annual' meeting of the Council of Representatives. American
As a member of an autonomous profession. a psychologist P.yclwlopt. 1977. 32. 408-438.
rejects limitations upon his [or her) freedom of thought and Council for the National Register of Health Service Providers
action other than those imposed by his [or her) mora!; legal. in Psychology. NatIonal ,eple, of heallh .ervice proWl."
and social responsibilities. The Association is always prepared in psychology. Washington. D.C.: Author. 1980.
to provide appropriate assistance to any responsible member Farling. W. H .• & Hoedt. K. C. National.urvey of .ehool psy-
who becomes subjected to unreasonable limitations upon his elwlopl•. Washington. D.C.: Department 01 Health. Edu-
[or her) opportunity to function as a practitioner. teacher, cation, and Welfare, 1971.
researcher, administrator. or consultant. The Association is Kicklighter. R. H. School psychology in the U.S.: A quantitative
always prepared to cooperate with any responsible profes- survey. Journal of School P.yclwlogy. 1976. 14. 151-156.
APPENDIX C
683
684 ApPENDIXC
/cal findings and techniques with full recognition of the to ensure that announcements and advertisements are
limits and uncertaintie8 of such evklence. presented in a professional, scienti6cally acceptable, and
a. When announcing or advertising professional ser- factually informative manner.
vices, psychologists may list the following information f. Psychologists do not participate for personal gain
to describe the provider and services provided: name, In commercial announcements or advertisements rec-
highest relevant academic degree earned from a region- ommending to the public the purchase or use of pro-
ally accredited institUtion, date, type, and level of cer- prietary or single-source products or services when that
tification or licensure, diplomate status, APA member- participation Is based solely upon their identification as
ship status, address, telephone number, of6ce hours, a psychologists.
brief listing of the type of psychological services offered, g. Psychologists present the science of psychology and
an appropriate presentation of fee information, foreign offer their services, products, and publications fairly and
languages spoken, and policy with regard to third-party accurately, avoiding misrepresentation through sensa-
payments. Additional relevant or important consumer tionalism, exaggeration, or superficiality. Psychologists
information may be included if not prohibited by other are guided by the primary obligation to aid the public
sections of these Ethical Principles. in developing Informed judgments, opinions, and choices.
b. In announcing or advertising the availability of h. As teachers, psychologists ensure that statements in
psychological products, publications, or services, psy- catalogs and course outlines are accurate and not mis-
chologists do not present their affiliation with any or- leading, particularly in terms of subject matter to be
ganization in a manner that falsely implies sponsorship covered, bases for evaluating progress, and the nature
or certification by that organization. In particular and of course experiences. Announcements, brochures, or
for example, psychologists do not state APA membership advertisements describing workshops, seminars, or other
or fellow status in a way to suggest that such status im- educational programs accurately describe the audience
plies specialized professional competence or quali6ca- for which the program is intended as well as eligibility
tions. Public statements include, but are not limited to, requirements, educational objectives, and nature of the
communication by means of periodical, book, list, di- materials to be covered. These announcements also ac-
rectory, television, radio, or motion picture. They do not curately represent the education, training, and experi-
contain (i) a false, fraudulent, misleading. deceptive, or ence of the psychologists presenting the programs and
unfair statement; (ii) a misinterpretation of fact or a any fees involved.
statement likely to mislead or deceive because in context i. Public announcements or advertisements soliciting
it makes only a partial disclosure of relevant facts; (iii) research partiCipants in which clinical services or other
a testimonial from a patient regarding the quality of a professional services are offered as an inducement make
psychologists' services or products; (Iv) a statement in- clear the nature of the services as well as the costs and
tended or likely to create false or unjustified expectations other obligations to be accepted by participants In the
of favorable results; (v) a statement implying unusual, research.
unique, or one-of-a-kind abilities; (vi) a statement in- j. A psychologist accepts the obligation to correct oth-
tended or likely to appeal to a client's fears, anxieties, ers who represent the psychologist's professional quali-
or emotions concerning the possible results of failure to fications, or associations with products or services, in a
obtain the offered services; (vii) a statement concerning manner incompatible with these gnldelines.
the comparative desirability of offered services; (viii) a k. Individual diagnostic and therapeutic services are
statement of direct solicitation of individual clients. provided only in the context of a professional psycho-
logical relationship. When personal advice is given by
c. Psychologists do not compensate or give anything
means of public lectures or demonstrations, nllwSpaper
of value to a representative of the press, radio, television,
or magazine articles, radio or television programs, mail,
or other communication medium in anticipation of or
or similar media, the psychologist utilizes the most cur-
in return for professional publicity In a news item. A paid
rent relevant data and exercises the highest level of
advertisement must be identified as such, unless it is ap-
professional judgment.
parent from the context that It Is a paid advertisement.
I. Products that are described or presented by means
If communicated to the public by use of radio or tele-
of public lectures or demonstrations, newspaper or mag-
vision, an advertisement is prerecorded and approved
azine articles, radio or television programs, or similar
for broadcast by the psychologist, and a recording of the
media meet the same recognized standards as exist for
actual transmission is retained by the psychologist.
products used in the context of a professional relation-
d. Announcements or advertisements of "personal ship.
growth groups," clinics, and agencies give a clear state-
ment of purpose and a clear description of the experi-
ences to be provided. The education, training. and ex- Principle 5
perience cl the staff members are appropriately speci6ed.
CONFIDENTIALITY
e. Psychologists associated with the development or
promotion of psychological devices, books, or other prod- P,ychologfBI' haoe /J primary obllgtJUOO 10 reapect lhe
ucts offered for commercial sale make reasonable efforts confident/tdlly of Informallon obIdiDIld from persons
686 ApPENDIXC
in the course of their work as psychologists. They reveal chologists to violate these Ethical Principles, psycholo-
such information to others only with the consent of the gists clarify the nature of the conflict between the de-
person or the person's legal representative. except in mands and these principles. They inform all parties of
those unusual circumstances in which not to do so psychologists' ethical responsibilities and take appropri-
would result in clear danger to the person or to others. ate action.
Where appropriate, psychologists inform their clients d. Psychologists make advance financial arrangements
of the legal limits of confidentiality. that safeguard the best interests of and are clearly under-
a. Information obtained in clinical or consulting re- stood by their clients. They neither give nor receive any
lationships, or evaluative data concerning children. stu- remuneration for referring clients for professional ser-
dents, employees, and others, is discussed only for profes- vices. They contribute a portion of their services to work
sional purposes and only with persons clearly concerned for which they receive little or no financial return.
with the case. Written and oral reports present only data e. Psychologists terminate a clinical or consulting re-
germane to the purposes of the evaluation, and every lationship when it is reasonably clear that the consumer
effort is made to avoid undue invasion of privacy. is not benefiting from it. They offer to help the consumer
b. Psychologists who present personal information ob- locate alternative sources of assistance.
tained during the course of professional work in writings,
lectures, or other public forums either obtain adequate
prior consent to do so or adequately dISguise all identi-
fying information.
Principle 7
c. Psychologists make provisions for maintaining con-
PROFESSIONAL RELATIONSHIPS
fidentiality in the storage and disposal of records.
d. When working with minors or other persons who
are unable to give voluntary, informed consent, psy- PsycholOgists act with due regard for the needs, special
chologists take special care to protect these persons' best competencies, and obligations of their colleagues in
interests. psychology and other professions. They respect the pre-
rogatioes and obligations of the institutions or orga-
nizations with which these other colleagues are asso-
ciated.
a. Psychologists understand the areas of competence
Principle 6 of related professions. They make full use of all the
WELFARE OF THE CONSUMER professional, technical, and administrative resources that
serve the best interests of consumers. The absence of
PsycholOgists respect the integrity and protect the wel- formal relationships with other professional workers does
fare of the people and groups with whom they work. not relieve psychologists of the responsibility of securing
When conflicts of interest arise between clients and for their clients the best possible professional service, nor
psychologists' employing Institutions, psychologists does it relieve them of the obligation to exercise foresight,
clarify the nature and direction of their loyalties and diligence, and tact in obtaining the complementary or
responsibilities and keep all parties informed of their alternative assistance needed by clients.
commitments. Psychologists fully inform consumers as h. Psychologists know and take into account the tra-
to the purpose and nature of an evaluatioe, treatment, ~itioru and practices of other professional groups with
educational, or training procedure, and they freely ac- whom they work and cooperate fully with such groups.
knowledge that clients, students, or participants in re- If a person is receiving similar services from another
search haoe freedom of choice with regard to partici- professional, psychologists do not offer their own services
pation. directly to such a person. If a psychologist is contacted
a. Psychologists are continually cognizant of their own by a person who is already receiving similar services
needs and of their potentially influential position vis-a- from another professional, the psychologist carefully con-
vis persons such as clients, students, and subordinates. siders that professional relationship and proceeds with
They avoid exploiting the trust and dependency of such caution and sensitivity to the therapeutic issues as well
persons. Psychologists make every effort to avoid dual as the client's welfare. The psychologist discusses these
relationships that could impair their professional judg- issues with the client so as to minimize the risk of con-
ment or increase the risk of exploitation. Examples of fusion and conflict.
such dual relationships include, but are not limited to, c. Psychologists who employ or supervise other profes-
research with and treatment of employees, students, su- sionals or professionals in training accept the obligation
pervisees, close friends, or relatives. Sexual intimacies to facilitate the further profeSSional development of these
with clients are unethical. individuals. They provide appropriate working condi-
b. When a psychologist agrees to provide services to tions, timely evaluations, constructive consultation, and
a client at the request of a third party, the psychologist experience opportunities.
assumes the responsibility of clarifying the nature of the d. Psychologists do not exploit their professional re-
relatioruhips to all parties concerned. lationships with clients, supervisees, students, employees,
c. Where the demands of an organization require psy- or research participants sexually or otherwise. Psychol-
ETHICAL PRINCIPLES OF PSYCHOLOGISTS 687
ogists do not condone or engage in sexual harassment. spect the right of clients to have full explanations of the
Sexual harassment is defined as deliberate or repeated nature and purpose of the techniques in language the
comments, gestures, or physical contacts of a sexual na- clients can understand, unless an explicit exception to
ture that are unwanted by the recipient. this right has been agreed upon in advance. When the
e. In conducting research in institutions or organiza- explanations are to be provided by others, psychologists
tions, psychologists secure appropriate authorization to establish procedures for ensuring the adequacy of these
conduct such research. They are aware of their obliga- explanations.
tions to future research workers and ensure that host b. Psychologists responsible for the development and
institutions receive adequate information about the re- standardization of psychological tests and other assess-
search and proper acknowledgment of their contribu- ment techniques utilize established scientific procedures
tions. and observe the relevant APA standards.
f. Publication credit is assigned to those who have c. In reporting assessment results, psychologists indi-
contributed to a publication in proportion to their profes- cate any reservations that exist regarding validity or re-
sional contributions. Major contributions of a professional liability because of the circumstances of the assessment
character made by several persons to a common project or the inappropriateness of the norms for the person
are recognized by joint authorship, with the individual tested. PsychologiSts strive to ensure that the results of
who made the principal contribution listed first. Minor assessments and their interpretations are not misused by
contributions of a professional character and extensive others.
clerical or similar nonprofessional assistance may be ac- d. Psychologists recognize that assessment results may
knowledged in footnotes or in an introductory statement. become obsolet.e. They make every effort to avoid and
Acknowledgment through specific citations is made for prevent the misuse of obsolete measures.
unpublished as well as published material that has di- e. Psychologists offering scoring and interpretation
rectly inDuenced the research or writing. Psychologists services are able to produce appropriate evidence for the
who compile and edit material of others for publication validity of the programs and procedures used in arriving
publish the material in the name of the originating group, at interpretations. The public offering of an automated
if appropriate, with their own name appearing as chair- interpretation service is considered a professional-to-
person or editor. All contributors are to be acknowledged professional consultation. Psychologists make every ef-
and named. fort to avoid misuse of assessment reports.
g. When psychologists know of an ethical violation by f. Psychologists do not encourage or promote the use
another psychologist, and it seems appropriate, they in- of psychological assessment techniques by inappro-
formally attempt to resolve the issue by bringing the priately trained or otherwise unqualified persons through
behavior to the attention of the psycbologist. If the mis- teaching, sponsorship, or supervision.
conduct is of a minor nature and/or appears to be due
to lack of sensitivity, knowledge, or experience, such an
informal solution is usually appropriate. Such informal
corrective efforts are made with sensitivity to any rights
Principle 9
to confidentiality involved. If the violation does not seem
amenable to an informal solution, or is of a more serious RESEARCH WITH HUMAN PARTICIPANTS
nature, psychologists bring it to the attention of the ap-
propriate local, state, and/or national committee on TM decisjon 10 unde1'take research resls upon a con-
professional ethics and conduct. side1'ed Judgmenl by 1M individual psychologisl aboul
how besl 10 conlribute 10 psychological science and hu-
man welfare. Having made 1M decision to conducl re-
search, the psychologist consUkr. ailem4t1ce directions
in which research ene1'gies and resources mighl be in-
Principle 8 vested. On tM basis of Ihis Conside1'allon, 1M psychol-
ASSESSMENT TECHNIQUES oglsl carries OUI 1M investlgallon wllh respecI and con-
cern for tM dignily and welfare of tM people who
In 1M developmenl, publlcallon, and utilizallon of psy- partlcipale and with cognizance of fede1'al and slale
chological assessmenl lechnlques, psychologlsls make regulalions and professional slandards governing tM
""""J efforl 10 promole 1M welfare and besl inle1'ests conduct of research wilh human participants.
of tM client. TMy guard against tM misuse of _ess- a. In planning a study, the investigator has the re-
ment resu/ls. TMy respect tM client's rlghl to know sponsibility to make a careful evaluation of its ethical
1M resu/ls, 1M inlerprelations made, and tM bases for acceptability. To the extent that the weighing of scien-
their conclusions and recommendations. PsycholOgisls tific and human values suggests a compromise of any
make every efforl to mainlain tM securlly of lesls and principle, the investigator incurs a correspondingly se-
olhel' assessment techniqueS within limits of legal man- rious obligation to seek ethical advice and to observe
dates. TMII slrlve 10 ensure 1M aJl1lropriale use of as- stringent safeguards to protect the rights of human par-
sessmenl lechnlques by olhel's. ticipants.
a. In using assessment techniques, psychologists re- b. Considering whether a participant in a planned
688 ApPENDIXC
study will be a "subject at risk" or a "subject at minimal h. After the data are collected, the investigator pro-
risk," according to recognized standards. is of primary vides the participant with information about the nature
ethical concern to the investigator. of the study and attempts to remove any misconceptions
c. The investigator always retains the responsibility that may have arisen. Where seienti6c or humane values
for ensuring ethical practice in research. The investigator justify delaying or withbolding this information, the in-
is also responsible for the ethical treatment of research vestigator incurs a special responsibility to monitor the
participants by collaborators, assistants, students, and research and to ensure that there are no damaging cOn-
employ_, all of whom, however. incur similar obliga- sequences for the participant.
tions. i. Where research procedures result in undesirable
d. Except in minimal-risk research. the investigator consequences for the individual participant, the inves-
establishes a clear and fair agreement with research par- tigator has the responsibility to detect and remove or
ticipants, prior to their participation, that clarl6es the correct these consequences, including long-term effects.
obligations and responsibilities of each. The investigator j. Information obtained about a research participant
has the obligation to honor all promises and commitments during the course of an investigation is con6dential unless
included in that agreement. The investigator informs the otherwise agreed upon in advance. When the possibility
participants of all aspects of the research that might rea- exists that others may obtain access to such information.
sonably be expected to inlluence willingness to partici- this possibility. together with the plans for protecting
pate and explains all other aspects of the research about con6dentiality, is explained to the participant as part of
which the participants inquire. Failure to make full dis- the procedure for obtaining informed consent.
closure prior to obtaining informed consent requires ad-
ditional safeguards to protect the welfare and dignity of
the research participants. Research with children or with
participants who have impairments that would limit un- Principle 10
derstanding and/or communication requires special safe- CARE AND USE OF ANIMALS
guarding procedures.
e. Methodological requirements of a study may make An investigator of animal behavior .trlve. to advance
the use of concealment or deception necessary. Before understanding of basic behavioral principles and/or to
conducting such a study, the investigator has a special contribute to the improvement of human health and
responsibility to (i) determine whether the use of such welfare. In seeking these ends, the investigator ensures
techniques is justi6ed by the study's prospective seien- the welfare of animals and treat. them humanely. Laws
ti6c. educationaL or applied value; (ii) determine whether and regulations notwithstanding, an animar. imme-
alternative procedures are available that do not use con- dtate protection depends upon the scientist's own con-
cealment or deception; and (iii) ensure that the partic- sctence.
ipants are provided with suf6cient explanation as soon a. The acquisition, care, use. and disposal of all ani-
as possible. mals are in compliance with current federal, state or
f. The investigator respects the individual's freedom provincial, and local laws and regulations.
to decline to participate in or to withdraw from the re- b. A psychologist trained in research methods and
search at any time. The obligation to protect this freedom experienced in the care of laboratory animals closely
requires careful thought and consideration when the in- supervises all procedures involving animals and is re-
vestigator is in a position of authority or influence over sponsible for ensuring appropriate consideration of their
the participant. Such positions of authority include. but comfort. health, and humane treatment.
are not limited to, situations in which research partici· c. Psychologists ensure that all individuals using ani-
pation is required as part of employment or in which mals under their supervision have received explicit in-
the participant is a student. client. or employee of the struction in experimental methods and in the care. main·
investigator. tenance. and handling of the species being used.
g. The investigator protects the participant from phys- Responsibilities and activities of individuals partiCipating
ical and mental discomfort. harm. and danger that may in a research project are consistent with their respective
arise from research procedures. If risks of such conse- competencies.
quences exist, the investigator informs the participant of d. Psychologists make every effort to minimize dis-
that fact. Research procedures likely to cause serious or cemfort. illness, and pain of animals. A procedure sub-
lasting harm to a participant are not used unless the jecting animals to pain, stress, or privation is used only
failure to use these procedures might expose the partic- when an alternative procedure is unavailable and the
ipant to risk of greater harm. or unless the research has goal is justi6ed by its prospective seienti6c, educational.
great potential bene6t and fully informed and voluntary or applied value. Surgical procedures are performed un-
consent is obtained from each participant. The partici- der appropriate anesthesia; techniques to avoid infection
pant should be informed of procedures for contacting and minimize pain are followed during and after sur-
the investigator within a reasonable time period follow- gery.
ing participation should stress. potential harm. or related e. When it is appropriate that the animal's life be
questions or concerns arise. terminated, it is done rapidly and painlessly.
APPENDIX 0
standards
FOR EDUCATIONAL
&PSYCHOLOGICAL
TESTS
689
690 ApPENDIXD
INTRODUCTION
priateness. A test score describes but it behavior when presented under stan-
does not explain a level of performance. dardized conditions and to yield scores
Test performance may be influenced by that will have desirable psychometric
many factors such as amount and properties such as high reliability and
quality of certain kinds of training, dis- high validity.
tractions during testing, sensory de- Tests include standardized aptitude
fects, inability to hear instructions
because of poor administration, inap- and achievement instruments, diag-
propriate language in instructions or in nostic and evaluative devices, interest
the test, inability to read, brain inventories, personality inventories,
damage, motivation level, illumination projective instruments and related
level, cultural background of the clinical techniques, and many kinds of
examinee, or test-taking strategies. personal history forms. It was pointed
Some unfairness may be built into a out in the 1966 Standards that the same
test, for example. requiring an inor- general types of information are needed
dinately high level of verbal ability to for all these varieties of published
comprehend the instructions for a non- diagnostic, prognostic, and evaluative
verbal test. Many of the social ills at- devices. It is equally appropriate to
tributed to tests, however. seem more a point out that unpublished assessment
result of the ways in which tests have devices can be better used if the same
been used than of characteristics of the kind of information is available to
tests themselves; for example. errors in users.'
administration. failure to consider the
appropriateness of normative data. I It is sometimes suggested in response to per-
failure to choose an appropriate test. ceptions of test abuse and unfair uses of tests that
use of incorrect assumptions about the a moratorium on testing be observed until better
and more appropriate instruments are developed
causes of a low or deviant test score. or and more equitable procedures can be instituted.
administrative rigidity in using test The suggestion of such an extreme measure may
scores for making decisions. be indicative of the growing sense of frustration
and indignation felt particularly by some minority
group members who sense that testing has had a
disproportionately negative impact on their op-
portunities for equal access to success in
Tests and Test Uses to Which education and employment. This suggestion.
These Standards Apply although well intended. seems futile for several
reasons:
Hrst. it fails to consider unfairness resulting from
It is intended that these standards the mIsuses of tests. If new and better tests were
apply to any assessment procedure. subject to the same sorts of misuse. they might
well produce the same sorts of errors (or errors of
assessment device. or assessment aid; the same magnitudes) in the decisions based on
that is. to any systematic basis for them.
making inferences about characteristics Second. it requires a corresponding but
unlikely moratorium on decisions. Employers will
of people. continue to make employment decisions with or
A test is a special case of an without standardized tests. Colleges and univer-
assessment procedure. It may be sities will still select students. some elementary
pupils will still be recommended for special
thought of as a set of tasks or questions education. and boards of education will continue
intended to elicit particular types of to evaluate the success of specific programs. If
692 ApPENDIXD
There are wide variations in the dards). he will find the standards useful
sophistication of assessment tech- guides for developing information
niques. At one extreme is the test that similar to that in good test manuals: the
has gone through several revision.s based principles are as relevant to him as to
on many research studies. Such a test the professional test developer. If he
may provide normative data based on chooses to use a test that has been
thousands of cases classified into developed by someone else. he may find
dozens of subpopulations. At the other the standards helpful in evaluating
extreme is the casual interview that alternatives from which he may choose;
provides assessments based on varying moreover. the standards may help in
and unsystematically observed cues. developing a program of application.
These standards are written There are many dimensions along
specitically to apply to standardized which measuring instruments can be
tests. They apply in varying degrees. c1assitied. Some are designed to
however. to the entire range of measure abilities. some to measure ac-
assessment techniques. If it is required complishments. others to measure at-
that a relationship be demonstrated titudes or interests. Some are in-
between scores (assessments) on an em- ventories. interview aids. biographical
ployment test and subsequent per- data forms. and experimental
formance on a job. the requirement diagnostic devices. and are not called
should in principle also apply to the tests. Generally. however. the word
judgments (assessments) of the em- "test" is used in these standards to ap-
ployment interviewer. It may not be ply to all kinds of measurement. What
possible to apply the standards with the these different kinds have in common is
same rigor. but the kind of judgments that scores with desirable psychometric
the interviewer is to make can be iden- properties may be derived from each.
tified: the time and procedures for These standards also apply to
developing and recording them can be criterion measures. Studies evaluating
standardized; and they can be validated uses of well-developed tests too often
in the same ways that scores are employ inadequate criterion data. A
validated. When someone who makes criterion measure should have the
personnel decisions developes his own psychometric properties expected of
assessment techniques (a practice not any other measurement. such as
discouraged intentionally in these stan- validity. including in special instances
some form of criterion-related validity.
those responsible for making decisions do not use for example. the relationship of an im-
standardized assessment techniques. they will use mediate criterion measure to an in-
less dependable methods of assessment. termediate or more nearly ultimate
Third. tests are often useful for finding talent
but are too often used only as devices for rejecting measure. Criterion development should
those with low scores; they can also be used to be guided by the standards guiding test
discover potential for performance that might not development.
otherwise be observed. In this way. the use of tests
may sometimes improve the prospects of minority Some assessment techniques are used
group members and women. as il)terview aids. The intent of such use
STANDARDS FOR EDUCATIONAL & PSYCHOLOGICAL TESTS 693
situation, there may be some Essen- some function and in some situations.
tial standards that do not apply. It but even the best test can have
should be noted that many of these damaging consequences if used inap-
standards require thought rather than propriately. Therefore. the primary
specific action as an outcome of responsibility for the improvement of
thought; for example. "A test user testing continues to rest on the
should consider .... " In most cases. shoulders of test users. It is hoped that
such statements are listed as Essential. these standards will be used to extend
If some type of Essential in- the professional training of many test
tormation is not available on a given users who are not now being trained ap-
test. it is important to help the reader propriately. Professional training of
recognize that the research on the test is personnel managers, school admin-
incomplete in this respect. A test istrators' and classroom teachers
manual should include clear statements should prepare them to better under-
of what research has been done and stand information about tests, test in-
avoid misleading statements. terpretations. and these standards.
The category Very Desirable is used to Such training will do much to improve
draw attention to types of in- the quality of test use and to minimize
formation or practices that contribute the extent of test misuse. The standards
greatly to the user's understanding of draw attention to recent developments
the test and to competence in its use. in thinking about tests. test analysis.
Standards in this category have not and test use. A com parison of these
been listed as Essential if their standards with those in earlier editions
usefulness is debatable. should remind test developers and test
The category Desirable includes users that testing is a stable but not a
information and practices that are help- static enterprise and that. in fact. there
ful but not Essential or Very Desirable. is room for improvement in the quality
When a test is widely used. the of assessments that are being made.
developer has a greater responsibility Tests are often developed and used in
for investigating it thoroughly and circumstances that lead to maintaining
providing more extensive reports about less than the highest standards of
it than when the test is limited in use. technical excellence. We do not intend
Large sales make research financially to discourage those who must make
possible. Therefore. the developer of a assessments of people from doing the
popular test can add information in best they can with whatever training
subsequent editions of the manual. For and collaborative resources are
tests having limited sales. it is available to them. These standards.
unreasonable to expect that as much in- however. are written to promote ex-
formation will be furnished. cellence. They provide a kind of checklist
of factors to be considered in designing.
Cautions To Be Exercised in the standardizing. validating. scoring. and
Use of These Standards interpreting tests. They may help test
developers and test users decide what
Almost any test can be useful for studies are needed and how those
STANDARDS FOR EDUCATIONAL & PSYCHOLOGICAL TESTS 697
information) that makes every reason- should satisfy the intent of standard A I
able effort to follow the recommen- by pointing out the absence and
dations of these standards and, in importance of this information.
particular, to provide the information Essential
required to substantiate any claims that
have been made for its use. Essential Al.2. Where the information is too
[Comment: The term "operational
extensive to be fully reported in the
use" refers to making practical
manual. the essential information
decisions about the evaluation or
should be summarized and
handling of individuals. groups.
accompanied by references to other
curricula. therapeutic treatments, and
soon. sources of information. such as
The term "manual" refers to technical supplements. articles. or
documents describing procedures of books. Very Desirable
test development. use. interpretation. [Comment: Developers of some well-
relevant research. normative data. and known tests provide extensive technical
related information. Depending on manuals. make further research data
such things as the amount of available through other sources (such as
information to report and the diversity the Education Resources Information
of uses and users. the term may Center), prepare annotated bibliog-
designate a document entirely within raphies, or include relevant information
one cover or a series of separately in technical books which users are
bound pamphlets. This term might also encouraged to consult. In other in-
be extended to include procedural stances, the essential information is
manuals governing the use of tests or of given in the manual sold with the
test batteries in. for example. selection instrument, along with references to
situations; the wording and importance other useful sources.
of many of these standards would be Publications by persons other than
different for a procedural manual. but the author of the test frequently fulfill
the principles applicable to test many functions of a manual. If a book
manuals would at least, therefore, be about a test is designed to serve as a
analogous. manual. its author and publisher have
Not all of the standards in this report the same responsibility in preparing it
will apply to anyone particular test. A as do the author and publisher of a
standard may be ignored if it is test.]
irrelevant in light of the purpose of the
test and the claims made for it. but it AI.2.I. When information about a
may not be ignored merely because it is test is provided in a separate
difficult to meet or has not usually been publication. that publication should
met by a similar test. J meet the same standards of accuracy
and freedom from misleading impres-
ALl. If information needed to sions that apply to the manual.
support interpretations suggested in the Essential
manual cannot be presented at the time
the manual is published, the manual AI.2.2. Promotional material for a
700 ApPENDIXD
test should be accurate and should not the need for maintaining necessary test
give the reader false impressions. security. Very Desirable
Essential [Comment: For example, a manual
[Comment: One publisher presents might describe some acceptable
an extensive and complete bibliog- coaching practices. If so, it would be
raphy, without comment or annotation, appropriate to add warnings against
of research involving a test; he does not unacceptable practices that might
mention that many of the entries are jeopardize test security.]
studies with negative findings. The
A2.3. A test manual or supple-
impression is one of extensive use, not
mentary document should provide rep-
of limitations to the usefulness of the
resentative sample items and a state-
test.]
ment of the intended purpose of the test
A1.2.3. Informational material dis- in a form that can be made available to
tributed within a using organization those concerned about the nature and
should be accurate, complete for the quality of a testing program. Very
purposes of the reader's need, and writ- Desirable
ten in language that will not give the [Comment: The evaluation of a test
reader a false impression. Essential may not fall exclusively to those who are
[Comment: Such information is often technically trained. Examinees, mem-
given in brief memoranda. In preparing bers of citizen panels, civil rights advo-
these brief reports, the technical cates, and parents are among those who
capability of the readers may be kept in may have reason to make judgments
mind, but this does not suggest that about the appropriateness of a test.
essential information be either omitted Their right to do so need not contlict
or distorted in the interest of simplicity. with the necessity to maintain test
Where a reader may be expected to security if descriptive and explanatory
receive such reports regularly, efforts materials are made available.
can be made to increase his ability to One publisher of educational tests
understand technical detail.] has published descriptive material in
nontechnical language for a wide
A2. A test manual should describe
variety of tests; pamphlets include
fully the development of the test: the
information on test development and
rationale, specifications followed in
rationale as well as examples of items
writing items or selecting observations,
and suggestions on test-taking strate-
and procedures and results of item
gies.]
analysis or other research. Essential
A2.4. The identity and professional
A2.1. Data gathered during the
qualifications of item writers and
process of developing a test before it is
editors should be described in instances
in final form should be clearly
where they are relevant; for example,
distinguished from data pertaining to
when adequacy of coverage of a subject-
the test in tinal form. Essential
matter achievement test cannot appro-
A2.2. A test manual should specify priately or practically be measured
STANDARDS FOR EDUCATIONAL & PSYCHOLOGICAL TESTS 701
against any external criterion. increase the probability that test users
Desirable have current information.]
A3. The test and its manual should A3.2.1. If a short form of a test is
be revised at appropriate intervals. The prepared by reducing the number of
time for revision has arrived whenever items or organizing a portion of the test
changing conditions of use or new into a separate form. new evidence
research data make any statements in should be obtained and reported for
the manual incorrect or misleading. that shorter test. Essential
Very Desirable [Comment: It is especially important
[Comment: The technical charac- to report the reliability and other
teristics and the appropriateness of a technical data for the test in its shorter
test may change as social conditions form. since placing items in a new
and attitudes. job definitions. context may alter responses to them.
educational pressures. or the composi- In the manual for one test that has
tion of relevant school populations two alternate forms, the validity data
change.] presented were obtained using the sum
of the scores of the two forms. It would
A3.1. Competent studies of the test have been more appropriate to have
following its publication. whether the presented the data for each form
results are favorable or unfavorable to independently. ]
the test. should be taken into account in
A3.2.2. When a short form is
revised editions of the manual or its
prepared from an established test. the
supplementary reports. Pertinent stud-
manual should present evidence that
ies by investigators other than the test
the items in the short form represent
authors and publishers should be
the items in the long form or measure
included. Very Desirable
the same characteristics as the long
[Comment: The developer of one test form. Very Desirable
has published a comprehensive review
[Comment: When no short form of a
of validity studies of the test covering a
test has been prepared but there is
IS-year period.]
reason to believe that it is commonly
A3.2. When the test is revised or a used in a shortened form. the manual
new form is issued. the manual should should remind the reader that data in
be suitably revised to take those the manual may not be applicable to
changes into account. In addition. the results of administration of a shortened
nature and extent of the revision and form.
the comparability of data from the old One revision of a long-established
test and the revised test should be achievement test battery illustrates a
explicitly stated. Essential desirable practice by listing all previous
[Comment: It is useful for publishers editions and then describing in detail
to identify revisions of test manuals in the relation of the new revision to the
their catalogs and to take other steps to previous editions.]
702 ApPENDIXD
B3. The test manual should describe [Comment: One manual differen-
clearly the psychological, educational, tiates psychologists who work with
or other reasoning underlying the test children from those who work only with
and nature of the characteristic it Is adults in identifying qualifications
intended to measure. Essential needed to use an individually adminis-
tered test for children. Another offers
(Comment: There ordinarily are specifications for administering the test
explicit reasons for setting up the test as to non-English-speaking students.
it has been done; it may be assumed
that certain psychological processes are User qualifications might be
required in taking the test and that described in terms of special training
certain traits are being measured as a generally thought necessary to achieve
result. The identification of these competence. It may be possible for
processes may be based on a theory. some test manuals to identify the most
empirical research. or empirical frequent sources of error in test use and
processes internal to the test itself. In to specify the kind of user training
any case. a clear description of the necessary to eliminate these common
construct or content and of the manner errors.
of measurement enables a user to judge B4.1. The test manual should not
the test by its conformity to his own imply that a test is "self-interpreting."
psychological or educational insight as It should specify information to be
well as by statistical evidence of its given about test results to persons who
efficacy.) lack the training usually required to
interpret them. Essential
B3.1. In the case of tests developed
for content-referenced interpretation. (Comment: It is not ordinarily de-
special attention should be given to sirable to entrust interpretation of
defining the content domain in scores to an untrained person. There
operational terms. In the case of a are. of course. tests that can be scored
mastery test, the test developer's by the examinee. and it is often useful
rationale for any cutting score that he to give scores to students or parents.
suggests should be specified. or the Where these practices are followed. the
procedures that the user might employ sense of this standard is that interpre-
to establish mastery levels should be tative aids should also be given.
described. Essential The manual should indicate what
(Comment: The test user needs such may be done by untrained persons and
information so that he can compare his what should not be done. The manual
concept of mastery or competence with for one well-known interests test, for
that of the test author.) example, indicates that examinees may
perform the mechanics of scoring their
B4. The test manual should identify own tests but properly stresses that they
any special qualifications required to need the help of a trained teacher or
administer the test and to interpret it counselor in making interpretations
properly. Essential and future plans.)
STANDARDS FOR EDUCATIONAL & PSYCHOLOGICAL TESTS 705
that has no practical usefulness can possible the storage and recall of large
often be obtained by using a very large amounts of data; test interpretation can
number of cases. For example. a well- be greatly assisted by the use of
known inventory yields statistically computer data banks. Computer
significant differences between large scoring services may provide lengthy
samples of males and of females. but printouts of descriptive and prognostic
the differences are too small to be of information from individual profiles on
practical importance. Conversely. one a test battery or personality inventory.
who uses an insensitive statistical test The user of such printouts needs to
can falsely conclude that there is no know the reasoning and the evidence
difference of practical importance. In supporting the suggested interpreta-
general. it is more appropriate in tions because they are as fallible as
reporting test data to state a confidence other SUbjective interpretations.]
interval or the likelihood function for
C. Directions for Administration
the parameter of interest than to report
and Scoring
only that the null hypothesis can or
cannot be rejected.] Interpretations of test and measure-
ment techniques, like those of experi-
85.4. The manual should differen- mental results, are most reliable when
tiate between an interpretation that is the measurements are obtained under
applicable only to average tendencies of standardized or controlled conditions.
a group and one that is applicable to an To be sure, there are circumstances in
individual within the group. Very testing where it may be important to
Desirable change conditions systematically for
85.5. The manual should state maximum understanding of the
clearly what interpretations are in- performance of an individual. For
tended for each subscore as well as for example, an examiner may system-
the total test. Essential atically modify procedures in successive
[Comment: Where subscores are readministrations of a test to explore
obtained only for convenience in the limits of a child's mastery of a
scoring the test. and no interpretation is specific content area such as a set of
intended, this should be made clear. concepts. Nevertheless, the test deve-
For some tests. keys are provided for loper should provide a standard pro-
subscores that have possible research cedure from which modifications can be
use but are not intended to be made. Without standardization, the
interpreted; this should be made clear.] quality of interpretations will be
reduced, to whatever extent differences
86. Test developers or others in procedure influence performance.
offering computer services for test For most purposes, great emphasis is
interpretation should provide a manual properly placed on strict standard-
reporting the rationale and evidence in ization of procedures for adminis-
support of computer-based interpreta- tering a test and reciting its instruc-
tions of scores. Essential tions. If a test is to be used for a wide
[Comment: A computer makes range of subpopulations, these pro-
STANDARDS FOR EDUCATIONAL & PSYCHOLOGICAL TESTS 707
the accuracy of scoring an objective test validity of the test or the applicability of
by outlining a procedure for checking the test norms.)
the obtained scores for computational
C3.4. If an unusual or complicated
or clerical errors. Very Desirable
scoring system is used. the test manual
C3.2. Where sUbjective processes should indicate the approximate
enter into the scoring of a test, evidence amount of time required to score the
on the degree of agreement between in- test. Desirable
dependent scorings under operational C3.S. "Correction-for-guessing"
conditions should be presented in the formulas should be used with multiple-
test manual. If such evidence is not choice and true-false items when the
provided, the manual should draw at- test is speeded. Desirable
tention to scoring variations as a
possible significant source of errors of D. Norms and Scales
measurement. Very Desirable Interpretations of test scores tradi-
tionally have been norm referenced;
C3.2.1. The bases for scoring and that is. an individuals score is inter-
the procedures for training scorers preted in terms of comparisons with
should be presented in the test manual scores made by other individuals. Alter-
in sufficient detail to permit other native interpretations are possible.-
scorers to reach the level of agreement Content-referenced interpretations are
reported in studies of scorer agreement those where the score is directly inter-
given in the manual. Very Desirable preted in terms of performance at each
point on the achievement continuum
C3.2.2. If persons having various being measured. Criterion-referenced
degrees of supervised training are ex- interpretations are those where the
pected to score the test, studies of the score is directly interpreted in terms of
interscorer agreement at each skill level performance at any given point on the
should be presented in the test manual. continuum of an external variable. An
Desirable external criterion variable might be
grade averages or levels of job
C3.3. If the test is designed to use
performance. 2
more than one method for the
examinee's recording of his reponses, 'Current usage in educational measurement
such as hand-scored answer sheets, or commonly refers to "criterion-referenced" in-
terpretations for both alternatives to in-
entering of responses in the test terpretations requiring norms. The different
booklet, the test manual should report meanings of the word "criterion," however,
data on the degree to which results from produce some confusion; some measurement
specialists have therefore turned to the term "con-
these methods are interchangeable. tent referenced" and this usage is adopted here.
Essential The word "criterion," as it is used in the phrase
"criterion-related" validity (that is, an external
[Comment: The different amounts of variable) has suggested a similar but
time required for responding to items in distinguishable alternative to normative in-
terpretation; therefore, "content-referenced and
forms adapted to different scoring criterion-referenced" are not interchangeable terms
methods may affect the reliability or as used in this document.)
STANDARDS FOR EDUCATIONAL & PSYCHOLOGICAL TESTS 709
The standards in this section refer "populations" are plural; in nearly all
principally to tests intended for norm- instances of tests developed for other
referenced test interpretations rather than purely local use, the user needs to
than for content-reterenced interpre- know the applicability of the test to dif-
tations. ferent groups. For tests developed with
a view to widespread use in schools or
Dl. Norms should be published in
industry, information is needed about
the test manual at the time of release of
differences or similarities of normative
the test for operational use. Essential
data for appropriate subgroups such as
D1.1. Norms should be established sex, ethnic, grade, or age groups. Users
even for a test developed only for local need to be alert to situations when norms
use or only for predictive purposes. are less extensive for one group than
Desirable another.
[Comment: It is sometimes forgotten For example, the manual for an oc-
that norms tables provide infor- cupational interest inventory, or for an
mation useful for purposes other than aptitUde test particularly useful in cer-
comparing one individual with group tain occupations, should point out that
data. For example, a test user can a person who has a high degree of in-
derive information from a normative terest or aptitude in a curriculum or oc-
table about the score levels at which the cupation when compared to people in
discrimination power of the measure- general will usually have a lower degree
ment is good or poor.] of interest or aptitude compared to per-
sons actually engaged in that field.
D1.2. Even though a test is ex- Thus, a high percentile score on a scale
pected to be used primarily with local reflecting musical interest, in which the
norms, the test manual should never- examinee is compared with people in
theless provide normative data to aid general, may be equivalent to a low per-
the interpreter who lacks local norms. centile where the examinee is compared
Very Desirable with professional musicians.]
[Comment: The manual for one in-
D2.1. Care should be taken to avoid
strument designed to measure employee misleading impressions about the
aptitude stresses the value of local norms
generality of normative data. Essential
but also includes norms based on a
wide variety of occupational and [Comment: Truly representative na-
educational classifications.] tional norms, for example, are rarely if
ever obtained; normative data
D2. Norms presented in the test collected from people or schools with
manual should refer to defined and specific characteristics, however, are
clearly described populations. These frequently used as if they were taken
populations should be the groups with from a representative national group.
whom users of the test will ordinarily Thus, we have test users who may say
wish to compare the persons tested. that an examinee's performance is at a
Essential "tenth-grade reading level," without
[Comment: It should be noted that qualification when the norms are in fact
710 ApPENDIXD
obtained only from superior schools complete enough so that the user can
voluntarily participating in the test judge its appropriateness for his use.
research. It is an error of interpretation The description should include number
to assume that the norms of the volun- of cases, classified by one or more of
teer group of schools apply to schools in such relevant variables as ethnic mix,
general; the incidence of such erros may socioeconomic level, age, sex, locale,
be reduced by manuals that clearly and educational status. If cluster
define the characteristics of the norma- sampling is employed, the description
tive populations.] of the norms group should state the
number of separate groups tested.
D2.1.1. The test manual should
Essential
report the method of sampling from the
population of examinees and should [Comment: Manuals often use too
discuss any probable bias in this sam- gross a classification system in
pling procedure. Essential describing their normative data. For
example, the manual for one employee
D2.1.2. Norms reported in any test aptitude test provides a variety of
manual should be based on well- normative data for many occupational
planned samplings rather than on data and educational groupings. However,
collected primarily because it is readily the lack of information as to sex, ethnic
available. Any deviations from the plan origins, age, education, and experience
should be reported along with levels within these groupings consider-
descriptions of actions taken or not ably reduces the usefulness of the
taken with respect to them. Essential norms.]
[Comment: Occupational and educa- D2.2.1. The popUlations upon
tional test norms have often been based which the psychometric properties of a
on scattered groups of test papers, for test were determined and for which
authors sometimes have requested that normative data are available should be
all users mail in results for use in subse- clearly and prominently described in
quent reports of norms. Distributions the manual. Any accompanying report
so obtained are subject to unknown de- forms should provide space for
grees and types of biases. Hence. the identifying the normative groups used
methods of obtaining such samples in interpreting the scores. Essential
should be clearly described.] [Comment: The intent of this
D2.1.3. In addition to reporting the standard is to provide a warning to
consumers (users and examinees)
number of individuals in a set of
against unwarranted interpretations. If
normative data, the manual should also
a standard report form results in
report the number of sampling units
from which those individuals were percentile-rank or standard-score
interpretations by consistently using the
drawn along with the numbers of
same normative population, the
individuals in each unit. Essential
definition of that popUlation, with an
D2.2. The description of the norms indication of the time period of data
group in the test manual should be collection, would be sufficient.]
STANDARDS FOR EDUCATIONAL & PSYCHOLOGICAL TESTS 711
A test developer must provide The second question inquires into the
evidence of the reliability and validity of
usefulness of the measurement as an
indicator of some other variable as a
his test; it is usually reported in the test
manual. Many test users should do predictor of behavior. In this context,
similar research on their own the essential problem is to reach some
application of the test. Their reports conclusion about how well scores on the
often differ from those in test manuals test are related to some other
by being more detailed or more specific performance, and it is appropriate to
to a particular problem, or by speak of the closeness of the
validating test batteries rather than relationship.
individual tests. Despite such dif- The two questions are not necessarily
ferences, the standards of research, and independent. For example, where the
of research reporting, should be gen- test is a sample of the "other behavior,"
erally similar in the two situations. the answer is the same for either
question. Moreover, answers to both
E. Validity questions may require a knowledge of
Questions of validity are questions of the interrelationships between the test
what may properly be inferred from a scores and other variables. A thorough
test score; validity refers to the understanding of validity may require
appropriateness of inferences from test many investigations. The investigative
scores or other forms of assessment. processes of gathering or evaluating the
The many types of validity questions necessary data are called validation.
can, for convenience, be reduced to two: There are various methods of
(a) What can be inferred about what is validation, and all, in a fundamental
being measured by the test? (b) What sense, require a definition of what is to
can be inferred about other behavior? be inferred from the scores and data to
The first question inquires into the show that there is an acceptable basis
intrinsic nature of the measurement for such inferences.
itself. The measuring instrument is an It is important to note that validity is
operational definition of a specified itself inferred, not measured. Validity
domain of skill or knowledge, or of a coefficients may be presented in a
trait, of interest to the test developer or manual, but validity for a particular
user. The essential problem in this aspect of test use is inferred from this
context is to reach some conclusion as collection of coefficients. It is, there-
to how faithfully the scores represent fore, something that is judged as ade-
that domain, and it is appropriate to quate, or marginal, or unsatisfactory.
speak of the validity of the mea- The kinds of validity depend upon
surement. the kinds of inferences one might wish
STANDARDS FOR EDUCATIONAL & PSYCHOLOGICAL TESTS 715
to draw from test scores. Four evaluate construct validity, all know-
interdependent kinds of inferential ledge regarding validity is relevant. A
interpretation are traditionally de- reading comprehension test. for
scribed to summarize most test use: the example. may be used and validated for
criten'on-related validities (predictive all three types of inference: how well it
and concurrent); content validity; and predicts future academic perfonnance.
construct validity.' (So-called "face" how well it samples a defined content
validity, the mere appearance of vali- area of material to read, and how well it
dity, is not an acceptable basis for inter- measures the construct of compre-
pretive interferences from test scores.) hension.
These aspects of validity can be Criterion-Related Validities
discussed independently, but only for
Criterion-related validities apply
convenience. They are interrelated
when one wishes to infer from a test
operationally and logically; only rarely
score an individual's most probable
is one of them alone important in a
standing on some other variable called
particular situation. A thorough study
a criterion. Statements of predictive
of a test may often involve information
validity indicate the extent to which an
about all types of validity. In developing
individual's future level on the criterion
or choosing a test for prediction. one
can be predicted from a knowledge of
should first postulate the constructs
prior test performance; statements of
likely to provide a basis for useful
concurrent validity indicate the extent
prediction of the variable of interest;
to which the test may be used to esti-
the measures chosen should have
mate an individual's present standing
adequate construct validity. The
on the criterion. The distinction is
content universe from which items are
important. Predictive validity involves a
sampled may also be an important early
time interval during which something
step in producing a predictive test. in
may happen (e.g., people are trained. or
evaluating a test considered for use as a
gain experience. or are subjected to some
predictor. or in developing the criterion
treatment). Concurrent validity reflects
measure to be predicted. Even if the
only the status quo at a particular time.
accuracy of prediction is good.
Under appropriate circumstances. data
information about construct validity
obtained in a concurrent study may be
may make a test more usefuL To
used to estimate the predictive validity
of a test. However. concurrent validity
'Many other terms have been used. Examples should not be used as a substitute for
include synthetic validity. convergent validity. predictive validity without an approp-
job-analytic validity. rational validity. and fac-
torial validity. In general. such terms refer to riate supporting rationale.
specific procedures for evaluating validity rather For many test uses, such as for
than to new kinds of interpretive inferences. Any
specially-named procedures. including these
selection decisions or assignment to
examples. should meet the standards of in· treatment, predictive validity provides
vestigation contained in this section. These stan· the appropriate model for evaluating
dards apply generally to the various statistics or
procedures that might be used in support of one
the use of a test or test battery. In
or more classes of inferences from test scores. employment testing, for example. use of
716 ApPENDIXD
validity are useful in efforts to improve theses, the investigator increases his
measures for the scientific study of a understanding of the qualities mea-
construct. They are also useful when a sured by the test. Through the process
test developer or test user wishes to of confirmation or disconfirmation, test
learn more about the psychological revision, and new research on the
qualities being measured by a test than revised instrument, he improves the
can be learned from a single criterion- usefulness of the test as a measure of a
related validity coeffficient. construct.
Evidence of construct validity is not It is important to note in this that the
found in a single study; rather, investigation of construct validity refers
judgments of construct validity are to a specific test and not necessarily to
based upon an accumulation of any other test given the same label.
research results. In obtaining the Evidence of construct validity may
information needed to establish also be inferred from the procedures
construct validity, the investigator followed in developing a test. For
begins by formulating hypotheses about example, in a measure of mechanical
the characteristics of those who have interest, a double item analysis may be
high scores on the test in contrast to used to reduce the effect of verbal
those who have low scores. Taken ability. A preliminary item analysis
together, such hypotheses form at least might be done using a standard verbal-
a tentative theory about the nature of comprehension test as an external
the construct the test is believed to be criterion. Those items with a very low
measuring. In a full investigation, the discrimination index in this analysis
test may be the dependent variable in could then be subjected to a second
some studies and the independent item analysis, a conventional internal-
variable in others. Some hypotheses consistency analysis. Only those items
may be "counterhypotheses" suggested with a low discrimination index in the
by competing interpretations or first analysis and a high discrimination
theories. index in the second analysis would be
Such hypotheses or theoretical included in the final item pool.
formulations lead to certain predictions Although evidence of construct
about how people at different score validity may be developed on the basis
levels on the test will behave on certain of a series of criterion-related studies, it
other tests or in certain defined is important to note that evidence ofthe
situations. If the investigator's theory construct validity of a test is not
about what the test measures is adequate evidence of the usefulness of
essentially correct, most of his the construct in specific further
predictions should be confirmed. If they hypotheses. In the selection of
are not, he may revise his definition of salespersons, for example, it is often
the construct, or he may revise the test hypothesized that success is a function
to make it a better measure of the of sociability. If one has a measure of
construct he had in mind. Through the sociability with generally acceptable
process of successive verification, evidence of its validity as a measure of
modification, or elimination of hypo- that construct, he may expect to find it
720 ApPENDlxD
E2.3. When a test user plans to E3.I. When the validity of a test for
make a substantial change in test predicting occupational performance is
format. instructions, language. or reported, the manual should describe
content, he should revalidate the use of the duties of the workers as well as give
the tests for the changed conditions. their job titles. Very Desirable
Essential [Comment: The principle is that
information should be given from which
Criterion-Related Validity
the reader can make judgments of the
E3. All measures of criteria should relevance of the criterion. The
STANDARDS FOR EDUCATIONAL & PSYCHOLOGICAL TESTS 723
manual should include evidence of the ES.4. When information other than
test's ability to place individuals in the test scores is known to have an
diagnostic groups rather than merely to appreciable degree of criterion-related
separate diagnosed abnormal cases validity and is ordinarily available to
from the normal population. Essential the prospective test user. the user
[Comment: When a test is shOUld consider both the validity of the
recommended for the purpose of other information and the resulting
assigning patients to discrete cate- mUltiple correlation when the new test
gories. such statistics as contingency information is combined with it.
coefficients. phi coefficients. or dis- Essential
criminant functions should be sup- [Comment: Whether a test should be
plemented by a table of misclassi- used for prediction and classification
fication rates giving. for example. the when other information is readily
proportion of patients falsely included available sometimes depends not on the
in a category or falsely excluded from it. validity of the test but on its
Such proportions should be compared "incremental validity." that is. what it
with base rates. that is, the proportions adds to the soundness of the judgment
of correct classifications made possible that would otherwise be made.
by a mere knowledge of the sizes of the For a questionnaire intended to
categories.] predict marital success. delinquency.
E8.3.2. If validity is demonstrated and similar behavioral variables. the
by comparing groups that differ on the investigator should find out how much
criterion (e.g.. where one group is the questionnaire enhances prediction
identified as a high-performanc~ group over that provided by base rates
and another as a low-performance developed from demographic variables
group). all cases should be assigned to such as socioeconomic status.)
one or the other of the groups. Very ES.5. Where more than one test is to
Desirable be used. validity information should
[Comment: The most reliable report the validity of the combination
statistics are obtained if all cases are actually used. Where composite scores
used; validity coefficients derived from are developed. the basis for weighting
extreme groups may be misleading. In (e.g.. multiple regression equations)
some situations. analyses using extreme should be given. Essential
groups may be useful for identifying [Comment: In one organization. a
predictors. but generally the validity composite was developed and validated
reported for any given predictor should by multiple regression in which the
be based on all cases. If the use of optimal weighting of one test was
extreme groups is deemed necessary or negative. Nevertheless. the organization
appropriate to a particular study. added unweighted scores to form a
appropriate estimates of correlatio~ different composite for use in making
should be used. The typical product- decisions. The multiple correlation
moment and biserial estimates are lIot coefficient did not. therefore. describe
appropriate in this situation.) the validity of the test battery as it was
732 ApPENDIX 0
predictions for applicants in either the test with other variables, the state-
group should be based on the regressi6n ment of the validity of the composite
line developed for his own group. If the should be based on a crossvalidation
differences in intercepts are statistical sample. Essential
artifacts (due. for example. to
[Comment: Cross-validation is par-
unreliability). the result might be
ticularly necessary when the number of
considered unfair to blacks (if they have
predictors entering the study (not the
the lower regression line) since their
final equation) is greater than 4 or 5
performance might be systematicaIly
under predicted. The effect can, of and when the sample size is less than
200.]
course, work both ways depending
on the direction of differences in
regression. EIO.1.1. When the scoring of tests
It is important to recognize that there in a battery is based on regression
are different definitions of fairness, and coefficients, negative scoring weights
whether a given procedure is or is not should be used only if they have been
fair may depend upon the deiinition verified by cross-validation in large
accepted. Moreover, there are statisti- samples and if their use will not be
cal and psychometric uncertainties invalid (and thus unfair) to one or more
about some of the sources of apparent subgroups in the population to be
differences in validity or regression. tested. Essential
Unless a difference is observed on
samples of substantial size, and unless EIO.2. If it is proposed that
there is a reasonably sound psycho- decisions be based on a complex
logical or sociological theory upon nonlinear combination of scores, it
which to explain an observed dif- should be shown that this combination
ference, the difference should be viewed has greater validity than a simpler
with caution. linear combination, that the equation
Bias is not necessarily detected by can be logically explained, and that the
criterion-related validity alone; cf. procedures for combining scores have
EI2.12l. been cross validated. Essential
[Comment: The use of "moderator
EIO. When a scoring key, the
variables," for example, is to be
selection of items, or the weighting of
recommended only where a moderator
tests is based on one sample, the
is shown to produce a clear
manual should report validity
improvement in validity in a cross-
coefficients based on data obtained
validation sample. Similarly, when it is
from one or more independent cross-
proposed that some pattern of scores
validation samples. Validity statements
(e.g., high standing in scores on both
should not be based on the original
Variables 2 and 5) is an indicator of
sample. Essential
success, it is necessary to show that the
EIO.1. If the user recommends proportion of successful persons in the
certain regression weights for com- group so identified is higher than would
bining scores on a test or for combining be expected from the regression of
734 ApPENDIXD
empirical evidence support the pro- constructs other than those proposed by
posed interpretation. Ordinarily, how- the author account for variance in
ever, the test author will have a more scores on the test. Very Desirable
elaborate conception. He may wish to [Comment: Although it is unrea-
rule out such originality as derives only sonable to require a test author to anti-
from a large and varied store of infor-
mation. He may propose explicitly to cipate or to include every counterinter-
identify the creative person as one who pretation in a test manual, he ought to
produces numerous ideas, whether of present data relevant to those counter-
high or low quality. He may propose to hypotheses most likely to account for
distinguish the ability to criticize ideas variance in the test scores.]
from the ability to be "creative." He
may go on to hypothesize that the E13.2.1. The manual for any
person who shows originality in iden- specialized test or inventory used in
tifying or describing pictures will also educational selection and guidance
have unconventional preferences in should report the correlation of scores
food and clothing. All such charac- derived from it with well-established
terizations or hypotheses are part of the measures of verbal and quantitative
author's concept of "what the test mea- ability in an appropriately represen-
sures" and are needed in designing and tative popu!ation. Very Desirable
in drawing conclusions from empirical
investigations of the psychological [Comment: Verbal and quantitative
interpretation of the construct. ] abilities are specified here because their
importance in educational performance
E13.1. The manual should indicate is recognized. because they often
the extent to which the proposed account for much of total test variance.
interpretation has been substantiated and because numerous tests of these
and should summarize investigations of abilities are already available. To be of
the hypotheses derived from the theory. practical value. a new test designed to
Essential measure other constructs <e.g .• spatial
abilities) must not closely duplicate the
measurement of verbal and quantitative
E13.1.1. Each study investigating a ability.)
theoretical inference regarding the test
should be summarized in a way that E13.2.2. If a test has been included
covers both the operational procedures in factorial studies that indicate the
of the study and the implications of the proportion of the test variance
results for the theory. Very Desirable attributable to widely known reference
factors. such information should be
E13.1.2. The manual should report presented in the manual. Desirable
correlations between the test and other E13.2.3. For inventories such as
relevant tests for which interpretations personality. interest. or attitude
are relatively clear. Very Desirable measures. evidence should be presented
of the extent to which scores are
E13.2. The manual should report susceptible to an attempt by the
evidence about the extent to which examinee to present a socially desirable.
STANDARDS FOR EDUCATIONAL & PSYCHOLOGICAL TESTS 737
include the effects of item sampling and clear that d(f.t'erent methods of
response variation over time as sources estimating reliability take account of
of variance. we may use two sets of different sources of error. Thus. from
items developed or selected according one testing to the other. the result is
to the same specifications. These are affected not only by random response
called parallel forms of the test. variability and changes in subjects over
If the effect of content sampling time but also by differences in
alone is sought without the effects of administration (especially if different
memory or response variability over persons administer the test on the two
time. or if it is not practical to occasions). Reliability coefficients
administer two parallel forms with based on a single administration of a
separate time limits. reliability can be test exclude response variability over
estimated from a single administration time; these effects on scores do not
of an unspeeded test. The test may be appear as errors of measurement.
divided into two sets of items of equal. Hence. "reliability coefficient" is a
or approximately equal. length that are generic term. It can be based on various
judged by competent authorities to types of evidence; each type of evidence
sample as nearly as possible the same suggests a different meaning. It is
functions. Any items based on the same essential that any method used to
source of data (such as a reading estimate reliability be clearly described.
passage) must be assigned to the same The estimation of clearly labeled
set. Then the correlation between scores components of score variance is the
on the two parallel halves is a matched- most informative outcome of a
half coefficient from which an estimate reliability study. both for the test
of the parallel-forms reliability developer wishing to improve the
coefficient for the total test may be reliability of his instrument and for the
obtained by a procedure that does not user desiring to interpret test scores
assume that the numbers of items or the with maximum understanding. The
variances of the two sets are exactly analysis of score variance calls for the
equal. use of an appropriate experimental
Estimates of reliability from a single design. There are many different
administration may also be obtained by multivariate designs that can be used in
analysis-of-variance procedures. Such reliability studies; the choice of design
estimates will be spuriously high if the for studying a particular test is
test is speeded or if the items are not determined by its intended inter-
independent of each other. On the other pretation and by practical limitations.
hand. for unspeeded tests. such It is recommended that test authors
estimates will tend to be lower than describe the meanings of any
matched-half coefficients because they coefficients they report as accurately
constitute. given certain assumptions. and precisely as possible. It is
the mean of coefficients obtained by informative to say. for example. "This
correlating scores on all possible pairs coefficient indicates the stability of
of halves ofthe test. measurement of equivalent scores
From the preceding discussion. it is based on parallel forms of the test
STANDARDS FOR EDUCATIONAL & PSYCHOLOGICAL TESTS 739
and for girls. The manual reports the described, with references to their
reliability coefficients for each sex in development. Essential
each grade.] [Comment: Test authors and
F2.3.1. At least one estimate of the publishers should avoid unconventional
standard error of measurement should statistics unless conventional statistics
be provided in the manual for every are inappropriate. If unusual statistical
group for which reliability data are analyses are presented, explanations
given. Essential should minimize the likelihood of
misinterpretation.]
[Comment: When it is specifically
recommended that scores be trans-
formed to a particular metric, the stan- Comparability o.lForms
dard errors should be presented in that
F4. H two or more forms of a test
metric.]
are published for use with the same
F2.3.2. The test manual should examinees, information on means,
report the standard errors of mea- variances, and characteristics of items
surement at different score levels. in the forms should be reported in the
Desirable test manual along with the coefficients
[Comment: The manual for one test of correlation among their scores. H
of college aptitude reports standard necessary evidence is not provided, the
errors of measurement for three score test manuaI should warn the reader
levels: the mean, one standard against assuming equivalence of
deviation above the mean, and one scores. Essential
standard deviation below the mean. [Comment: Information to be
Since more important changes in the examined would include a summary of
standard error of measurement are item statistics for each form, such as a
associated with extreme scores, it might frequency distribution of item
be better to use more widely separated difficulties and of indices of item
score levels if the number of cases discrimination. Content analyses of
available justifies this action. each of the forms should be presented.
Thus, both frequency distributions of
F2.4. Item statistics (such as
item statistics and a tabulation of items
difficulty or discrimination indices, etc.)
by categories of subject-matter content
should be presented in at least
and of behavioral or instructional
summary form in a test manual.
objectives should be furnished.
Desirable
The forms should represent different
F3. Reports of reliability studies samples of items within each category
should ordinarUy be expressed in the of content. Insofar as one's concern is
test manual in terms of variances of for error arising from sampling a
error components, standard erron of content universe, the forms to be
measurement, or product-moment compared should have been developed
reliability coefficients. Unfamiliar from a common universe according to
expressions of data should be clearly an appropriate plan. An artificially
742 APPENDIxD
close similarity between forms will should be described so the reader will
result from item-by-item matching or be able to understand them in relation
by creating a second form merely by to more conventional estimates.]
rephrasing items on a first form. A
reliability coefficient based on forms FS.2. Internal reliability estimates
created in this way will be spuriously should not be obtained for highly
high because it does not properly take speeded tests. Essential
into account sampling error in drawing
items from the universe ofitems.]
F5.3. When a test consists of
separately scored parts or sections, the
Internal Consistency
correlation between the parts or sec-
FS. Evidence of intemal consis· tions should be reported in the test
tency should be reported for any un- manual along with relevant reliability
speeded test. Very Desirable estimates, relevant means, and relevant
standard deviations. Very Desirable
(Comment: Internal consistency is
important if items are viewed as a
sample from a relatively homogeneous FS.3.1. If a test manual reports the
universe, as in a test of addition with correlation between a subtest and a
integers, a test of general high school total score, it should call attention to
vocabulary, or a test presumed to the fact that the coefficient is spuriously
measure introversion. Nevertheless, high because it is based partly on the
estimates of internal consistency should perfect correspondence of identical
not be regarded as a substitute for other errors of measurement in the subtest
measures.] and in the total score. Essential
chosen will help one achieve those what is to be learned about a person,
goals. In choosing or building a test one and why, there will be no clear direction
should be able to articulate such in the counseling relationship.
assumptions and values. As a general One's purposes in developing a
rule, the assumptions take the form of testing program define his criteria, and
at least an implicit hypothesis: "If I the nature of the criteria should suggest
come to a clearer understanding of this to the informed user hypotheses, that is,
individual, in terms ofthe characteristic test variables, that might be associated
or set of characteristics assessed, I will with them. Such hypotheses should be
be able to infer something about his reasonable. There is no clear reason, for
vocational success, or his academic example, to use a mechanical-aptitude
problems, or his prognosis in marriage, test to try to predict performance in
or whatever." English classes. Similarly, it is not easy
The use of a test in a decision context to see what purpose is intended when a
implies a hypothesis of the form that a vocabulary test is adopted for use in the
designated outcome is a function of the selection of rolling-mill employees.
test variable. A test user should be able Some hypotheses are much more
to state clearly the desired outcome, the easily justified than others. Few people
nature of the variables believed to be will quarrel with the suggestion that
related to it, and the probable applicants who type rapidly with few
effectiveness of alternative methods of errors will become preferred employees
assessing those variables. in a stenographic pool. The hypotheses
The purpose of administering a test that those who are likely to work with
should be explicit. In some school greater persistence at a routine,
systems, it has been alleged, tests are manipulative task can be identified by
routinely administered with no purpose scores on a very long but easy
other than an apparent hope that they perceptual speed and accuracy test may
will someday be useful. Such routine require a more detailed explanation of
testing is unwise.] the logic and background data.)
81.1. The test user should 81.2. The test user should consider
formulate goals clearly enough so that the possibility that different hypotheses
he can later evaluate his success in may be appropriate for people from dif-
achieving them and can communicate ferent populations. Essential
that evaluation to other qualified
persons. Very Desirable H2. A test user should consider
[Comment: In a clinical or counseling more than one variable for assessment
situation. there is a continuing and the assessment of any given
relationship with a person who has been variable by more than one method.
tested. If a test user has clear purposes, Essential
later events can provide evidence of [Comment: For most purposes. the
some success in achieving goals or evaluation of a person requires descrip-
information for changing inferences or tion that is both broad and precise; a
procedures. Without a clear idea of single assessment or assessment
STANDARDS FOR EDUCATIONAL & PSYCHOLOGICAL TESTS 751
procedure rarely provides all relevant varying the sources and increasing the
facets of a description. amount of information on which the in-
Decisions about individuals should ferences are made. In addition to tests.
ordinarily be based on assessment of one might consider ratings. references.
more than one dimension; when observations of actual performance. etc.
feasible. all major dimensions related to Of these. a test is probably most valid.
the outcome of the decision should be If the others add to the validity of an
assessed and validated. This is the prin- assessment. they should be
ciple of multivariate prediction; where systematically considered in statistical
individual predictors have some validity prediction; otherwise. they should be
and relatively low intercorrelations. the ignored. Frequently. however. one will
composite is usually more valid than not have enough confidence in test in-
prediction based on a single variable. It terpretations to justify overlooking
is not a,lways possible to conduct the other data. In particular. when using a
empirical validation study (certainly not given test with minorities. one may
in working with problems of individuals question the validity of test inferences
one at a time). but the principle can be for those populations and want to get as
observed. much additional information as
In any case. care shQuld be taken that possible before making decisions.]
assessment procedures focus on im- H2.1. In choosing a method of
portant characteristics; decisions are assessment. a test user should consider
too often based on assessment of only his own degree of experience with it and
those dimensions that can be convenient- also the prior experience of the test
ly measured with known validity. For taker. Essential
example. mental retardation is often
[Comment: Inexperience of the test
defined as both deficiency in tested in-
user can be alleviated by reading. prac-
telligence and poor adaptive behavior.
tice. and training. Warm-up tests or
If both parts of this definition are ac-
other methods of acclimatization are
cepted. then both variables should be
advocated to alleviate the inexperience
considered in deciding whether an in-
dividual is to be classified as a mental of test takers. In addition. attention
should be given to the degree of in-
retardate. even though it is much more
teraction between test user and test
difficult to measure adaptive behavior
taker; there may be special sources of
than to find an acceptable scale for
anxiety in situations where they are of
testing intelligence.
different cultural or ethnic back-
Test users should also consider more
ground.]
than one method of assessment. Even a
test yielding generally valid scores may 82.2. The choice or development of
in an individual case be susceptible to a test or test procedure. or the addition
idiosyncratic errors of interpretation. of a test or test procedure to existing
and a pattern of confirming or assessments. should involve con-
modifying assessments may be useful. sideration of the relationship between
Confidence in inferences drawn from the cost of the choice and the benefit ex-
assessments may be increased by pected. Very Desirable
752 ApPENDIXD
[Comment: Both costs and benefits This standard caBs for a general
may involve broader considerations evaluation of the validity of the
than the specific problem at hand. proposed use of a test. Such an
Although quantification may be dif- evaluation includes evaluation of the
ficult and even unreliable, costs and procedures folIowed in the development
benefits to the individuals tested and to of the test and of the quality and
the broader society should enter into relevance of the research that has been
consideration.) done with it.)
H3. In choosing an existing test, a H4. In general a test user should try
test user should relate its history of to choose or to develop an assessment
research and development to his in- technique in which "tester-effect" is
tended use of the instrument. Essential minimized, or in which reliability of
[Comment: A school system was assessment across testers can be
faced with the necessity of reducing its assured. Essential
faculty. Reductions in force, according [Comment: In general, the less the
to policy, were to be based on teacher influence of the tester on scores, the
competence. However, decisions were in fairer the test. The influence of the
fact based on scores on a test that had tester is obviously greater in an un-
been developed to eval uate the structured interview than in a struc-
educational backgrounds of new tured one, and there may be more tester
teachers-col1ege graduates. Nothing effect in a structured interview than in a
about the test established its validity as structured personal history form. Tester
a measure of classroom effectiveness, effect is most likely to be minimized by
nor was any local research conducted standardized testing. In using tests,
on this point. Its choice was, therefore, some organizations have turned to tape-
inappropriate. recorded instructions in an effort to
In a different situation, a decision minimize further possible tester effect.]
had been made to use a standard
achievement test to evaluate pupil HS. Test scores used for selection or
progress. Upon investigation of the other administrative decisions about an
test's development, it was found in- individual may not be useful for in-
consistent with the curriculum ob- dividual or program evaluation and vice
jectives of that school. Other tests were versa. Desirable
examined and an alternative test was [Comment: The purposes of in-
chosen that more closely matched the stitutional testing and of evaluative
curriculum content. (In some cases, testing are not always compatible.
closely matching curriculum content Whereas the typical evaluative use is in-
may not be advantageous since it tended to help the individual (or
prevents one from knowing the extent program), institutional decisions
to which pupils may be deficient in frequently have the apparent effect of
skills or knowledge not deliberately hurting, even if the decision may have
specified in the local curriculum ob- unseen long-term benefits to the in-
jectives') dividual (such as avoidance of an un-
STANDARDS FOR EDUCATIONAL & PSYCHOLOGICAL TESTS 753
[Comment: This standard refers, for examinees. especially when the tester
example, to the constancy of graphics and the examinee differ in race, sex, or
and of printing. or the accuracy of stop status. A testing situation contains
watches. It also seeks the elimination of elements that are nonrecurring and
bad habits that may creep into ad- unique to the persons tested. Although
ministrative procedures. It applies par- these may have negligible effects on test
ticularly to any testing procedures that reliability, they may include events per-
make use of physical equipment which ceived as denigrating or questioning of
is subject to wear. Such equipment the worth of the individual. A complete
should be regularly examined to assure catalog of such events is not possible or
that its characteristics remain within easily described. In general. however.
acceptable tolerances; for example, a the social amenities of respect,
pegboard should be replaced if holes politeness. and due regard for ex-
become enlarged or beveled through tenuating circumstances are relevant
use.] guides for insuring the dignity of per-
son&. While it m.ay not be demonstrated
12. The test administrator is
that abuse of these principles leads to
responsible for establishing conditions,
poor test performance, such abuse is
consistent with the principle of stan-
not likely to enhance performance.
dardization, that enable each examinee
It is often difficult to maximize the
to do his best. Essential
motivation of the examinees. The at-
[Comment: In a negative sense, the tempt is important; a major source of
goal of this standard is that conditions error may arise when examinees do not
inhibiting maximum performance like or trust the test. tester. or test
should be avoided. The principle can be situation, and therefore make no
followed in part simply by being sure special effort to do well in it.]
that all materials-such as answer
sheets, pencils, and erasers-are on 12.1. Procedures manuals should be
hand and that precautions have been prepared for use in organizations when
taken to avoid distractions. In a more there is repeated testing. Very Desirable
positive sense. the administrator should [Comment: Just as a manual is
be sure that the examinee understands needed for a test. a manual is needed
the tasks involved in taking the test: for a testing program. Changes in per-
what kinds of responses are to be made sonnel or lapses in memory make a
and on what answer sheets. the im- record of procedures developed and
plications for test-taking strategy of followed necessary for standardization.
erasures or multiple marking or Such a manual might indicate ap-
guessing, and how to know whether the propriate circumstances for testing or
test has been completed. for referral for testing, standard
The tester should try to create a sequences of tests, or guides to in-
nonhostile environment; standardized terpretations of test batteries in ad-
procedures are impersonal. but the test dition to instructions for administering
administrator must avoid being either and scoring tests tal en or adapted from
patronizing or unresponsive to the individual test manuals.]
STANDARDS FOR EDUCATIONAL & PSYCHOLOGICAL TESTS 755
13. A test user is responsible for ac· data used in the continuing research
curacy in scoring, checking, coding, or program.]
recording test results. Essential
13.2. When test scoring requires
[Comment: Any agent of the user jUdgment, the test user should deter-
shares this responsibility. The clerk who mine inters corer or intrascorer
scores a test must understand and ac- reliability. Very Desirable
cept the necessity for accuracy. The test
[Comment: When the test user does
user. who mayor may not do the actual
his own scoring, he should make
scoring. nevertheless has the respon-
periodic comparisons of scores he has
sibility to be sure that procedures are
determined against scores on the same
established and followed for verifying
sets of responses determined by other
accuracy. It is unfair to individuals or
scorers or by himself at other times.]
organizations when decisions are based
on avoidable error.] 14. If specific cutting scores are to
be used as a basis for decisions, a test
13.1. When test scoring equipment user should have a rationale,
is used. the test user should insist on justification, or explanation of the cut·
evidence of its accuracy; when feasible. ting scores adopted. Essential
he should make spot checks against [Comment: When a cutting score is
hand scoring or develop some other adopted, the effect is to reduce scoring
system of quality control. Essential to a scale of only two points: pass and
[Comment: The frequency of such fail. The validity of the test scored in
checks will depend on what is known of this way is different at different cutting
the procedures on checking within the scotes and. in general, is different from
scoring service. Commercial scoring the validity found with continuous
services may be queried about their scores.
procedures if they have not already an- The test user should have some
nounced them; if the procedures seem justifiable reason for the adoption of a
well designed. such spot checks may be given cutting score. Many kinds of
needed only infrequently. Some com- arguments might be used. In a content-
puter services, on the other hand, may referenced interpretation of a mastery
be less meticulous, and some hand test, such a score might be determined
scoring may be required in each batch as the obtained score at which one can
of tests scored by machine. One test reject. at a preselected level of prob-
user in a certification program, where ability, the hypothesis that a pre-
machine analysis of answers not only designated confidence interval for that
yields individual scores but also sup- score includes the perfect score on
plies data for analysis prior to revisions, the test. If interpretations are referenced
has adopted the policy of hand scoring against an external criterion, the
as well as machine scoring each test. cutting score might be one where there
This assures the accuracy of every score is a designated probability of achieving
used in individual decisions, and it also a specified level of success (e.g., "We do
assures the accuracy of the computer not admit students who have less than a
756 ApPENDIXD
[Comment: The user of a special ser- isolation>, skill and experience in the
vice has the obligation to be thoroughly use of standard English, interests, or
familiar with the principles on which similar variables which may seem to be
such interpretations are derived, and he related to sex or racial differences in
should have the ability to evaluate a test performance.]
computer-based interpretation of test
performance in light of other evidence J5.1. It is usually better to interpret
he may have. scores with reference to a specified norms
group in terms of percentile ranks or
J5. In norm-referenced interpre-
standard scores than to use terms like
tations, a test user should interpret an
IQ or grade equivalents that may falsely
obtained score with reference to sets of
imply a fully representative or national
norms appropriate for the individual
norms group. Essential
tested and for the intended use. Essen-
tial J5.2. Test users should avoid the
[Comment: The reverse is also a stan- use of terms such as IQ, IQ equivalent,
dard of competent test use: The test or grade equivalent where other terms
user ordinarily should not interpret an provide more meaningful in-
obtained score with reference to a set of terpretations of a score. Essential
norms that is inappropriate for the in- [Comment: Such scores are ob-
dividual tested or for the purposes of jectionable for several reasons. Most
the testing. This is a relatively simple important, they generally involve
standard to state, but it often is difficult spurious projections of growth. They in-
to apply. Contemporary social problems volve an interpretation which is at best
suggest that men and women or mem- awkward. (To illustrate: It is much sim-
bers of different ethnic groups should pler to ask, in interpreting a score,
for some purposes be evaluated in terms "Where does this person stand in
of several norms groups. For other pur- relation to specific norm groups?" than
poses, such as vocational counseling, to ask, "What group is this person's
students should know how they stand performance like the average of?" The
relative to those in or entering a semantic awkwardness of the latter
relevant occupation, regardless of their question illustrates its psychometric
ethnic background. Of course, women awkwardness as well.> They are labels to
or members of minority groups should which the general public attaches many
not be counseled to avoid non- different inappropriate meanings.
traditional occupations (e.g., women in Some of these scores, such as mental
engineering> merely for lack of ap- age or grade equivalent scores, involve
propriate norms. severe technical problems. For exam-
It is by no means certain that sex or ple, serious misinterpretations occur
race is the crucial variable in in- when grade levels are extrapolated
terpreting a given score. It may well be beyond the range for which the test is
that more important variables for dif- designed. Moreover, it should be
ferential norms would be breadth of recognized that the standard error of
cultural exposure (or degree of cultural measurement for some widely used
760 ApPENDlxD
pretation should clearly indicate the do· SUbjectivity can reduce rather than
main to which one can generalize. enhance validity. The intent is to avoid
Essential a mechanical rigidity in using test
scores of imperfect validity. See also
J7. The test user should consider H2.]
alternative interpretations of a given
score. Essential J7.2. A person tested should have
[Comment: In a sense, a test-score in- more than one kind of opportunity to
terpretation implies the hypothesis that qualify for a favorable decision.
the score obtained is a function of the Desirable
trait level "really" possessed. Alter- [Comment: In some situations, a can-
native hypotheses can be suggested. didate might be given the option to
The obtained score might be a function qualify on the basis of characteristics
of anxiety, prior knowledge of the test. other than those measured by the test.
inadequate understanding of the in- If a person with a score so low that his
structions. a general sort of test best prognosis is academic failure.
wiseness, deliberate faking. or any of nevertheless succeeds in college, he may
several other possibilities. The test user have demonstrated qualities necessary
needs to consider more than the obvious for success other than those measured
interpretation and to have the skill and by the test, and the fact might well be
sensitivity necessary to develop alter- considered.
native explanations and to evaluate Again. the standard must be
them.] judiciously applied. In general. the
most valid methods available should
J7.1. Where cutting scores are
guide decisions; the SUbjective use of in-
established as guides for decision. the
formation not validated can reduce
test user should retain some degree of
validity. When compelling information
discretion over their use. Desirable
exists. however, it should not be ignored
[Comment: The point bears in individual cases. It should be noted
repeating that a test user cannot ab- that it would be unethical as well as in-
dicate the responsibility for the decision valid to invoke this principle in the ap-
to use the test. In most circumstances. plication of particular biases of the test
there are alternatives. Despite the fact user.]
that a given test may have a high
predictive validity for a specific func- J7.3. A procedure for reporting test
tion, it may represent a trait which is results should include checks on ac-
not the only path to success in the curacy and make provision for
predicted venture; and its validity for a retesting. Desirable
given individual. tested at a particular [Comment: Errors in procedures and
time and under particular cir- in test scoring occur; procedures should
cumstances, may be in doubt. be available for checking. Retesting is
This standard may not be taken as a one form of checking results. There
license to discriminate; it is to be used should be some limits to a retesting
sparingly in recognition that excessive provision. The number of allowable
762 ApPENDIX 0
763
764 ApPENDIXD
criterion· related intro. to, E, E3, E4, Validity sample, E6, EI2
E4.4, ES.l, EB collection of data. E7. E12
general principles, E, EB.4 cross·validation E1 Off
local studies, ES.2.2 description, E6.2ff. E8.3ff
predictive vs. concurrent, E7.4.2, E7.4.3 interpretation of El.l ff, E1.3, El.3.1
occupational E3.1, E3.1.1 other relevant attributes, E12.1ff
revision ofvalidity claims, E6ff subsamples. El
content, intro. to E, E1.2ff
corrected vs. uncorrected EB.2.1 Variance
proof of, BS for actual and corrected samples, E12.1
psychiatric agreement. E4.4.2. E4.2.3 for scores, E7.4.1, E13.2
report of. in manual, E3.1, ESff, E7.2, E8 for subgroups, E9, ElO.l.l, E13.2.3, E13.i.S
types. intro. to. El in validity studies, E7.4ff
Index
767
768 INDEX
Center for Science in the Public Interest, Committee on Standards for Providers of
552 Psychological Services (COSPOPS).
Certification See American Psychological
licensure contrasted, 287 Association
See also Licensing and certification Compensation neurosis, 393
CHAMPUS. See Civilian Health and Competence (mental)
Medical Plan of the Uniformed civil rights, 373-374
Services (CHAMPUS) right to refuse treatment, 382-383, 385
Child abuse and neglect, 442, 443-444, Competency (professional)
484 ethical standards, 87-88
Children, 349-351, 443-444 legislative process, 604
Christian Science, 381 licensure and certification, 309, 327-329,
Christy v. Salitermann, 461 581-583
Civil commitment self-regulation, 330-331
adults, 344-349 standards, 65-66
bases of, 343 testing standards, 131
competency to stand trial, 358 training and, 50-51
considerations in, 11 Competency to stand trial
deinstitutionalization, 355 basis of, 343
initiation, 347 developmental disabilities law, 448-449
insanity defense, 365, 366 expert testimony, 400-401
least restrictive alternatives, 351-355 legal considerations in, 10
malpractice liability, 481 mental health law, 357-359
mental health law, 341 C<!ncurrent review, 224, 225
minors, 349-351 Confidentiality
public interest, 558 casual attitude toward, 100-101
release from, 367 death of psychologist, 100
rights of committed, 372-373 ethical concerns, 94-101, 106
right to refuse treatment, 384, 388 expert testimony, 399, 400
sexually dangerous persons, 370 health insurance, 254
standards for, 346 malpractice liability, 483-486
treatment, 380 peer review, 231, 234
Civilian Health and Medical Program of privelege contrasted, 96-99. See also
the Uniformed Services Privilege
(CHAMPUS), 231-237, 251-255, recordkeeping and, 52
261,275,279-282 right to refuse treatment, 381
Civil rights, 373-374 test security, 132
Civil Rights Act (1964), 450 third-party access, 99-100
Client regulation, 11 Conflict management, 531-535
Clients Conflict situations, 565-566
retention of, 104-105 Consent. See Informed consent
rights safeguarded, 106-107 Conservatorship. See Guardianship and
Client solicitation. See Advertising conservatorship
Client welfare Content bias, 120
advocacy and, 575 Content domain, 119-120
ethical concerns, 104-105 Content-referenced interpretations, 118
Clinical psychology, 251-252, 255 Continuing education, 7-8
Cobbs v. Grant, 465, 466 licensing, 327 -329
Colleagues See also Education and training
ethical concerns, 101-106 Contracts
referral generation, 276 breach of contract, 486-489
Commission on Accreditation of client retention, 104
Rehabilitation Facilities (CARF), ethical standards, 95-96
56 mental health law, 341, 390-391
Commitment. See Civil commitment "Control" test, 361-362
770 INDEX