Differing view/Should psychologists

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Should psychologists refuse care for clients they find morally objectionable?{Below}

Differing views on PSYPACT

Paul C. Berman, Ph.D.

Hamid Mirsalimi, Ph.D.

Maryland enacted PSYPACT during the 2021 legislative session. The Maryland Psychological Association (MPA) actively advocated for the bill despite significant opposition from our licensing board. The bill unanimously passed the Maryland House of Delegates and Senate and was signed into law by Governor Larry Hogan. It became effect on May 18, 2021.

MPA mounted a full-court press to advance the legislation. We are a small state with Delaware, Pennsylvania, Virginia, West Virginia, and the District of Columbia as neighbors. Many psychologists who practice in our most populous county, Montgomery County, see patients who live in Maryland, Washington DC, and/or Virginia. When COVID forced the shutdown in the spring of 2020, and we all moved to telehealth, most psychologists were able to continue to work with their patients across state lines because of the permissive changes to state licensing laws because of the Public Health Emergency.

Paul C. Berman, Ph.D., Professional Affairs Officer for the MPA, said, "The association took advantage of the COVID-related favorable telehealth environment and introduced PSYPACT in our legislature in January 2021." PSYPACT’s educational requirements are the same as Maryland’s requirements for licensure (a doctoral degree in psychology from an APA or CPA accredited program or from a program designated by the National Register of Health Service Providers), so we were able to allay concerns expressed by some legislators that PSYPACT would allow psychologists from states with less stringent licensure requirements to practice into Maryland via PSYPACT.

PSYPACT is far from perfect, and we have become aware of some unexpected problems during the last two years, Berman said. For example, some of our most experienced psychologists in Maryland cannot be credentialed by PSYPACT because they did not graduate from an APA-accredited program. The PSYPACT Commission, however, did make a change in its rules to allow PSYPACT accreditation for psychologists who possess a doctoral degree in psychology from a regionally accredited institution (as opposed to an APA or CPA-accredited institution) and have been continuously licensed since January 1, 1985.

The PSYPACT Commission also clarified the sometimes confusing rules regarding which state laws prevail (home state or receiving/distant state) and in what circumstances. The Commission clarified that a psychologist practicing via PSYPACT in a distant/receiving state must follow that state’s scope of practice and other laws to protect the health and safety of the distant/receiving state’s citizens, including abuse reporting, informed consent, duty to warn, and involuntary commitment and/or involuntary treatment.

Hamid Mirsalimi, Ph.D., a Georgia psychologist, says that PSYPACT-credentialed practitioners must attest that they will familiarize themselves with the rules and regulations of the state in which their patient resides. State boards have published such laws and regulations for the practice of psychology in their states. Such documents are readily available online. If an unusual circumstance arises, the psychologist can refer to those laws and regulations and determine the legal course of action according to the laws and regulations of that state. The psychologist can also contact an attorney in the state in which the patient resides (e.g., Iowa) to clarify any questions or concerns they may have.

He continued, "Psychologists have a duty to protect their patients as well as the public."

Whether the patient resides in the psychologist’s home state (where they are licensed)

or in a PsyPact state, the psychologist is not relieved from that duty. The IPA would not

be correct in assuming that an offending psychologist (one who does not protect their

patient or the public from harm) cannot be sanctioned because they are not licensed in

Iowa. If a psychologist does not abide by the legal and ethical expectations of the

profession, any state licensing authority can send a complaint to the psychologist’s

home state and ask the home state to sanction that psychologist for their unethical

conduct. In addition, if a psychologist is found to have acted unethically, they will not

be able to continue their participation in PSYPACT when they attempt to renew their annual PSYPACT credentialing. PSYPACT-credentialed psychologists are aware of those expectations and know that they can be sanctioned by both the licensing board of their home state and by PSYPACT if they don’t act legally, ethically, and according to professional expectations.

Regarding the assertion that the Iowa Board of Psychology makes it very easy to get licensed in Iowa, Mirsalimi said one needs to consider that it is not feasible for most psychologists to apply for licensure and pay a new license for the sake of just one patient who might be traveling to Iowa for a short period of time. Consider what would happen if a psychologist were expected to do the same for other states as well. How many licenses is the psychologist expected to get, and how many license fees are we expected to pay? It is just not feasible for psychologists, and they are not likely to do so.

In 2022, Berman Said, 261 Maryland licensed psychologists were authorized by PSYPACT to practice via telepsychology, and 17 were authorized to temporarily practice in person. The PSYPACT Commission projected that approximately 1% of the psychologists in each state would participate with PSYPACT. The actual participation rate of almost 8% of Maryland’s licensed psychologists suggests that PSYPACT is meeting an important need for Maryland’s psychologists and their clients/patients.

Aside from concerns for college students, consider the needs of other groups as well. Mirsalimi said that he is a member of the Iranian-American community. There are very few Iranian-American psychologists in the United States. I imagine the situation is also the same for other immigrant, ethnic, racial, gender, and other minority groups as well, many of whom would prefer to receive therapy from a psychologist who shares their background and first language.

Consider the limited number of psychologists who do not accept any insurance and others who do not accept certain types of health insurance. Another factor is life stressors associated with being immigrants, ethnic, racial, gender, and other kinds of minorities, and the fact that some immigrants are low in English proficiency. We realize that for such communities, the limited supply of psychologists per state is far more dire than one might think. I know of Iranian Americans who do telepsychology with a psychologist in Iran because of such a shortage in the United States.

While PsyPact cannot resolve all such limited access issues, it can help tremendously Mirsalimi said.

Editor's note: This article was written by Paul C. Berman, Ph.D., from the Maryland Psychological Association, and Hamid Mirsalimi, Ph.D., from the Georgia Psychological Association. It was compiled from two articles by the staff of The National Psychologist.

Opinions expressed in this article are the individuals and do not necessarily reflect those of their affiliations.

Paul C. Berman, Ph.D. is in practice in Towson, Maryland and he is the Professional Affairs Officer for the Maryland Psychological Association. His email address is pcberman@bermankilleen.com

Hamid Marsalimi, Ph.D., is an adjunct professor at Emory University and current president of the American Academy of Couple and Family Psychology (AACFP). His email address is hamid@drmirsalimi.com

Should psychologists refuse care for clients they find morally objectionable?

By Thomas G. Plante, PhD, ABPP

SHOULD PSYCHOLOGISTS RUFUSE ON MORALLY OBJECTIONABLE

In recent years, much attention has been focused on mental health professionals and graduate students in training who refuse to treat certain clients due to conflicts associated with the values and religious beliefs of the therapist or student and their client’s behavior. Most notably, these conflicts often occur when a therapist or graduate student in training refuses to accept training or take on clients who identify as being from the LGBTQI+ community. Laws have been passed in several states (e.g., Arizona, Tennessee) that allow therapists and students to refuse to work with clients that they find objectionable on religious or moral grounds. These “conscience clauses” have been around since the United States Civil War, but they have more recently been applied to psychologists and other mental health professionals during the past decade or so.

All psychotherapy clients have the right to receive evidence-based best practices in clinical care from competent mental health professionals who do their best to put aside their personal feelings, beliefs, and practices for the benefit of their patients. We call our work the “helping profession” for a reason. We seek to serve and help those who are in need of their psychological, behavioral, and relationship challenges, regardless of who they are or what they do. In a nutshell, our professional work, such as psychotherapy, is not about us as providers but about helping our clients.

Regardless of the “conscience clause” laws in the states where we practice our craft, the APA Code of Ethics has much to say about these issues. Let me review a few of the most salient sections of the APA’s Code of Ethics that address these conflicts.

First, Principle D of the Code (Justice) states that “Psychologists recognize that fairness and justice entitle all persons to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures, and services being conducted by psychologists. Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to or condone unjust practices.” Therefore, psychologists must be sure that all clients have access to quality care and that we must keep our biases in check when working with others.

Second, Principle E of the Code (Respect for People's Rights and Dignity) states,

“Psychologists respect the dignity and worth of all people, and the rights of individuals

to privacy, confidentiality, and self-determination… Psychologists are aware of and

respect cultural, individual, and role differences, including those based on age, gender,

gender identity, race, ethnicity, culture, national origin, religion, sexual orientation,

disability, language, and socioeconomic status, and consider these factors when

working with members of such groups. Psychologists try to eliminate the effect on

their work of biases based on those factors, and they do not knowingly participate

in or condone activities of others based upon such prejudices.” Thus, psychologists

must respect the dignity of all and respect diversity in all forms, including sexual

orientation and gender identity. They must keep their own prejudices in check as well.

Finally, Section 3.01 of the Code of Ethics (Unfair Discrimination) states, “In their work-related activities, psychologists do not engage in unfair discrimination based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, socioeconomic status, or any basis proscribed by law.” Once again, the Code demands that we avoid unfair discrimination based on diversity, including diversity associated with sexual orientation and gender identity.

All of us who provide professional psychological services to the public have our own unique areas of competence and expertise. We do not have the competence to treat everyone who requests our services regardless of their diagnoses or treatment goals. However, this reality does not excuse us from putting the best interests of our clients, or potential clients, aside due to our personal beliefs, practices, values, and preferences. We must always be mindful of our own potential biases, implicit or not, and avoid imposing our personal views on others.

Certainly, not everyone can put their own interests and biases aside while conducting their professional work. Not everyone has enough insight and self-awareness to thoughtfully care for the needs of others, including those whom we may not like or agree with when it comes to lifestyle, identity, and behaviors. We must always remember that our personal views and perspectives do not take precedence over the needs of those we are asked to serve.

However, if we are conflicted between our own personal views and the needs of our clients, we should seek out professional consultation with a skilled colleague to find a resolution that is in the best interest and respectful of our clients, keeping our ethical principles in mind.

While reflecting on this important issue, I’m reminded of the saying, “If you can’t take the heat, then stay out of the kitchen.” Being a professional psychologist requires us to work with diverse clientele of whom some will feel more comfortable than others. We must always provide quality care to all of them at all times. To do otherwise is unethical and professionally questionable.

References available from author

Thomas G. Plante is the Augustin Cardinal Bea, SJ University Professor, Professor of Psychology and, by courtesy, Religious Studies at Santa Clara University, and an Adjunct Clinical Professor of Psychiatry and Behavioral Sciences at Stanford University School of Medicine. He is also the editor-in-chief of the APA journal, Spirituality in Clinical Practice. He can be reached at tplante@scu.edu.