As noted, there are four ethical standards applicable to all psychologists regardless of setting: competence, informed consent, privacy and confidentiality, and avoiding harm or exploitation [1]. Ethical rules and standards provide a frame of reference for guidance in decision making about the most appropriate action to take in a given situation. As experience and circumstances change, the ethical standards for psychologists evolve from a strict set of rules about behavior and conduct to becoming more aspirational in nature. The practice of being ethical changes to being more involved with thinking through the consequences of actions and more cognizant about the day-to-day impact of ethics on practice.

Psychology has developed ethics and ethical decision making over several decades with multiple revisions to the APA Ethics Code. The APA Ethics Code has attempted to be scientifically based in principles that will allow for decision making and are generalizable to the profession as a whole. More recently, it has focused more on problem areas that serve as the basis of complaints against psychologists to licensing boards.

Following the Civil War, the United States entered into a rapid growth phase. There was corruption in the building of the Transcontinental Railroad and there were Congressional scandals related to the misuse of governmental funds, bribery, and excess charges. In addition to corruption in the government, there was a high crime rate, a high poverty rate, concerns about the use of "greenbacks" (or Confederate money), and limitations in the monetary supply based on reliance on the gold standard. G. Stanley Hall had established Clark University as a research institution and founded the American Journal of Psychology. Psychology as a young field was moving into research, which was controversial, and away from work with healthy individuals and anthropology. The field was expanding to include work with animals, children, sick people, and the new practice of hypnosis [4,5]. Ideas of what was and was not appropriate for the field began to coalesce. After World War II, the APA began to expand and grow quickly. The need for an ethical code and ethical standards came out of the expanding profession and out of situations in which psychologists found themselves without clarity for decision making.

Competence is a fundamental ethical principle in the healthcare professions. Medicine and psychology define competence as, "the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served" [1,10]. To be considered adequately or well qualified to practice psychology (i.e., competent) is a process of evaluation of a specific area. Both the individual psychologist and the profession as a whole strive to determine areas of competent practice and the basis on which to form those evaluations.

The profession has set forth educational standards for doctoral programs in psychology. This involves accreditation of schools and colleges at a regional level and setting forth standards for accreditation by the APA for graduate school. Internships and postdoctoral fellowships may also be accredited by the APA, the Association of Psychology Postdoctoral and Internship Centers, or both.

Competence involves knowing all aspects about the services, treatment, evaluation, and decisions made in an area of expertise being provided. Clinical practice recommendations and evidence-based approaches provide guidelines regarding what constitutes effective practice. The purpose of the guidelines is to limit idiosyncratic, self-serving methodologies that may cause harm to an individual or to the profession.

In emergencies, when psychologists provide services to individuals for whom other mental health services are not available and for which psychologists have not obtained the necessary training, psychologists may provide such services in order to ensure that services are not denied. The services are discontinued as soon as the emergency has ended or appropriate services are available.

When starting a new position, it is important to know exactly what will be required to determine whether or not the psychologist will be competent to perform the task. Positions that are described as "training" or "under supervision" should provide to the psychologist a clear delineation of the supervision, training expectations, methods of evaluation, and feedback or evaluation procedures. In recent years, more focus has been given to models of training and supervision, including competency-based supervision.

In 2007, the Assessment of Competency Benchmarks Workgroup published their document for the APA entitled The Assessment of Competency Benchmarks Workgroup: A Developmental Model for the Defining and Measuring of Competence in Professional Psychology [12]. They created a three-dimensional "Cube Model," with foundational competencies and functional competencies forming the 12 core competencies for clinical practice. These were placed in a developmental model to guide supervisors from practicum training through advanced practice to lifelong learning.

Informed consent in psychology has several aspects. The first part is that psychologists know what it is that they are anticipating in providing services and can provide that information clearly to the client. The second part is that the person receiving services is able to understand and make use of the information the psychologist is providing. The third part is that the person receiving the services has the legal ability to consent to the services to be provided. Fourth, the person receiving the services must have the intellectual and psychological capacity to consent to the services being provided. The fifth part is the client's ability to form rational decisions about the information being provided. Lastly, the documentation of the agreement to provide services and to consent to those services being provided is essential.

(a) When psychologists conduct research or provide assessment, therapy, counseling, or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person or persons except when conducting such activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Code. (See also Standards 8.02, Informed Consent to Research; 9.03, Informed Consent in Assessments; and 10.01, Informed Consent to Therapy.)

(b) For persons who are legally incapable of giving informed consent, psychologists nevertheless (1) provide an appropriate explanation, (2) seek the individual's assent, (3) consider such persons' preferences and best interests, and (4) obtain appropriate permission from a legally authorized person, if such substitute consent is permitted or required by law. When consent by a legally authorized person is not permitted or required by law, psychologists take reasonable steps to protect the individual's rights and welfare.

(c) When psychological services are court ordered or otherwise mandated, psychologists inform the individual of the nature of the anticipated services, including whether the services are court ordered or mandated and any limits of confidentiality, before proceeding.

(d) Psychologists appropriately document written or oral consent, permission, and assent. (See also Standards 8.02, Informed Consent to Research; 9.03, Informed Consent in Assessments; and 10.01, Informed Consent to Therapy.)

It is possible to abdicate or waive the informed consent process. In these cases, the client must demonstrate an understanding of the right to have information about treatment and be involved in decisions about the treatment process. The client then may specifically indicate that he or she wants the psychologist to make those decisions on the client's behalf. This is often referred to as an "opt-out" procedure and involves research with minimal risk, in which full disclosure will be detrimental; emergency process and potentially life-saving techniques are being studied; or a substitute for the consent process is not readily available and failure to provide treatment would result in harm.

Confidentiality concerns information that is gathered by a psychologist. Federal and state laws govern which records must be kept, and the Ethics Code stipulates that psychologists are to keep records [8]. The nature and extent of the records will vary based on the purpose, setting, and context of the psychological services [16]. Records benefit both the client and the psychologist, allowing a delineated treatment plan, notation of services provided, monitoring of treatment, and assistance in legal or ethical proceedings or when transferring care to another provider. Guidelines for record keeping were set forth by the APA and were approved in February 2007. The guidelines expired in 2017. As of that date, users are encouraged to contact the APA Practice Directorate to determine whether the guidelines remain in effect [16]:

Confidentiality is a concern in each of the following cases:

There are basic exceptions to confidentiality based on the ideas of doing no harm and providing a benevolent relationship to the community in which a psychologist works. Breaches of confidentiality can produce feelings of betrayal and loss of trust in the therapeutic relationship, and such breaches are made only when it is necessary to do so. One exception to confidentiality is to ensure the safety of the person in treatment or any others. If a person divulges intent to harm or kill him- or herself, then it is the duty of the therapist to assist the patient in maintaining his or her safety. This may include breaching confidentiality to law enforcement, family members, hospital personnel, or treating physicians to ensure that no harm comes to the patient. The APA Ethics Code notes, "Psychologists [should] take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm where it is foreseeable and unavoidable" [8].

Under some circumstances, the holder of privilege to release information is not the patient. This is true when the court has ordered an evaluation and the psychologist is court-appointed, when there are legal proceedings to establish sanity or competency, or when the patient has put his or her mental state at issue in a legal proceeding, such as a malpractice claim, a personal injury claim, or a claim for disability benefits due to a mental disorder. Confidentiality is also voided in cases when a patient sues a therapist for breach of duty or a therapist sues a patient for inappropriate behavior.

The use of technology in psychotherapy impacts confidentiality, privacy, privilege, and even how therapy is conducted. It is now common for therapists to have websites, and the use of search engines enables patients and therapists alike to obtain information that previously was not generally available. Some psychologists have embraced the use of technology, setting up telehealth services and offering treatment via video-conferencing, e-mail, and cell phone, while others have incorporated policy statements on the use of Google, Facebook, and Twitter into their practices [29,30]. While the APA Ethics Code is not continually revised to reflect the rapid advances in technology, supplementary publications (e.g., the Guidelines for the Optimal Use of Social Media in Professional Psychological Practice and the Guidelines for the Practice of Telepsychology) are informed by the Ethics Code and legal regulatory requirements and are available to assist providers in maintaining compliance with HIPAA laws [30,32,35]. While point-to-point contacts with computers may be secure, remote access and the use of video conferencing (e.g., Skype) and other Internet-based phone services or the utilization of cloud computing, email, and social networking sites may limit privacy and confidentiality. In all of these instances, patients must be advised that others may have access to their information. Well-understood protocols for all individuals using technological systems (e.g., psychologists, billing agencies, patients, support staff) should be in place to limit the risk of others obtaining data they are not entitled to. The use of laptop and tablet computers increases the risk of data being stolen or lost; password encryption is required. Up-to-date virus protection is also required to limit dissemination of information or being immobilized. Clients should be informed of the risks of the use of technology prior to their use in therapy [30,32,35].

Harm may or may not be intentional; it may result from incompetence or lack of awareness. However, exploitation is more deliberate and consists of using someone unfairly or benefiting unjustly from someone. Some harmful relationships may not be exploitative, while other relationships are both harmful and exploitative. Incompetence that results in harm has been addressed earlier in this course. Harm from a lack of awareness may arise when the psychologist has issues that impact his or her mental or physical well-being, a lack of insight into his or her own perceptions and biases, and/or a lack of understanding of the foreseeable consequences of a course of action. Harmful and exploitative relationships generally involve boundary violations and role-confusion, such as sexual involvement with a patient, research subject, supervisee, or student. The involvement of third parties as payors, grant funders, or other types of relationships that include remuneration may create a conflict of interest situation. Conflicts of interest may also arise when the psychologist is acting in multiple roles, such as in providing an objective assessment in a forensic case as well as being a patient advocate in treatment.

In many situations, psychologists need a framework for determining the most ethical course of action. The theoretical orientation of the psychologist may provide some guidance, such as in how much to disclose about one's personal life or whether or not nonsexual touch is permitted. For others, religious views dictate overriding concepts of morality and values and guide ethical decision making. Models have been proposed to assist with ethical decision making in forensic cases, general ethical decisions, and health care [33,36]. Nagy documents seven different models for ethical decision making [1,37,38,39,40,41,42,43,44]:

When psychologists violate ethical standards or state or federal laws, people who believe they were harmed can file a complaint with the state licensing authority or can institute a lawsuit against the psychologist. If the psychologist is a member of the APA, a grievance can be filed through the APA Ethics Office. The psychologist has the option to withdraw membership when contacted to begin the preliminary investigation. The process of investigation is lengthy and can take more than a year. The psychologist may seek legal advice from an attorney in responding to the investigation. The Ethics Office ultimately will make a decision whether or not to impose sanctions on the psychologist. These sanctions can range from: