array of patients listed above each entering that agency, walking to the reception desk, and asking about getting help there. To what extent do you think each person would actually feel welcomed and get the help they need?
The opening chapters of this book rejected views of ethics as rigid rule following and presented an approach in which professional codes, administrative directives, legislative requirements, and other givens mark the start of a process of creative questioning and critical thinking. We search for the most ethical and positive way to respond to each unique patient with unique needs and resources in a unique context.
We carry on this creative questioning and critical thinking with a sense of humility as fallible human beings, vulnerable to fatigue, discouragement, frustration, anger, fear, and feeling overwhelmed. Our work depends on not just intellectual competence (knowing about and knowing how) but also what might be called emotional competence for therapy (Pope & Brown, 1996).
COMPETENCE AS AN ETHICAL AND LEGAL RESPONSIBILITY
Competence is hard to define. Licensing boards and civil courts sometimes specify defining criteria for areas of practice. More often, they require only that in whatever area of therapy and counseling the clinician is practicing, they should possess demonstrable competence. Demonstrable competence requires clinicians to produce evidence of their abilities. Usually this evidence comes from formal education, professional training, and supervised experience, followed by continuing education.
A competence requirement often appears in ethical, legal, and professional standards. Here are some examples:
Section 1396, of California Title 16 states: “A psychologist shall not function outside his or her particular field or fields of competence as established by his or her education, training and experience.”
Ethical Standard 2.01a of the APA’s “Ethical Principles of Psychologists and Code of Conduct” (2017a) states: “Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.”
The Canadian Code of Ethics for Psychologists (CPA, 2017a) states that “psychologists recognize the need for competence and self-knowledge. They consider incompetent action to be unethical in itself, as it is unlikely to be of benefit and likely to be harmful. They engage only in those activities in which they have competence or for which they are receiving supervision, and they perform their activities as competently as possible” (p. 18).
The American Counseling Association (2014) ACA Code of Ethics states: “Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience” (p. 8). It also states that “multicultural counseling competency is required across all counseling specialties” and that “counselors gain knowledge, personal awareness, sensitivity, dispositions, and skills pertinent to being a culturally competent counselor in working with a diverse client population” (p. 8).
APA’s (2017a) Multicultural Guidelines: An Ecological Approach to Context, Identity, and Intersectionality states: “It is important to note that, for the purposes of the Multicultural Guidelines, cultural competence does not refer to a process that ends simply because the psychologist is deemed competent. Rather, cultural competence incorporates the role of cultural humility whereby cultural competence is considered a lifelong process of reflection and commitment” (Hook & Watkins, 2015; Waters & Asbill, 2013). This current iteration of the Multicultural Guidelines also recognizes the contributions of other culturally competent models of practice such as the American Counseling Association’s (ACA) Multicultural and Social Justice Counseling Competencies: Guidelines for the Counseling Profession (Ratts et al., 2016); the American Psychiatric Association’s Cultural Formulation Interview (American Psychiatric Association, 2013); and the Standards and Indicators for Cultural Competence in Social Work Practice (National Association of Social Workers, 2015, pp. 8–9).
The ethical requirement of competence recognizes that the therapist’s power and influence (see Chapter 5) should not be handled in a careless, ignorant, and thoughtless manner. The complex, hard-to-define nature of therapy tends to cloud why this requirement makes sense. It becomes clearer by analogy to other fields. A physician who is an internist or general practitioner may do excellent work, but would any of us want that physician to perform coronary surgery or neurosurgery on us if they did not have adequate education, training, and supervised experience in these forms of surgery? A skilled professor of linguistics may have a solid grasp of a variety of Indo-European languages and dialects but be completely unable to translate a Swahili text.
COMPETENCE AND CONFLICT
Pulled by patients holding exaggerated beliefs about our abilities and pushed by our own impulse to step in and help, our humility may fail us and we may resist admitting to ourselves and the client that we lack competence for a particular situation. We may need new clients to pay the bills and fear shutting off a valued referral source. Managed care may require us to take the patient. Nevertheless, extensive education, training, and supervised experience in working with adults does not qualify us to work with children; solid competence in providing individual therapy does not qualify us to lead a therapy group; and expertise in working with people who are profoundly depressed does not qualify us to work with people who have developmental disabilities.
At times, complex situations require great care to determine how to respond to a client’s needs while staying within our areas of competence. For example, a counselor may begin working with a client on issues related to depression, an area in which the counselor has had considerable education, training, and supervised experience. Much later the therapeutic journey leads into a problem area—bulimia—for which the counselor has little or no competence.
Alternatively, a client starts meeting with a counselor to deal with problems concentrating at work. Soon, the client says they suffer from agoraphobia. Can the counselor ethically assume that the course on anxieties and phobias that they took 10 years ago in graduate school makes them competent? The counselor must decide whether they have the time, energy, and interest in gaining competence through continuing education, study, or consultation to provide up-to-date treatment for agoraphobia or whether they need to refer the client or find some other way for the client to get competent help for agoraphobia.
Clinicians who work in isolated or small and rural communities often face this dilemma. They take workshops, consult long distance with experts, and come up with creative strategies to make sure that their clients receive competent care. Despite the clear ethical and legal mandates to practice only with competence, some of us suffer lapses. A national survey of psychologists, for example, found that almost one-fourth of the respondents indicated that they had practiced outside their area of competence either rarely or occasionally (Pope et al., 1987).
INTELLECTUAL COMPETENCE: KNOWING ABOUT AND KNOWING HOW
Intellectual competence involves one’s fund of knowledge or “knowing about.” In our graduate training, internships, supervised experience, continuing education, and other contexts, we learn about the research, theories, interventions, and other topics that we need to do our work. We learn to question the information and assess its validity and relevance for different situations and populations. We learn to create and test hypotheses about assessment and interventions. We find ways to keep up with the latest therapy research.
Part of intellectual competence is learning which clinical approaches, strategies, or techniques show
