Ethical Considerations for Military Clinical Psychologists

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MILITARY PSYCHOLOGY, 20, 7–20, 2008 Copyright © Taylor & Francis Group, LLC ISSN: 0899-5606 print / 1532-7876 online DOI: 10.1080/08995600701753128

Ethical Considerations for Military Clinical Psychologists: A Review of Selected Literature Mathew McCauley 48th Fighter Wing, United States Air Force, RAF Lakenheath, United Kingdom

Jamie Hacker Hughes Clinical Psychology Service, Defence Medical Services, Ministry of Defence, London, United Kingdom

Helen Liebling-Kalifani Faculty of Health and Life Sciences, Coventry University, Coventry, United Kingdom

Clinical psychology has had a long and distinguished association with the practice of mental health care in the military. Although clinical psychologists are trained both to adopt and implement ethical values and principles, the military environment holds many contextual and tangible differences from other clinical settings. This literature review investigates the ethical considerations arising from the practice of clinical psychology within the military. Several ethical issues were identified and confidentiality and boundary violations emerged as the two main areas of ethical concern. The findings may have implications for the overall practice of mental health care in the military, the contributions that clinical psychologists make to such services, the role of clinical psychology in times of international conflict, the training of clinical psy-

Correspondence should be addressed to: Mathew McCauley, Chartered Clinical Psychologist, Sterling Medical Contractor, 48th MDOS/SGOH, 48th Fighter Wing, United States Air Force, RAF Lakenheath, IP279PN, United Kingdom. E-mail: [email protected] The views expressed in this article are those of the authors and do not reflect those of the Sterling Medical Corporation, the United States Air Force, the Department of Defense, the Royal Air Force, the Ministry of Defence, or Coventry University.

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chologists for military service, and avenues for future research on the practices of military mental health professionals.

Clinical psychologists work in a diverse range of settings and with various patient populations. Each environment has the potential to bring with it a set of professional, personal and ethical challenges. Although clinical psychologists are trained to understand and apply ethical practice within their work, organizational and clinical obligations can occasionally conflict. This can be seen with the emergence of new areas of practice for clinical psychologists (e.g., Folen, Kellar, James, Porter, & Peterson, 1998; Gutierrez & Silk, 1998). However, it is also found in highly specific occupational environments such as in the military (e.g., Jeffrey, Rankin, & Jeffrey, 1992; Johnson, Ralph, & Johnson, 2005). The purpose of this article is to clarify and highlight the ethical considerations faced by uniformed clinical psychologists in the military (UCPs). This has been approached through a review of selected literature. For consistency and clarity, only publications specifically referring to the practice of clinical psychology in the military have been included in this article. As a result, while related topics were reviewed to provide a context to the focus of the article, publications concerning research, academic, occupational, and industrial/organizational psychology and psychiatry in the military were not overtly included. The search terms applied were clinical psychology, ethics, military psychology, and military mental health. Various databases were used, including Psych Lit, Psych Info, Med Line, Cochrane, and reference lists from published literature. This article begins with a discussion of the historical context of military mental health and an introduction to the field of military clinical psychology in particular. This is followed by an overview of the nature of ethical practice in clinical psychology. Common ethical dilemmas encountered by UCPs are then examined. Finally, suggestions for possible future research in this area are presented and ways in which the existing findings might be used in clinical practice are highlighted.

MILITARY MENTAL HEALTH Many studies have been carried out into the psychological effects of war on military personnel (e.g., Hacker Hughes et al., 2005; Hoge et al., 2004; Ikin et al., 2004; Turner et al., 2005). The existing literature suggests that mental health problems have been identified in veterans of recent conflicts. For example, O’Brien and Hughes (1991) surveyed British Falkland War veterans 5 years after the conflict and found that 50% of participants had some symptoms of posttraumatic stress disorder (PTSD), with 22% meeting full criteria for the disorder. Research into the

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current war in Iraq suggests that British reserve troops deployed to the conflict in 2003 were twice as likely to develop symptoms indicative of general psychological problems (e.g., depression, anxiety) than reservists who were not deployed to Iraq. Furthermore, they were six times as likely to develop symptoms of PTSD (Hotopf et al., 2006). The link between military service and the development of psychopathology has particularly been reviewed and examined during the 20th century (e.g., Shephard, 2002). In recent years, greater appreciation has been achieved regarding the specific psychological issues arising during military service. In particular, research suggests that mood and adjustment disorders, rather than PTSD, are increasingly becoming identified as the main forms of psychological disorders within military populations (e.g., Turner et al., 2005). Armed forces across the world have addressed the mental health needs of their service personnel by applying the expertise of a variety of mental health professionals. For example, psychiatrists, mental health nurses, social workers, and mental health technicians have been involved in providing services. Psychologists have also had a long history of involvement within the military. Indeed, for nearly 100 years, the British have used many noted military clinicians with a background in psychology, including Charles Myers, William Brown, and William Rivers, all of whom made significant and highly notable contributions to our understanding of the effects of war on soldiers during World War I (Shephard, 2002). Psychologists of other specialties have also regularly participated in military research and personnel support. For example, occupational and industrial/organizational psychologists have been involved in screening and assessing pilots and developing organizational systems to maximize human performance. Since its emergence as a distinct discipline in the mid-20th century, clinical psychology has had a substantial impact on the direction of military mental health care (Sammons, 2005). Clinical psychology is now a significant component of health care within many international armed forces. Indeed, UCPs are the main providers of mental health care for the Australian military. Furthermore, UCPs are involved in the delivery of mental health care services in the military of nations including The Netherlands, Belgium, Luxembourg, and Spain. Canada, Greece, Italy, and Ireland have recently incorporated UCPs into their military (Adler & Bartone, 1999; Gamble, 2006; Hacker Hughes, 2004a, 2004b, 2004c). Finally, the United States relies heavily on UCPs and retains approximately 400 psychologists on active duty for clinical practice (Staal & King, 2000). As a result, clinical psychology has established itself as a significant force for the production and delivery of psychological science and clinical services with military populations (Page, 1996; Sammons, 2005). Currently, while the United Kingdom’s military mainly relies on psychiatrists and mental health nurses to provide mental health care services, it also employs a cadre of civilian clinical psychologists who deliver an array of psychological services across the Royal Navy, British Army, and Royal Air Force.

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ETHICS AND CLINICAL PSYCHOLOGY Adherence to an ethical code of practice forms the cornerstone of professional psychology. Ethical codes are devised and enforced by the professional bodies overseeing the practice of psychology and each country has its own governing body for this purpose. Furthermore, national legal systems influence ethical practice. As a result, ethical and legal codes differ between nations, and psychologists are responsible for understanding and complying with the ethical standards within their jurisdiction. Ethical practice is a particularly important issue for clinical psychologists because they are responsible for planning and delivering interventions that can significantly impact the lives of others. For example, in providing treatments, they are entrusted with the psychological and, at times, physical (e.g., behavioral medicine, psychologist-prescribing) integrity of those seeking help. In consultation and teaching, clinical psychologists are responsible for delivering objective, up-to-date, and unbiased information. In their role as researchers, clinical psychologists design and carry out research, protecting the rights of participants and carefully interpreting and presenting the results so as to contribute to the scientific understanding of human behavior (Plante, 1999). Clinical psychologists, therefore, must follow ethical guidelines with regard to issues such as professional competence, confidentiality, respecting the rights and dignity of others, client consent, interpersonal boundaries, and maintaining high standards of personal conduct (e.g., American Psychological Association [APA], 2002; British Psychological Society [BPS], 2000, 2001). However, clinical psychologists are faced with ethical challenges on a regular basis. Problems can arise as a result of the contexts in which clinical psychologists work, such as organizational, interprofessional, or intrapersonal complications. As clinical psychologists work with other health care professionals and in various institutions, pressures can develop between the desire to balance patient care and other occupational and personal demands. UCPs are not immune from such difficulties.

ETHICS AND UNIFORMED CLINICAL PSYCHOLOGISTS Few clinical practice settings can compare to the challenges faced in the armed forces (Mangelsdorff, 1989). UCPs and other military mental health professionals (MMHPs) regularly work and live in close proximity with their potential patient population. They often oversee or engage in nonclinical duties with past, current, and/or future patients. While some similarities might be drawn on these points to the context of practicing clinical psychology in rural locations (e.g., Stockman, 1990) and forensic settings (e.g., Weinberger & Sreenivasan, 1994), the occupational context of the UCP has a number of unique factors that distinguish it from

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other clinical environments. For example, UCPs are members of hierarchical organizations in which they normally assume senior positions. They are almost always first and foremost commissioned military officers. As a result, they hold significant responsibilities for participation in, and maintenance of, military boundaries and discipline. The primary commitments of UCPs are to work toward the success of the particular mission and to maintain fitness for role. While this mainly involves the practice of clinical psychology, they are also answerable to the chain of command and, if required or ordered, UCPs must be ready to engage in other military activities, including combat (Jeffrey et al., 1992). Indeed, it is hard to imagine other environments that present similar challenges for clinical psychologists (Staal & King, 2000). This article has identified a variety of publications concerning the ethical issues encountered by UCPs. In one case, an empirical method of investigation was applied to quantify the ethical difficulties faced by UCPs. Orme and Doerman (2001) conducted a survey of UCPs in the United States Air Force (USAF). Two hundred sixty-three participants were asked to describe incidents that they or a colleague encountered during the previous 24 months that they found ethically challenging or troubling. With a 20% response rate, the study identified a set of ethically concerning areas of practice encountered by UCPs. The results were categorized and the five most common areas for ethical concern consisted of conflicts between ethical and organizational demands; maintaining confidentiality; multiple relationships; disclosures; and avoiding harm. This current review has also identified further publications that have applied alternative investigative methods. Some address the topic of ethical issues for UCPs by presenting case examples or clinical vignettes, whereas others cover the subject through opinion-based papers. Overwhelmingly, the issues of multiple relationships and confidentiality have constantly emerged as particularly concerning areas of ethical practice for UCPs. These two areas of professional practice will, therefore, now be considered separately. Examples from the published literature will be used to illustrate their significance.

MULTIPLE RELATIONSHIPS UCPs work in one of the most complex relationship settings for clinical psychologists. As discussed above, the balance that UCPs must strike between their commitment and loyalty to their individual clients and their ultimate client, the military, poses a serious dilemma (Zur & Gonzalez, 2002). The specific nature of this challenge exists regularly for UCPs in the contact they have with other service members. Johnson et al. (2005) have considered this unique area with the use of vignettes and explored the multiple roles held by UCPs when embedded on aircraft carriers. In this context, their use of the term embedded refers to the UCP being de-

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ployed as part of a unit. The UCP’s primary goal is the unit’s mission, which may not always be in the best interest of the patient. As a result, the establishment and maintenance of clear and professional boundaries between clinical psychologists and their patients is an important area of professional practice. Such considerations may arise when the treating clinical psychologist holds more than one role with a particular patient, either directly or indirectly. Furthermore, abuse of power by the clinical psychologist over the patient can arise from such boundary violations (e.g., APA, 2002; BPS, 2001). Johnson et al. (2005) identified several distinctive features of practicing in an embedded environment. In addition to the blended roles of officer and clinical psychologist, the UCP cannot necessarily choose to enter or exit clinical relationships (see also Moore & Reger, 2006). The UCP will have unavoidable close personal contact with patients. Also, services may have to be provided to colleagues, close friends, and/or supervisors. It is highly likely that the UCP will have profound power over many aspects of a patient’s life. Furthermore, he cannot easily predict sudden shifts in clinical and administrative duties with patients. Aircraft carriers deploy for months at a time and carry several thousand personnel. One UCP is usually the main provider of mental health care for the ship and its battle group. Working conditions may be sparse and restricted and treatment environments may have to be improvised. As a result, UCPs can struggle to maintain clear and professional boundaries. Johnson et al. (2005) presented the following vignettes in order to illustrate the experiences of UCPs who serve in such environments. Case 1: At morning quarters, I learn that my social security number has been randomly selected for the day’s “operation golden flow,” the term given to the command’s random urine collection and drug-testing program. No one enjoys being subjected to this rather demeaning process in which the master-at-arms personnel march you into a bathroom, closely observe while you urinate into a cup and then march you back to the security office carrying your sample in plain view. When I report to the master-at-arms office, it is crowded with male observers, requiring them to radio for a female observer. I hear the name and cringe as the voice of one of my long-term patients announces she’ll be right down. As I wait, I frantically try to think of some way to get out of this. I can’t think fast enough. My patient walks through the door and gasps. She is visibly embarrassed to be in this position and says aloud “Oh no, it’s you.” We both do our best to make small talk and maintain some professional demeanour as I disrobe and urinate in front of her. Fortunately, we are able to look back and laugh at the incident during later sessions. (p. 77) Case 2: While I was completing paperwork in my office, a colleague—a chaplain with whom I’ve had many social and professional dealings—stops to say hello. He makes small talk for a while, looks at some of my pictures, then sits down and quickly becomes tearful. I realize this is no longer a social call, and I quickly shift my demeanour from joking banter to that of a professional psychologist. More challenging

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is the need to then resume my normal social and professional relationship with this person after the session is over. (p. 77)

Clinical psychologists and professional governing bodies take boundary violations very seriously (Bennett, Bryant, VandenBos & Greenwood, 1990; Pope & Vetter, 1992). For example, in a report by the APA (1999), 19% of its membership terminations were for nonsexual boundary violations. Staal and King (2000) considered these observations and reviewed the issue with the use of case studies and Johnson (1995) applied similar methods to highlight the role dilemmas inherent in the work of the UCP. Indeed, this balance between patient advocate and military officer has been of concern to the profession of psychology for a number of years (Camp, 1993). Some have gone further and suggested that the practice of psychology in the military is in conflict with the ethics, values, and principles of the profession (Saks, 1970). As UCPs continue to function within such dilemmas, they begin to encounter further ethical problems. One very common and important ethical difficulty is that of confidentiality.

CONFIDENTIALITY Appropriate maintenance of patient confidentiality can be challenging for UCPs. Armed forces can often insist that the personal information of service personnel be shared between departments and commanders in order to ensure the effective management of military operations. As discussed by Johnson (1995), this interest overrides the confidentiality of the doctor-patient relationship (Hayden, 1989; Howe, 1989). Johnson further outlined such ethical quandaries in military psychology, which can specifically include access to patient information by members of the patient’s command; military investigative services or other legal bodies within the military system; military representatives charged with investigating or treating spouse abuse and substance dependence; and a range of military personnel responsible for maintenance and storage of health records. Patient records are the property of the government and not the UCP. As a result, UCPs can find themselves powerless over the eventual use of their patient’s psychological records. The following two vignettes highlight examples of UCPs facing ethical difficulties with confidentiality. Case 3: The patient, a 32 year old Army officer, was referred on an “emergency” basis by the patient’s supervisor for a psychological evaluation.…The patient refused to complete the clinic’s intake paperwork and requested that the psychologist not maintain a clinical case file (patient record), because of concerns regarding the potentially adverse impact of a psychological evaluation on one’s military career. The psychologist explained that service regulation mandated documentation…but failed to docu-

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ment this advisement in the patient’s…case file.…The patient was seen for eight 1-hr sessions of …therapy, after which the psychologist was transferred.…The case was discussed with the psychologist’s supervisor…to coordinate follow-up treatment. After the psychologist’s transfer, the patient’s supervisor…[requested from the clinic] information on the evaluation and consultation…to know whether the officer should be permitted to continue to perform regular military duties.…The [treating] psychologist had discussed these issues with the patient during treatment. It was mutually agreed that a change of duty would be in the patient’s best interest, and this was documented in the record…[As the treating] psychologist had been transferred, the chief of outpatient psychiatry responded to the supervisors request. This was done by reviewing the patient’s record.…Six months later the patient filed an ethics complaint with the APA, stating that, without knowledge or written consent, the psychologist divulged information to a supervisor and thereby violated confidentiality …[and] that the psychologist kept records of the sessions and left them behind after departing for a new duty assignment. The patient wrote that the psychological report discussed personal and sensitive issues and, in effect, forced him or her to resign from the service. The patient stated that the psychologist should never breach confidentiality and that to do so acted contrary to the ethical standards of the APA. (Jeffrey et al., 1992, pp. 91–92) Case 4: An agent for Defence Investigative Services presented at an outpatient mental health clinic and demanded the clinical chart on a Navy enlisted service member who had been treated at the clinic a year earlier. The treating psychologist had since transferred. Although the investigating agent had no client release, he furnished evidence of a valid DOD directive to obtain records for use in an annual security clearance evaluation. The new psychologist allowed the agent to review and copy evaluations and case notes from the chart. When the psychologist refused to allow the agent to copy test data, the agent became indignant and recorded the psychologist’s service number while threatening disciplinary action for obstructing an investigation. Though no military charges were forthcoming, the psychologist experienced anxiety about this eventuality and concern regarding the use of the information disclosed. (Johnson, 1995, p. 283)

These case vignettes highlight the vulnerability of the storage, safety, and divulgence of a military patient’s psychological records. In these examples, the psychologists attempted to adhere to ethical standards on confidentiality while meeting their responsibilities to the military. However, they were met with threats of reprimand from their employer and/or professional governing body on the grounds of obstructing business relating to national security and/or ethical guidelines set by, in this case, the APA (Johnson, 1995). In their survey of UCPs, Orme and Doerman (2001) reported examples of participants’ experience of handling such challenges. One UCP stated, “the fact is that the institution [or military organization] often doesn’t really know what they need to know, sometimes they fish for information.” In another case, a participant reported, “[the] base

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commander requested that he and others be briefed (two times per month) with a list of names of all new patients being seen along with some clinical information” (p. 307). Such illustrations show that UCPs are expected to serve both their employer and their psychological governing body. The UCP may gain some relief from these difficulties by clearly informing the patient as to the limits of confidentiality and gaining the patient’s informed consent for information to be passed to a third party. Such strategies are clearly found in ethical codes of psychological practice (e.g., APA, 2002; BPS, 2000, 2001). Leso (2000) used case examples concerning the provision of psychological services to Army aircrew members and further underscored the importance of providing patients with the necessary information concerning the limits of confidentiality. Unfortunately, though, it is not always possible for the UCP to be clear about the limits of confidentiality or to gain such consent. Johnson’s (1995) use of case examples helped to emphasize the reality that UCPs can be transferred and redeployed at short notice to national and international locations. Also, in times of operational deployment, UCPs can be embedded with combat and support units where they may be required to subtly suspend previously established confidentiality agreements with patients. UCPs, therefore, can find themselves in situations where they must rely on both their clinical judgment and their obligations as military officers when contracting confidentiality with patients and when disclosing patient information (APA, 1994). As a result, this can lead to ambiguity and anxiety and the UCP may experience uncertainty and inconsistency regarding the operational criteria of the military’s right-to-know about a service member’s personal treatment information (Orme & Doerman, 2001). However, clarity can be enhanced from referring to preestablished military institutional and operational instructions regarding the disclosure of mental health care information. As such, it can be helpful to educate commanders and supervisors as to the constraints on disclosing health care data. This can be achieved through methods such as briefings and informal meetings. These resources can also be drawn upon when, for example, the UCP needs to respond to an ambiguous and/or inappropriately directed patient evaluation. Finally, further guidance can be gained from sources such as professional peers and military lawyers.

DISCUSSION UCPs do face similar ethical challenges to clinicians working in nonmilitary settings (e.g., Hines, Adler, Chang, & Rundell, 1998; Orme & Doerman, 2001; Pope & Vetter, 1992). However, the evidence presented in this review suggests that they encounter highly specific working and cultural conditions. As a result, the ethical challenges faced by such professionals are qualitatively different from those expe-

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rienced by clinical psychologists in alternative environments. Johnson et al. (2005) indicated that a number of steps can be taken to manage ethical difficulties. For example, the UCP, especially in embedded environments, should aim to assume a neutral posture within the community. Namely, they should strive to avoid engaging in internal disputes and conflicts between unit members, so as to remain impartial and to be as receptive as possible to all potential clients within the community. The UCP should continue to aim to provide every patient with the opportunity to establish immediate and detailed informed consent. This is a legal, organizational, and professional requirement. Boundary violations can, on occasion, benefit the services being provided by the clinician. This could take the form of self-disclosure by the UCP within the psychotherapeutic process (Hines et al., 1998). Nevertheless, the literature referred to in this article has suggested that when boundary violations occur, serious issues may arise for the UCP, including abuse of power over the client; colluding with the patient’s psychopathological symptoms; placing the psychologist and the profession in a negative light; and undermining one’s ability to provide effective services are all possible when multiple relationships arise. As such, the UCP should aim to refrain from overt self-disclosure both within and during the broad delivery of various psychological services. Furthermore, clarity should be sought on the specific criteria of the need-to-know policy. This insight should be used to inform interprofessional and other military communications. For support and assistance, the UCP will want to have established a consultative supervisory relationship with a peer, who may not necessarily be accessed in person but may be consulting via teleconferencing or Web-based supervision. Also, it would be advisable for UCPs to develop a network of ancillary mental health services, such as the chaplaincy, other health care providers, and named service personnel within a unit (Johnson et al., 2005). UCPs should engage in ongoing training and preparation for practice in military settings, which involves instruction on the ethical requirements of their professional governing body, their responsibilities as military officers, military competencies, and their legal obligations within both national and local jurisdictions. These areas of knowledge and understanding should be clear and, where possible, congruent. However, as seen by the literature reviewed in this article, this is not always the case. For instance, there is often little attention given to the work of UCPs in the training curriculum of clinical psychology doctoral programs. Also, ethical guidelines tend to pay little attention to the specific ethics of practicing as a UCP. Furthermore, some professional governing bodies have no representative forum, specialist subgroup, or division on the practice of clinical psychology in the military. Thus, UCPs are often left to attain a balance between their ethical guidelines and the organizational realities. As a result, it may be fruitful for UCPs to take the lead in establishing collaboration and uniformity between these occasionally con-

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flicting areas of responsibility. Indeed, some have already begun this process (e.g., APA, 1994; Johnson, 1995).

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LIMITATIONS This review has drawn upon a range of literature relating to the ethical challenges faced by UCPs. The bulk of material used in this article originated in the United States of America and, therefore, the case material reviewed and examined may not reflect the experiences of UCPs in other countries. As highlighted earlier, each jurisdiction may vary in its role for UCPs, military culture and regulations, ethical principles, and legal systems. Adler and Bartone (1999) addressed this issue in their survey of military psychologists (and other military mental health professionals) in 23 countries. They identified differences in such areas as the function, scope of practice, and level of interprofessional support experienced by military clinicians. Notwithstanding these caveats, this article illustrates how the fundamental ethos and philosophy of clinical psychology as a discipline can be challenged by the values and practices of working in the military.

CONCLUSION The specific areas of confidentiality and multiple relationships for UCPs have been considered in this review. However, some in psychology have raised more global ethical considerations such as the appropriateness of clinical psychology’s involvement with the military in general. For example, Saks (1970) stated that the main goal of military psychology is to turn individuals into more effective murder machines and, thus, is contrary to the principles of ethical practice (Leuba, 1971). While these comments emanate from a different political and social era, not dissimilar notions have been expressed in recent times; e.g., in relation to the British Psychological Society’s stance toward the current Iraq War (Roberts, 2005). Clinical psychology is a strong and well-established profession and scientific discipline. With many countries now operating a doctoral training framework for clinical psychologists, and with an emphasis on science, practice, and research, clinical psychologists have added much to the field of health and social care. Specifically, the profession has contributed to our understanding of human behavior, established treatments for the reduction of mental and physical distress, and assisted in the betterment of all in society, including members of the armed forces (e.g., Plante, 1999; Sammons, 2005). UCPs are now a valued part of many military health care systems. While some in psychology may disagree with the politics of the military, clinical psychology as a profession continues to have a role and obli-

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gation to improve the lives of those serving their country. Nevertheless, the particular role occupied by UCPs when serving in the military will continue to create ethical challenges for clinical psychologists. The profession of clinical psychology and all those who contribute to the context in which UCPs practice are, as a whole, well placed to address the ethical issues identified in this article. In particular, military clinical internships or placements have a crucial role in preparing the UCP for effective management of the unique challenges of working in the military (e.g., Friedlander, 2005; Johnson & Wilson, 1993). Furthermore, by educating others about the importance of patient privacy and by respecting interpersonal and interprofessional boundaries, UCPs can share their values and ethos with those involved in the management and delivery of military health care. This, in turn, may help patients by improving the actual and/or perceived access to mental health care services, through lowering stigma associated with mental health problems and by promoting more collaborative and multidisciplinary preventative practices for the psychological well-being of military personnel. This article has revealed a dearth of non-American research on the ethical challenges faced by UCPs, and there appears to be an absence of much empirical evidence on the topic. Future research could consider how ethical challenges might differ both between UCPs of different nations and between UCPs and other military health care professionals. The authors of this article have recently conducted research into the practice of mental health care on operational deployments and the psychosocial impact that this has on military mental health care professionals (McCauley, Hacker Hughes, & Liebling-Kalifani, 2006). These studies drew upon the experiences of a sample of mental health care professionals who recently served in Iraq and such research may help to develop further some of the issues raised in this article. Overall, though, this article has highlighted how even in situations where ethical practice can be challenged, clinical psychologists continue to be mindful of (and attentive to) the ethical principles inherent in the ethos of their profession.

REFERENCES Adler, A. B., & Bartone, P. T. (1999). International survey of military mental health professionals. Military Medicine, 164, 788–792. American Psychological Association. (1994). Military psychologists and confidentiality. American Psychologist, 49, 665. American Psychological Association. (1999). The APA 1998 annual report. American Psychologist, 54, 537–568. American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060–1073.

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