Practical Ethics in Counselling and Psychotherapy

A Relational Approach

Linda Finlay

• Publisher: SAGE Publications Ltd
• Year: 2019
• ISBN:
  9781526481733
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Are you sometimes challenged by how to apply ethical principles in your own practice? Looking to understand what ethical practice can look like from different theoretical standpoints?

Linda Finlay takes you on an exploration of ethical therapeutic practice. She highlights how therapeutic decisions depend on the social and relational context and vary according to your theoretical lens. She provides you with guidance on how to engage in therapy relationally while remaining professional, ethical and evidence-based.

Split over three parts this book takes you through:

- The Context of Relational Ethics - introducing you to the foundational ideas, and considering how professional codes are applied within therapy

- Relational Ethics within the Therapeutic Relationship – exploring the complex judgements demanded by the therapeutic process, and looking at how therapy needs to be situation specific

- Relational Ethics in Practice – five extended, fictional case studies demonstrate relational ethics in practice, and discuss the issues raised.

Part I The Context of ‘Relational Ethics’

Preamble

Relational ethics requires [therapists] … to act from our hearts and minds, acknowledge our interpersonal bonds to others, and take responsibility for actions and their consequences. (Ellis, 2007, p. 3)

Ethics are not just remote, detached, philosophical principles enshrined in professional codes. Ethics are all about us, intricately worked into the personal and professional values which shape our work and give it meaning. They permeate every moment of our counselling and psychotherapy practice.

‘Relational ethics’ sees ethics in terms of relationship rather than directives. What’s in the client’s interests and risks of harm depend on the meanings in the situation. A therapist who asks lots of questions could be seen as invasive or genuinely interested. If a therapist encourages a client to do more self-care, it might be viewed as caring or critically blaming. The holding of a time boundary may feel safe or harsh. A therapeutic challenge issued to a client could be in their interests and feel uncomfortable simultaneously; one client might feel stimulated by it, another threatened. There are few hard and fast rules. It all depends.

Rather than simply respecting clients and prioritising their interests, relational ethics demands that we recognise the interconnection between therapist, client and our wider communities (Faris and van Ooijen, 2012). Professional guidelines have practical implications; they require us to be mindful about these wider relationships, critically appraising the impact of an imbalance of power and the use of unthinking or instrumental ways of relating.

The four chapters in Part I introduce the foundational ideas of relational ethics. They consider how our professional codes are applied practically within therapy and in our wider social world. You’re invited to marry externally-derived professional standards and internally-derived personal values in thoughtful, reflexive ways which attend to the specific relationship involved.

1 A Relational Approach to Ethics

A relational approach to ethics intertwines relational sensitivity with containing ethical frameworks. Our focus here is on ethics that embrace a relational attitude and acknowledge how moral and ethical horizons are ever-present in our therapeutic relationships (Gabriel and Casemore, 2009). Ethical guidelines, although useful, can never prepare us sufficiently for situations arising in practice which make our heads spin and hearts ache (Ellis, 2007; Finlay, 2012). Ethical judgements need to be made in context and it’s complicated. We can aspire to certain standards of practice but may not always meet these. The question is how to be a good enough, ethically responsive therapist.

This chapter adopts a relational approach to ethics in practice – ‘relational ethics’ for short. To illustrate this, eight situations from practice are sketched and the relational-ethical challenges involved in each are highlighted. The next section highlights the values which underpin relational ethics. The concluding reflections section begins a pattern of concluding each chapter with personal thoughts and an implicit invitation for us to dialogue – you and me.

Relational Ethics in Practice

Virtually every ethical issue and dilemma we encounter can be answered with the phrase ‘it depends’. Professional standards, personal values, legal requirements, agency policy, cultural context and relational considerations all complicate the field. At times our relational concerns may clash uncomfortably with wider professional, legal or institutional requirements. We face the unending professional challenge of marrying our personal values and wider professional and social contexts in ethically thoughtful and reflexive (critically self-aware) ways rather than rigidly following rules or defensive practices. In addition, relational ethics drive us towards collaborative, responsive, respectful, compassionate and authentic relationships as opposed to exploitative, instrumental or habitual ones. Beyond the bounds of written codes, there is an important place for professional experience and intuition. And, there is room to get it ‘wrong’ sometimes. When our behaviour falls short of the values we aspire to, we can still be a ‘good enough’ therapist.

The following eight vignettes illustrate typical ethical dilemmas, all of them potentially problematic. I invite you to dwell with your own responses to each before moving on to the ensuing discussion. Have you ever been in similar situations? Are there some situations where you have a clear and instant response and others where, while less sure of your ground, you have an intuitive sense of what feels right for you? Notice your reactions and what that tells you.

As you think about the eight specific situations presented here, you may well find professional standards, legal requirements and your own personal moral code conflict, pulling you down contradictory paths. All this before considering the extra complications of specific interpersonal and cultural contexts and your own professional intuitions! (These strands are set in bold below to show the way the issues are intertwined.)

Following each vignette, I indicate the issues at stake, then express my personal response (in italics) and invite you to dialogue with me. If you disagree with my ethical position, why is that? Do our personal values differ? Do we come from different theoretical perspectives? Or is it to do with the fact that we practise in different contexts and/or cultures?

• 1. A client texts a long message to you between sessions. He has experienced a melt-down following a traumatic meeting at work and requests a brief phone conversation as he’s ‘desperate’. Do you oblige?

Discussion

The primary ethical dilemma here concerns the need to hold a professional boundary and safe frame on the one hand, while the client’s desperate and acute need for support demands compassion and empathy. Overlaying this is our own desire (need?) to help. Professional and personal values may collide here, and institutional and legal/contractual structures also need thought. For example, some therapists may agree a ‘no text rule’ in advance or even prohibit between-session contact.

I know therapists who routinely offer text support between sessions to offer ‘holding’. However, personally, I would avoid offering therapy support out-of-session. Here, the well-meaning but unwary therapist could fall into the trap of communicating out of hours. (I’ve been there myself and learned the hard way when the therapy went pear-shaped.)

From a private practice perspective (it could be different in other settings), I would argue that providing extra contact between sessions is likely to prove counterproductive, for in these uncontracted times the normal safe relational frame is not available, and contact may be unduly rushed. Outside the formal therapy frame, too, we are likely to be tired, distracted, poorly grounded and unfocused. In addition, it could be that our client is replaying (in or out of awareness) a history of creating situations where they are not properly seen, thereby ensuring their needs cannot be met (Finlay, 2016a). For these reasons, I would simply acknowledge the text and offer (if I could) an extra formal session to talk through the trauma. Had I felt pulled to ‘rescue’, I would want to explore that in supervision.

• 2. A client is filling out an application form for a job and admits she is tempted to lie about her history of mental health problems. Do you condone this?

Discussion

This situation taps directly into our personal morality regarding the importance of truth-telling and honesty. But there are also professional, legal and relational considerations.

Many professional codes explicitly state the need to deal with others truthfully, with integrity and in straightforward manner. The professional standard implicated concerns our professional integrity and the need to work ethically and consider the law. In practice, of course, this can get muddied.

It would be worth exploring the nature of this client’s history some more. Did she become ill and hospitalised, and receive a diagnosis? There may be some associated trauma and stigma here which could be useful to explore (see Chapter 5 which discusses the issue of diagnosis some more). Otherwise, if her ‘history’ is simply having therapy, maybe this can be normalised. She may need reassurance that she is not ‘mad’ or ‘ill’ and that many people have therapy to handle life stresses or issues.

Legally speaking, both employment law and professional duty of care (ours and the employer’s) are relevant. All employment is based on some sort of contract, and material non-disclosure is relevant. If the undisclosed fact could have had a bearing on the decision to employ, then this could be breach of contract. From the employer’s perspective, they have a duty to act with care. If they are aware that an employee has a history of mental health issues, they need to treat that employee appropriately and not, for example, put them under inappropriate levels of stress. In this sense, it may be helpful for everyone if the employer is aware of the client’s history.

The relationship of trust between client and therapist is also at stake. Relationally speaking, when do we impose our own standards on clients rather than encourage autonomous choice? Also, if we’re too critical, the client may be reluctant to tell us things out of fear of negative evaluation.

My personal starting point would be to acknowledge the harsh reality of public ignorance regarding mental health problems and the social stigma surrounding it. I would feel sympathy for this client, who might suffer at work if they disclosed their full history. I might also raise the possibility of the potential employer being sympathetically unconcerned about her previous history or ready to benefit from some psychoeducation (my political agenda). I would note (for later consideration) that relational work related to self-acceptance of her history might be useful for this client.

While I might be tempted to condone lying on an official (legal) form, I know this would be wrong, and would say so. Nor in my professional role could I encourage deceit. However, I would want to try to express myself in sympathetic and protective terms rather than critical or judgemental ones. Discussion with my client about disclosure could be helpful to her and prove a useful lesson for the future in terms of when it’s OK to disclose or keep things private.

• 3. Your client often makes racist and anti-immigrant comments with which you strongly disagree. Do you share your own views?

Discussion

This situation highlights the role of personal values (and beliefs/attitudes) together with wider issues concerning social responsibilities. Some therapists consider it as good modelling to own and express a social or political position, while others are reluctant to introduce personal views. The professional standard at stake concerns the obligation not to condone, collude with or facilitate any prejudice, discrimination or oppressive behaviour.

How and when we might challenge prejudicial behaviour is the tricky bit. Some therapists might accept (in their mind) that this is the client’s way of talking and not jump on it; others wouldn’t let it pass. Some might tacitly agree with some prejudicial stereotyping.

Whether or not we disclose our own views is a personal and professional boundary issue about which opinions and practice diverge considerably. Some of us routinely express our views; others do not. Relationally, compassion and respect are relevant touchstones, but we must also consider the possible impact of our views on the client. Might they feel criticised or disparaged by us if we express opposing positions? Might this damage our therapeutic relationship? If we withhold our views but they emerge later, perhaps through a third party, might that undermine therapeutic progress?

It is also worth considering what we embody in terms of our ethnicity and the impact that has on others unconsciously and transferentially. Might there be some unspoken dynamics here? For example, a client who is black/Asian may well feel some subtle, unspoken, prejudice coming from a white therapist. And it would be important to note possible projections around this, i.e. where one unconsciously attributes characteristics that feel unacceptable in oneself on to others.

I hope that I would not ignore racist slurs and would challenge them immediately, at least discussing my discomfort with ‘stereotyping’. And I know that I’ve let racist comments slide in the past. Ideally, I would want to encourage exploration of what my client means and believes, and perhaps why. This requires a tricky balancing act, because by being critical of a client’s views we may drive them underground and contaminate therapeutic progress. This is where intuition and artful practice come in.

I know therapists who are open (even outspoken) about their political views and who openly own their cultural background and ethnicity. I am more reticent. Is my political position relevant? Might it offer some useful modelling? Sometimes I might own my own stance as part of being authentic and transparent – provided I thought this would deepen the therapeutic alliance and/or model respect for difference.

• 4. At the end of an emotional session, your client asks for a hug. Do you give it?

Discussion

This question goes to the heart of personal and professional boundaries. The answer depends on many things, including the specific relationship involved, the wider context and what the hug might mean to both parties. Would the hug be therapeutic for the client and in their long-term interests? If the hug was perceived as invasive or sexually suggestive (for either person) or confusingly ambiguous in intent, it would violate important ethical and relational boundaries. (See the theoretical debates around touch in Chapter 6.)

In my (humanistic) practice, yes, I probably would consider giving the hug (though I wouldn’t normally hug clients unless the client invited it, or I had first checked their consent). While I’ve sometimes given a hug because it seems to be ‘expected’, my growing edge is to be less adaptive and not just go along with hugs particularly when they feel uncomfortable, automatic, dissociated or ambiguous. I would want to explore the client’s possible needs and what the hug might represent. It’s not my job to supply a client’s apparent emotional needs through reflex action. In fact, deliberately withholding a requested hug (not easy to do) could prove more therapeu...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• About the Author
• Preface
• Acknowledgements
• Part I The Context of ‘Relational Ethics’
• 1 A Relational Approach to Ethics
• 2 Professional Codes and Legal Frameworks: Thinking Relationally
• 3 Care as a Relational Ethic and its ‘Shadow’
• 4 Living Ethics within a Social World: ‘Walking the Talk’
• Part II Relational Ethics within the Therapeutic Relationship
• 5 ‘First Contact’: Creating Ethical Therapeutic Spaces
• 6 Ethical Boundarying
• 7 Ethical ‘Holding’
• 8 Ethical Containing
• 9 Ethical Endings
• Part III Relational Ethics in Practice
• 10 Karim: Brief Therapy and CBT
• 11 Susan: Integrating Creatively?
• 12 Gary: Working with Anger in Context
• 13 Star: Containing and Boundarying?
• 14 Luke: Intergenerational Trauma work
• Epilogue
• References
• Index