Ethics and Professional Issues in Couple and Family Therapy

Megan J. Murphy, Lorna Hecker, Megan J. Murphy, Lorna Hecker

• Publisher: Routledge
• Year: 2016
• Print ISBN: 9781138645257
• eBook ISBN: 9781317240440
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Ethics and Professional Issues in Couple and Family Therapy, Second Edition builds upon the strong foundations of the first edition. This new edition addresses the 2015 AAMFT Code of Ethics as well as other professional organizations' codes of ethics, and includes three new chapters: one on in-home family therapy, a common method of providing therapy to clients, particularly those involved with child protective services; one chapter on HIPAA and HITECH Regulations that practicing therapists need to know; and one chapter on professional issues, in which topics such as advertising, professional identity, supervision, and research ethics are addressed. This book is intended as a training text for students studying to be marriage and family therapists.

1

Introduction

Lorna Hecker and Megan J. Murphy

The Lincoln family attends therapy for concerns about their oldest daughter, Elise, who is 15 years old. Elise has been breaking curfew, and the family fears she is using drugs. Dr. Shindell sees all the family members, parents Kelly and Sam Lincoln, Elise, and her younger sister, Macy, age 12. Family therapy focuses on getting the parents to synchronize their parenting efforts to strengthen the parental hierarchy. As therapy progresses, Dr. Shindell receives a voicemail from Sam’s mother, Mrs. Lincoln, stating her concern that Kelly and Sam are unfit parents, and that she and her husband would like to try to gain custody of the girls. The elder Mrs. Lincoln states in the message that Sam has been known to hit Elise out of frustration for her misbehavior.

Ethics is about what actions we should take, which rules govern our conduct, what “right thing” we should do, and what we ought not to do. It is also about how we justify our actions. When making ethical decisions, couple and family therapists need well-founded reasons to support their actions. Our sense of ethics is influenced by scholarship and evidence, and is shaped by our values, worldview, and context (Roberts & Dyer, 2004). Ethics involves cognition and affect, and a “moral sensitivity” that includes the recognition that our actions affect the welfare of others (Welfel & Kitchener, 2003). Clients’ values and morals also need to be clearly understood so that empowering, collaborative decisions can be made.

When facing situations that may have ethical quandaries, couple and family therapists can make decisions using the following four criteria:

• What are the ethical components?

• What are the clinical components?

• Are there any potential legal issues?

• Are there any professional issues to reflect upon?

Ethical components inform how professionals should conduct themselves within the context of the professional relationship and the specific situation. Ethical dilemmas arise most often when the welfare of people may be at stake. For example, when a therapist sees a family and suspects that the parents are abusing their child, an ethical issue is posed because the welfare of the child is at stake, as one can imagine Dr. Shindell, in our case scenario, must be contemplating. However, the ethical dilemma is embedded within the clinical issues at hand and is entangled in legal issues because of reporting statutes.

Clinical components relate to the therapeutic context in which the ethical issue is occurring. Ethical issues typically arise out of the clinical context and can affect the therapist–client relationship. The effect of ethical issues may have a positive or negative valence. For example, a therapist who ethically and legally must report parents to child protective services may severely damage the therapist–client relationship because this violates the confidentiality and trust the parents put in the therapist. Additionally, clients may feel betrayed and angry that the therapist involved authorities in the therapeutic relationship. Steinberg, Levine, and Doueck (1997) found that 27% of people leave therapy when they are reported to child protective services. Conversely, the vast majority of parents may understand that the therapist had a legal obligation to report to child protective services and are interested in bettering their parenting skills so that the abuse never happens again.

There may or may not be legal issues in an ethical situation. In the case of the parents who abuse a child, all 50 states have child abuse reporting statutes, but even though this may be a legal requirement, apparently not all therapists find this ethical or advisable in all situations. Jankowski and Martin (2003) found that, in cases of child maltreatment, family therapists in Illinois made the decision to report child abuse based on their worldview assumptions, ethical principles, prior clinical and life experiences, situational factors including type and severity of abuse, the amount of evidence presented to them, client characteristics such as age and personal history, and interactional factors including willingness on the part of adult clients to comply with therapy. Even though therapists realize they are legally bound to report abuse, the legal requirement may not appear ethical to the therapist. In other cases, it would be unethical to the therapist if they do not report actual, ongoing abuse.

Last, there are professional components to any situation. How the therapists conducts themselves reflect on the profession as a whole. For example, a therapist who is constantly late to sessions, while strictly not generating an ethical issue, is behaving in a way that reflects poorly on the professional and the profession. If, as discussed previously, the therapist does not report abuse and the child continues to be abused or dies, it would be both a tragedy and a poor reflection on couple and family therapists.

Consider the scenario at the beginning of this chapter. Dr. Shindell is faced with potential ethical issues. First, she may not speak to Sam’s mother without a written release from her clients. This is an ethical issue, but because confidentiality is statutorily defined, it is also a legal issue. Clinically, Dr. Shindell will need to be cautious about how she handles the issue of the voicemail. She wants to avoid the perception of an alliance or coalition developing with Sam’s mother that will derail therapy and erode therapeutic trust. Yet she now holds some information that may be relevant to therapy—either if there is actual abuse, or if this is not true, the sabotage of the parents by Mrs. Lincoln is of import. Legally, in Dr. Shindell’s state, she is bound to report suspected child abuse. Professionally, if Dr. Shindell speaks to Sam’s mother about Sam, Kelly, and Elise, she will have acted in an unprofessional manner; confidentiality is the foundation on which therapy is built. If the public cannot count on confidentiality being upheld, there is no reason for clients to confide in couple and family therapists. Ultimately, Dr. Shindell cannot “confirm or deny” to Sam’s mother that the Lincoln family is a client.

All ethical decisions should be evaluated in these four realms. The process of ethical decision-making is much more complex and is discussed by Elisabeth Shaw in Chapter 2, Ethical Decision-Making from a Relational Perspective. In her chapter, she describes a more contextual, relationally based way of making ethical decisions, as opposed to the step-by-step models familiar to many therapy professionals. Professional codes of ethics provide some guidance on our basic ethical responsibilities; they provide a floor of protection for clients. Codes give us specific “dos” and “don’ts,” but do not aid the couple and family therapist in making ethical decisions when the complexities extend beyond the professional code.

Philosophical Roots to Ethical Decision-Making

Historically, in analyzing ethical decisions, therapists have borrowed from philosophy and use the moral principles of autonomy, nonmaleficence, justice, beneficence (Beauchamp & Childress, 2013), veracity, and fidelity (Nash, 2002; Sidgwick, 1981):

• Autonomy refers to respecting individuals and their right to make decisions for themselves with regard to their own health and well-being. When we ask clients to give informed consent for treatment, we are respecting their autonomy, providing information so that they may make an autonomous decision about their care. Even the labeling of “client” vs. “patient” has shades of the level of autonomy we believe clients should hold.

• Nonmaleficence means “above all, do no harm.” We educate clients in our informed consent about the risks and benefits of treatment. An assumption of nonmaleficence is that the benefits of treatment outweigh the risks.

• Justice means all humans should be treated fairly. When ethical codes dictate that therapists provide services without discrimination (e.g., on the basis of race, age, ethnicity, gender, religion, sexual orientation) the principle of justice is employed.

• Beneficence refers to actions intended to do good for others; the value of caring in couple and family therapist is derived from this principle.

• Veracity refers to the importance of truth telling. We want to be honest and transparent with our clients. There has long been questioning of the use of paradoxical interventions and emotional manipulation (e.g., strategic family therapy), and whether or not these types of interventions are ethical, because of deceit/lack of transparency (Lakin, 1988).

• Fidelity refers to honoring commitments and promoting trust. For example, when therapists promise confidentiality, clients expect that promise to be honored (within legal limits).

Now, let us again consider our case scenario with the Lincoln family. When considering client autonomy, Dr. Shindell may be evaluating how much therapy time to devote to Elise individually to honor her developing autonomy as a teenager. She may also be evaluating the autonomy of Kelly and Sam to seek treatment without the involvement of Sam’s mother. Yet, Dr. Shindell does not want to cause harm (nonmaleficence) and must work to keep Elise safe (beneficence) both from abuse and involvement with harmful substances. Likewise, in evaluating the principle of justice, Dr. Shindell may wonder if it is fair to report Kelly and Sam based on the report of a potentially maligned grandparent who may be acting in her own interests, not those of the family. Dr. Shindell wishes to do well by this family, help the parents regain their parental role in relation to their child, and keep her from harm (beneficence). There is also the question of reporting the grandmother’s allegation of abuse to the authorities, as is legally required in her state (e.g., reporting of suspected abuse and neglect). Dr. Shindell’s first allegiance is to the family and she fears revealing the phone call with Sam’s mother may cause harm to her relationship with the Lincoln family; likewise, she may be rightly concerned about the effect on the therapeutic relationship should she report Kelly and Sam to child protection authorities (fidelity). These are but a few examples of ethical components that may go into one ethical decision. Couple and family therapists make daily decisions with ethical ramifications.

Historically, ethical decision-making has been done in a linear fashion with basic steps including defining the problem, fact gathering, weighing the ethical principles mentioned previously, and then making a decision. Yet as Elisabeth Shaw (see Chapter 2) notes, our cognitive, linear decision-making models do not take into account the context of our relationships. One can imagine that culture and specific family rules can vary in what benevolent acts are believed to be. One culture may see the death penalty as a form of justice, whereas another sees it as morally repugnant. Although some ethical decisions may seem easy to discern with little thought (e.g., keep therapy information confidential), others will require an examination of a client’s relational context in order to evaluate the “right” thing to do. Our context shapes our ethical thinking. For example, those who ground their ethical beliefs in the notion of a divine being are likely to view the source of their morality as external and objective, whereas those who do not are more likely to view ethics as internal and subjective; in U.S. culture, we can see this difference in the impasse between conservative and liberal ideologies (Goodwin & Darley, 2008). Cultural context and worldviews are inherent in all ethical decisions. In the following chapters, information is presented on ethical decision-making around a variety of issues couple and family therapists confront daily.

Case Examples of Ethical Issues

What follows are examples of ethical issues relevant to chapters in this book.

Most scenarios are variations on actual case events. Names and details have been changed to maintain client confidentiality.

Martin was a family therapy intern at a university Couple and Family Therapy Center working with a young man, Jared, who was referred for anger management counseling. Jared, initially wary of counseling, revealed that he had been involved in a gang, but had changed his ways and was now a father with a partner and two young children. It was clear he had given up his gang activities, had obtained a job, and stated interest in couple’s therapy for him and his partner. Jared exhibited symptoms of posttraumatic stress disorder, having witnessed significant violence during his involvement with gangs. Although outwardly he portrayed bravado, the more he became comfortable with therapy, the more vulnerable he became with his therapist. Jared began to talk about how he had few friends and trusted no one. He described a chaotic family of origin whose members attacked each other frequently and only contacted Jared when they needed money. He trusted his partner the most, but he was even wary of her. He said he had made a pact with three gang buddies, and that was the deepest trust he had experienced. He began to discuss to the fact that these three friends of his had a secret that they had agreed to tell no one. It became clear to the therapist, over time, that this event was a criminal act. Jared eventually talked in terms that left no doubt to the therapist the men had murdered a rival gang member.

Sometime later, Martin was subpoenaed to testify in court about Jared’s involvement in the murder. Although Jared had thought what he shared was confidential, there was an exception to Jared’s legal right to privilege that was specified in the state statute. Specifically, the state statute read in part:

Matters communicated to the Couple and Family Therapist in the couple and family therapist’s official capacity by a client are privileged information and may not be disclosed by the couple and family therapist to any person, except under the following circumstances: (1) In a criminal proceeding involving a homicide if the disclosure relates directly to the fact or immediate circumstances of the homicide… (adapted from Indiana Code IC 25–23.6–6).

Although this exception had been detailed in the Couple and Family Therapy Center’s informed consent, Jared had unburdened himself of the information anyway, putting Martin in a very tenuous legal position. The judge ordered Martin to testify as to what Jared had confided to him in the therapy sessions. Martin was forced to comply. Confidentiality and legal privilege will be defined and discussed further in Chapter 3; informed consent to treatment will be detailed in Chapter 12.

Mrs. Lee attended therapy with her 10-year-old daughter, Rose, stating that she wanted therapy for Rose because of the divorce she had experienced the year prior. Rose seemed to be an outgoing and friendly fourth grader. Mrs. Lee stated she wanted a neutral place for Rose to talk about any concerns she had about the divorce. The family therapist, Dr. Snow, asked for a copy of the most recent custody order, which Mrs. Lee brought to the subsequent session. Dr. Snow ascertained that Mrs. Lee had sole legal custody of Rose. Rose lived with Mrs. Lee and only visited with Mr. Lee on alternate weekends plus one night per week. Dr. Snow saw Mrs. Lee and Rose conjointly for two sessions, and Rose alone for two sessions. Mrs. Lee stated that she had asked Mr. Lee to join therapy, but he had said that he was not interested. Dr. Snow made no attempt to contact Mr. Lee. During the fifth week of treatment, Dr. Snow received an irate phone call from Mr. Lee, who had learned from Rose that she was in therapy. Mr. Lee demanded to know why he was not notified his daughter was in treatment.

Dr. Snow correctly assumed that he only needed Mrs. Lee’s legal consent to treat Rose because Mrs. Lee had sole legal custody of Rose. However, Mr. and Mrs. Lee shared joint physical custody of Rose, indicating involvement in her parenting on a regular basis. Mrs. Lee was deceitful when she said Mr. Lee was not interested in therapy; she had never asked Mr. Lee to join them in therapy. Dr. Snow acted within proper legal guidelines, but he was not clinically sound in his decision to exclude Mr. Lee from treatment. This error could predictably lead to an ethical complaint, a growing concern when dealing with custody issues (Greenberg, Martindale, Gould, & Gould-Saltman, 2004). Chapter 10 will address Ethics in Therapy with Children in Families.

A counseling center in Wisconsin was forced to notify 509 of its patients of breach of personal information after a burglary occurred and someone stole a center psychologist’s unsecured laptop. The laptop had outpatient mental health records, mental health status examinations, and psychological evaluations. It also included client names, social security numbers, medical histories, diagnoses, and statements of work capacity, as well as personal information of the psychologist himself. In addition to no...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• 1 Introduction
• 2 Ethical Decision-Making from a Relational Perspective
• 3 Legal Issues in Couple and Family Therapy
• 4 The Impact of HIPAA and HITECH Regulations on the Couple and Family Therapist
• 5 Self of the Therapist: Being Aware, Prepared, and Ethical
• 6 Power, Privilege, and Ethics in Couple and Family Therapy
• 7 Sexuality, Boundaries, and Ethics
• 8 Risk Management in Practice
• 9 Spirituality and Religion
• 10 Ethics in Therapy with Children in Families
• 11 Ethical, Legal, and Professional Issues in Mediation and Parent Coordination
• 12 Ethical Issues in Clinical Practice
• 13 Ethical Issues with Systemic and Social Constructionist Family Therapies
• 14 Ethical Couple and Family E-Therapy
• 15 Ethical and Clinical Considerations for Home-Based Family Therapy
• 16 Ethics of Professionalism
• Index