When ethical problems emerge, they tend to evoke anxiety in psychotherapists, including the group psychotherapist, who wants to do right and avoid the negative consequences of ethical mistakes. This anxiety motivates practitioners to look for rules or laws that will unambiguously identify a correct course of conduct. In this search, as Acuff et al. (1999) note, the practitioner is likely to be disappointed:
No code of ethics, however well written, can anticipate all of the various situations in which psychologists may confront ethical dilemmas, and no code of ethics may be able to specify concrete actions for the psychologist to follow in all situations. Consequently, some of the possible ethical conflicts faced by psychologists have no clear solution and require psychologists to engage in an ethical decision process involving the balancing of competing ethical standards. (p. 565).
The quality of the solution the group psychotherapist generates is likely to be based on the extent to which the problem at hand is fully understood. Potentially elevating the group psychotherapist's understanding of the problem at hand is to make use of dominant ethical paradigms, frameworks in which ethical quandaries can be examined. Principlism (Beauchamp & Childress, 1979, 2013) is likely the most familiar to group psychotherapists, ensconced as it is in the ethical codes of most mental health disciplines. Indeed, this text emphasizes principlism. However, increasingly, we are seeing that other paradigms provide additional information and insight that are critical to doing justice to the complexity of the ethical problems that can emerge in psychotherapy groups. The ethical problem-solver need not choose a particular framework any more than a botanist needs to choose one lens to examine plant cells.
Principlism
Principlism is an ethical framework, created by Beauchamp and Childress, and described in their classic text Principles of Biomedical Ethics, first published in 1979 and now in its 7th (2013) edition. This framework initially assisted medical professionals and eventually, human service professionals more broadly, in solving ethical problems that emerge in everyday practice. Beauchamp and Childress identified five principles that they saw as having universal significance, that is, principles that can reasonably be applied to all clinical situations: Respect for Autonomy, Beneficence and Non-maleficence, Justice, and Fidelity:
- Respect for Autonomy means avoiding actions that would deprive or limit individualsā control over their own lives and, conversely, engaging in actions that would expand their autonomy. This principle is implicated in such clinical activity as providing informed consent when recruiting members for a group (Brabender, 2006). When patients are given all relevant information about the group they are considering entering, their autonomy (i.e., making a well-informed decision) is preserved.
- Beneficence refers to those clinical actions that aim to promote the welfare of the client. Specific Beneficence is directed at a particular party, typically the client, but also, perhaps, the client's family. General Beneficence has a non-specific referent. When practitioners strive to deliver services competently to contribute to the creation of a more just society, they are serving General Beneficence. Non-maleficence reflects the value of avoiding action that would harm a group member. For example, this principle would dictate that a group psychotherapist would avoid the use of a technique that, while having some potential to benefit a group member, could also damage the member in another respect.
- Justice entails that the therapist adopts an inclusive attitude toward the provision of services, offering members āā¦fair, equitable, and appropriate treatment in light of what is due or owed to personsā (Beauchamp & Childress, 2009, p. 241). For example, a therapist who conducts the group in a venue that is accessible to individuals with ambulatory challenges is acting in accordance with the principle of Justice. Justice is also served when a therapist is vigilant during the sessions to ensure that individuals who have been silenced or marginalized in society at large do not experience similar events in the group.
- Fidelity, or loyalty, is the practitioner's responsibility to place the patient's interest before self-interest. Adherence to Fidelity is seen in the behavior of the therapist who encourages an unimproved member to seek alternate treatment even though this recommendation might be at odds with the therapist's financial interests. At times, practitionersā relationships with third parties can threaten the observance of Fidelity (Beauchamp & Childress, 2009). For example, a group psychotherapist might allow a colleague to solicit group members for participation in a study. Even though creating this opportunity for the colleague might hold no advantage for members, the therapist might do so to enhance the collegial relationship. Fidelity does not demand that the therapist subordinate all self-interests to member interests. For example, a therapist might decide to move the group because the rent for the current office has risen dramatically. Even though the new location of the group might be somewhat less convenient for some members, the action is defensible because the therapist has a right to contain costs. Where Fidelity is most critically considered is where the therapist's consideration of self-interest can hinder the member in deriving benefit from the group.
From the standpoint of principlism, ethical quandaries can arise because following one of these four core principles could entail compromising another. For example, if a group psychotherapist describes in detail all the risks associated with being a member of a psychotherapy group (thereby complying with Respect for Autonomy), the therapist might in effect be discouraging that prospective member's willingness to be in the group (thereby compromising Beneficence). Oftentimes, ethical problems entail a conflict between Respect for Autonomy and Beneficence because what a professional believes might be in a patient's or group's interest might not be freely accepted by that individual or group. For example, an individual therapist might strongly believe that a patient would benefit from group treatment. The therapist might know the group experience would evoke uncomfortable feelings in the patient. Were this professional to soft-pedal the likely negative reactions to obtain the member's receptivity to the group, that professional would be placing Beneficence ahead of Respect for Autonomy. However, within individualistic cultures, Respect for Autonomy is broadly viewed as having precedence over Beneficence. That is, individuals should be free to make bad decisions. Still, in more collectivist cultures in which individuals, particularly family members, assume a high level of responsibility for one another, Respect for Autonomy does not occupy the same privileged position (Elliott, 2001). Even in individualistic societies, professionals are called upon to emphasize Beneficence over Respect for Autonomy at times. For example, the group psychotherapist might need to sacrifice Respect for Autonomy to protect a suicidal member.
Table 1.1 lists the principles, their definitions, and one or more examples of each.
Table 1.1 Core Ethical Principles as Applied to Group Psychotherapy Principle | Definition | Example of Behaviors Consistent with Principle |
Non-maleficence | The group psychotherapist will avoid actions that lead to harm for group members or other entities such as the therapist's profession or society at large. | The group psychotherapist avoids using techniques that have been shown to be harmful to members. |
Beneficence | The group psychotherapist will engage in actions that lead to positive outcomes for members. | The group psychotherapist develops a strong therapeutic alliance with members. |
Respect for Autonomy | The group psychotherapist honors membersā right to self-determination. | The group psychotherapist alerts the prospective member of the risks of group treatment. |
Justice | The group psychotherapist strives to provide equitable and fair treatment. | The group psychotherapist works in a physical environment that is accessible to individuals with varying physical abilities. |
Fidelity | The group psychotherapist gives priority to the membersā interests over self-interest. | A group psychotherapist, rather than abandoning group members, makes provisions for them in case the therapist needs to terminate the group. |
Although it is sometimes necessary to place one principle ahead of another, doing so should not entail abandoning those ethical principles that were not given the greatest weight. The group psychotherapist should find solutions that, while giving deference to a particular principle, allow other principles to be honored as much as possible. In our example of the individual therapist attempting to encourage a member to pursue group treatment, it would behoove the therapist to acquaint the member with the likely benefits of the group and to provide the individual with tools for managing any negative feelings that group treatment would evoke. In this way, the clinician would be at once observing the principle of Respect for Autonomy (by giving the member information about possible uncomfortable experiences) while heeding Beneficence (by diminishing the likelihood that worry about negative feelings will control the member's decision-making). Box 1.1 describes a training circumstance involving a conflict between ethical principles.
Box 1.1 Applying the Principles
Lettice was a second-year student in a doctoral program in clinical psychology. Lettice's academic advisor, who had her in a case conference that semester, noticed that she participated rarely. Lettice disclosed that she had always felt discomfort in group situations and frequently was passive. She expressed frustration over this longstanding reticence. The advisor recommended a particular private-practice outpatient group, which Lettice did join. Six months later, when the advisor met with her, he made a comment about an event in her family that she had mentioned in a group session and to a few close friends in the program. Lettice believed it was far more likely that he received information from the former rather than the latter source. She confronted him, saying it was evident to her that some communication had occurred between the therapist and advisor. She went on to say that both had acted unethically, and she intended to discontinue with the group. The advisor said that he had had a few conversations with the therapist and that it was to her benefit that some coordination occu...
