Ethical Issues in Psychotherapy

by Mary Stefanazzi

Introduction

In order to consider the role of ethics in the profession of psychotherapy, it is my intention to enquire into the topic of ethics under the following headings:-

• What are ethics?
• Why are they important?
• When do ethics not help?

I will use examples from my experience as an accredited psychotherapist and supervisor, in addition to examining related published literature and debating my findings.

What are ethics?

According to Aristotle (1963), morality consists in performing certain acts not because we recognise them as right in themselves, but because we see that they will bring us nearer to our end, viz. ‘the good for man’. Page and Wosket (1994) acknowledge that the theory underlying the establishment of ethical principles has its roots in moral philosophy. The purpose of such principles is, in general, to assist in determining how to act, how to decide what is good and what is bad. They outline five ethical principles as a basis for evaluating what constitutes good practice in psychotherapy. Autonomy – working towards the person being able to exercise maximum choice in his or her situation, fidelity – being faithful to promises made, justice – ensuring that benefits are distributed fairly, beneficence – to work to the benefit of others, and nonmaleficence – to do no harm to others. Relating these concepts to ethical issues which can arise on meeting a new client, for example, the readiness of that client for psychotherapy at this time; the match or mismatch between the needs of the client and the competence of the therapist; the competing financial need of the psychotherapist for a client, illustrates that issues of fidelity, justice, beneficence and nonmaleficence are brought to the fore in the first session.

“The role of psychotherapy is to facilitate the client’s work in ways which respect the client’s values, personal resources and capacity for self determination. The aim is to empower clients and encourage them to take control of their lives. Only when both therapist and client explicitly agree to enter into a therapy relationship does it become ‘psychotherapy’.” (See IAHIP Code of Ethics, p 1-2)

Ethical issues come into every aspect of my work on a daily basis. From the very first contact with a potential client, I find myself needing to reflect ‘…is this person ready for therapy? …am I the appropriate therapist? …does this person have sufficient capacity to examine their internal world and at the same time be able to function adequately?’  This reflection process is on-going for me. Sometimes it results in clarity, sometimes more questions arise. My personal value system, moral code and or ethical stance in relation to my work are what form the foundation for each decision I make. I am eager for lively exchange, debate, argument, on how others manage these dilemmas.

Psychotherapists, coming to me for supervision, rarely mention ethical issues. When I name an issue as an ethical one for reflection on, this is often met with confusion and lack of skill in how to approach such a task. These supervisees often say ethical issues are rarely referred to in training, beyond drawing attention to the relevant professional code of ethics.

Curious about the absence of on-going discussion on a topic which I considered to be a routine aspect of the work of a psychotherapist, I decided to compare my view with others by conducting an informal survey. During the month of January 2009 I asked every psychotherapy colleague I came in contact with for their first thoughts on the subject of ethics. The responses were as follows:-

•  Lots of paperwork
•  Codes of ethics and regulation issues
•  Trouble
•  Conflict between personal ethics and the ethics of the organisation they worked for
•  Issues around personal safety, i.e. suicide
•  Not an everyday concern and would not come to mind regularly
•  Have read the code of ethics but none of it has really sunk in
•  Refer to the code of ethics only when stuck
•  The role of ethics is unclear when put on the spot

Only one person had considered deeply the issue of ethics and displayed an in-depth understanding far beyond my knowledge of ethics. On further questioning, it emerged that this knowledge related to studies undertaken which were not connected to psychotherapy trainings. I concluded from this information that whatever ethics means to the individual psychotherapist, the collective response was clearly that ethics is not high on the agenda. I then turned to the literature to survey its answers to the questions I posed in my introductory paragraph.

Why are ethics important?

It is my intention to demonstrate here that ethics are important, because they provide a map, a science of morality, which can support us to determine where our duty lies, what is the right course of action to take, that will cause no harm, and is not limited to personal advantage.

Daniel (2006) suggests that in order to do the right thing, we sometimes have to act against our inclinations and that it can be hard to tell whether we are doing the right thing for the right reasons, as opposed to self-interested ones. The point Kant makes is that an action’s moral worth lies in the maxim, or rule of conduct, upon which it is decided, not on its consequences. I find this approach unhelpful when related to practical examples. To illustrate this point, there are conflicting views among therapists with regard to the issue of mandatory reporting of sexual abuse. While not yet a legal requirement in Ireland, the personal, moral, and ethical stance of the therapist will influence their response to a client disclosing abuse. The arguments for and against are based on consequence e.g. What affect has reporting on the therapeutic relationship? What affect has not reporting, if there are others potentially at risk in the wider community?

According to Tjeltveit (1999) informed consent is a legal and ethical concept which obliges professionals to provide clients with information of relevance to them about the prospective relationship, such as goals, procedures, possible benefits and side effects, and alternatives. Ensuring clients are knowledgeable about therapy, supports their capacity to engage in informed consent, which protects their rights and autonomy. He suggests that therapists need to provide clients with information about its ethical dimensions, including possible value conflicts between therapists and clients in a manner and extent that is appropriate to the particular therapeutic relationship. I agree with his view, and think it would therefore be a necessary for each therapist to have an explicit ethical framework as a foundation from which to work. There will always be a range of issues about which the therapist may have strong feelings that require reflection. Some examples are issues like abortion, in vitro fertilisation, homosexuality, promiscuity, self-harm, suicide, and criminal activities.

In the example of a client disclosing sexual abuse there is potential for a value conflict here between therapist and client when the therapist wants to report, and the client does not want the disclosure to be reported. If this has not been explicit at the outset, has the client been afforded the opportunity to make informed consent? I would argue they have not, and would suggest the implication of such an omission has the potential to breach the principle of nonmaleficence – to do no harm to others.

This example illustrates the difficulties some issues present, and that one ethical maxim is not sufficient. We need a varied knowledge of ethics and how to apply the principles to give guidelines from which to make difficult decisions. It is unlikely that ethical deliberation will result in clear, clean results. The nature of dilemmas relating to sexual abuse, suicide, and breaches of confidentiality require carefully reasoned consideration, which can stand up to scrutiny. Wiener (2001) agrees that ethics inform our codes of practice which place great stress on the moral importance of respecting our client’s right to confidentiality. He emphasises its link to the relationship of trust which is so crucial to our work, and suggests that ethical dilemmas are most likely to occur when conflicts of values are experienced.

I think the answer to why ethics are important, is well summarised by Bond (1996). In discussing the rational basis for ethics, he concludes with the comparison, that non-moral value choices tend to relate to the well-being of the person making the choice, while moral choices are linked to the well-being of the community or society as a whole.

In this section I have shown why ethics are important. In conclusion, my evaluation is that an ethical foundation needs to provide a structural basis to support the process of identifying and considering ethical dilemmas, from a variety of standpoints. While such a foundation will be the basis for codes of ethics and practice, its scope I believe, needs to extend wider than codes of ethics and legislation.

When do ethics not help?

Harris (1991) discusses the tragedy of his daughter’s suicide and how the college doctor who treated her was not aware of her previous history in relation to mental difficulties and previous suicide attempts, due to being restricted by his code of confidentiality. Her parents could not be informed without her expressed agreement because she was over eighteen. He makes the point that for a possible vital history to be obtained; medical ethics required a rational decision from a patient who was hearing the voices of a hundred or more imaginary people. He concludes with the thought,

“A reappraisal of the criteria used to make decisions in such cases may help all concerned. It does not seem right that the application of any rule should result in the mentally ill being discarded to cry in a wilderness of despair.” (1991)

Standpoint theory as described by Baggini and Fosl (2007) speaks to the dilemma outlined above. Not all standpoints are equal, and if moral reasoning is tied to one standpoint, then those with different standpoints will reason about ethics differently. How can we therefore judge the competing claims of different standpoints? They stress the danger of presenting the viewpoint of a particular social group as being more homogenous than it really is. While Harris felt his daughter was discarded and let down by the ethical restrictions of her helpers, he does not, understandably in the circumstances, acknowledge her choices or those of her doctors. It is possible, that she got the help she required at that time. The unfortunate reality is that we often never know the precise standpoint of the person who takes their own life.

Conclusion

In this examination of some of the ethical issues relating to psychotherapy, my summation is that we do have a responsibility to consider our personal, moral and ethical views on a wide range of issues, preferably not limited by the likelihood of them arising in practice. Bond (2000) refers to his personal experience with regard to the challenge faced by therapists who seek to work ethically. The diversity of ethical positions held by individual counsellors, their organizations and across cultures has challenged his previous thinking. He anticipates that trend will continue. Reflecting on his practice, he hopes to become more willing to listen in depth to clients who are conscientiously committed to ethics other than those that are familiar and acceptable to him.

My hope for the future would be that individual psychotherapists would use a variety of fora to express a range of standpoints. That they would be heard, respected, challenged and valued for taking that risk, with view to creating an environment that can foster a culture of ethical thinking which would support analysis and synthesis, without the need to always arrive at clear cut answers.

Mary Stefanazzi is an accredited Psychotherapist and Supervisor with a particular interest in ethics, and welcomes questions or comments to mstefanazzi@eircom.net.

Bibliography

The following bibliography is divided into three sections consisting of books, articles, and Internet resources.

Books

Aristotle. (1963). Ethics. London : Dent

Baggini, J. and Fosl, P. S. (2007) The Ethics Toolkit. Oxford : Blackwell.

Barnes, F P, Murdin L. (Wiener, J.) (2001) Values and Ethics in the Practice of Psychotherapy and Counselling. Buckingham : Open University Press.

Bond, E. J. (1996) Ethics and Human Well Being. Oxford : Blackwell.

Bond, T. (2000) Standards and Ethics for Counselling in Action. London : Sage.

Daniel, D. M. (2006). Kant’s Groundwork of the Metaphysics of Morals. London : SCM Press.

Page, S. and Wosket, V. (1994). Supervising the Counsellor. London : Routledge.

Tjeltveit, A. C. (1999). Ethics and Values in Psychotherapy. London : Routledge.

Wiener, J. (Barnes, F P, Murdin L) (2001) Values and Ethics in the Practice of Psychotherapy and Counselling. Buckingham : Open University Press.

Articles

Harris, R. (1991) When ethics do not help. British Medical Journal, Volume 303 : p.1143.

Internet Resources:

Irish Association of Humanistic and Integrative Psychotherapy, (IAHIP). 2005. Code of Ethics and Practice for Psychotherapists. [Online] Available from: http://www.iahip.com/ethics.htm  [Accessed 19.2.2009]