Module 3
Professional Issues & Ethical Practice
a. Professional Issues
Therapists of all backgrounds face similar professional issues involving
licensing and certification, the evaluation of work by peers, and interacting with
managed-care organizations. This introduces important aspects of each area. We hope
this brief survey will stimulate curiosity about professional ethics, as there is not a day
in clinical practice when ethical questions do not arise.
Statutes in each state in the United States and in all Canadian provinces
regulate professional practice (e.g., medicine, law, psychology, clinical social work,
etc.). Many licensed professionals provide family therapy. Since 1970, there has been
a concerted effort to set legal standards for credentialing marital and family therapists
(MFTs). Licensure has become synonymous with professionalism (Wilcoxon,
Remley, & Gladding, 2011), and reimbursements from health plans for providing
clinical services are paid only to licensed providers. Several important premises
support efforts at licensure.
Possessing a license, of course, does not ensure competency. Licenses are
generic in that they do not specify what client problems the licensee is competent to
work with nor what techniques he or she is trained to use. In the case of working with
families, for example, a practitioner may be trained to work with individuals while
lacking the experience or skills for family interventions. Ethically, that person should
seek additional training and supervision before undertaking clinical work in a new
modality (Patterson, 2009). In practice, however, the therapist accustomed to working
with individuals may sometimes erroneously convince himself or herself of
competence to provide family therapy without the necessary education, training, and
awareness of new developments in the family field.
An individual seeking professional status to provide marital and family
therapy may earn a graduate and/or professional degree from a university or obtain
professional preparation at a center offering specialized training in marital and family
therapy. A person who follows the academic route and has obtained the requisite
training supervision in a program accredited by the appropriate professional
association (APA, AAMFT, NASW, or CACREP) may seek either licensing or
certification (according to the law governing practice in a particular state or province).
State licensing law, more restrictive than certification, regulates who may practice
(e.g., licensed psychologist, licensed MFT, licensed clinical social worker, licensed
professional counselor) by defining educational and experience criteria, administering
qualifying examinations, and stating the conditions under which a license may be
revoked (terminating the right to practice). A license restricts who may use the title
(say, MFT or LCSW) and who may engage in practice.
State certification law, a weaker and less comprehensive form of regulation,
simply certifies who has the right to use a particular professional title. Such a law
does not govern practice or define permissible activities but simply guarantees that the
title (e.g., “psychologist”) will be used only by people who meet the standards
established by the law. Certification laws set up criteria for issuing and revoking
certificates, monitoring practice, at least regarding use of the title. Less desirable than
licensing, state certification may represent what advocates of a particular discipline
are able to achieve in the state legislature, often because of opposition from other
mental health occupations.
Regulatory boards and legislatures in many states have mandated the
successful completion of specific continuing education (CE) courses (e.g., child
abuse, human sexuality, chemical dependency, supervisory competence), plus
requiring a minimum number of CE hours (attending lectures, conferences,
workshops, local and national conventions) as a condition of renewing a license or
certificate. These mandates are an effort to ensure that practitioners remain current in
theory and practice, so they can offer the most up-to-date services (Nagy, 2005) and
retrain if they wish to change areas of practice. Family therapists are most likely to
attend annual meetings of the American Association for Marital and Family Therapy
(AAMFT), the American Family Therapy Academy (AFTA), the Psychotherapy
Networker Symposium, and the multidisciplinary American Orthopsychiatric
Association (AOA) meetings, in addition to conventions of the major organizations
(American Psychological Association, National Association of Social Workers,
American Counseling Association).
After a slow start, licensing of MFTs proceeded swiftly in the United States.
One reason for the lag in licensure was that some psychotherapy professions initially
opposed an independent profession of marital and family therapy, seeing it as but a
subspecialty of psychotherapy. However, MFTs argued that they are a separate
profession and that university preparation in a mental health field generally does not
sufficiently emphasize work with couples and families. Indeed, graduates of most
programs should seek additional education and training in couple and family therapy
if they wish to practice in the field. The subject remains controversial, touching on
such professional issues as eligibility for third-party payments from health insurance
plans to cover the treatment of marital or family dysfunction. Clearly, practitioners
educated to work with individual clients need further training before working with
families. On the other hand, some family therapists may lack the education and
training to treat individuals.
Marriage and family therapy practice is now regulated in all 50 states plus the
District of Columbia (West, Hinton, Grames, & Adams, 2013), and two Canadian
provinces have regulatory bills. Requirements may vary between states, although all
require that those licensed or certified as marriage and family therapists meet certain
educational and clinical experience criteria, usually comparable to the standards for
Clinical Membership in AAMFT. There were more than 50,000 licensed or certified
MFTs in the United States and Canada in 2015, and their interests are represented by
AAMFT (AAMFT, 2015).
Monitoring, examining, or assessing the work of one’s colleagues or having
one’s own work reviewed by one or more colleagues is hardly new for anyone who
has completed a training program in any of the disciplines involved in couple and
family therapy. By the time someone has become a professional, she or he typically
has presented work samples in numerous case conferences, as well as having been
videotaped or observed through a one-way mirror working with families. No doubt,
supervisors and classmates have dissected cases while in training. Having become a
professional, a therapist may seek further consultation when therapeutic issues arise,
in dealing with otherwise difficult or sticky clinical procedures, or whenever
upcoming ethical decisions need scrutiny. Therapists in private practice often seek
such self-regulating peer review and peer support by belonging to peer-consultation
groups, in which they deal with problematic cases, discuss ethical and legal issues that
arise, and exchange experiences to counter feelings of loneliness that are an inevitable
part of functioning as a sole practitioner. Professional participation in a community of
colleagues both sustains one’s professional health or competence and contributes to
the positive functioning of other therapists.
Peer review is also characteristic of publishing research in journals as a means
to ensure the validity, meaning, and value of the work to the profession. Before
accepting articles for publication, editors will ask professionals to evaluate them.
Articles will be accepted or rejected based on the collective view of the reviewers.
Typically, researchers provide in journal articles their hypothesis, the methodology
they use to explore the hypothesis, the results, a discussion of the results,
recommendations for further research, and conclusions. This process is designed to
ensure that the profession receives the most valuable and properly researched
information. It is generally viewed as an ethical responsibility for professionals to
remain current by reading professional journals.
The journal-review process is itself subject to ethical evaluation. Brock,
Whiting, Matern, and Fife (2009) note that the integrity of research in marriage and
family therapy is threatened by a reported increase in the fabrication, falsification, and
plagiarism occurring in research across all the sciences. These researchers claim that
MFT professionals lag behind researchers from other disciplines in taking
responsibility for the veracity of its research literature. They recommend that authors
of published research state in writing that their data are valid, and they reveal any
conflicts of interest that could possibly have influenced their hypotheses,
methodology, and conclusions. They also suggest that the ethical code for the
profession be expanded to include integrity training as part of a person’s training and
ongoing professional experience.
Managed care is the dominant economic force in healthcare delivery in the
United States. It has a profound impact on the way therapists and clients interact.
Managed care has forced psychotherapists to change professional billing practice
from insurance carriers (“third-party payors”) on a fee-for-service delivery basis to
managed care. Employers, who pay the major portion of healthcare bills for their
employees, want to control escalating costs. The Affordable Care Act is not fully
understood, but the law requires coverage of behavioral health, which includes mental
health and substance-abuse services. Family therapists who are educated and trained
to work with covered issues in a systemic fashion with demonstrated effectiveness
could benefit from the Act (Loewy, 2013). As of 2015, information on the subject can
be found at www.HealthCare.gov/coverage/ mental-health-substance-abuse-coverage.
Managed-care organizations contract with employers, insurance companies, or
union trusts to administer and finance their health benefit programs. Increasingly,
employers who offer health benefits have opted for managed-care programs—prepaid
health insurance coverage in which, in addition to employer contributions, a fixed
monthly fee is collected from each member enrolled who has voluntarily chosen to
participate in a particular medical (including mental health) plan as a subscriber.
Although marital and family therapy often is not covered by managed care, it may be
if it can be shown that overall healthcare costs decrease or the client can be treated in
a cost-effective manner in couple or family therapy (Crane & Christenson, 2012).
Managed care creates contracts between a therapist (usually referred to as a
provider) or a group of therapists, and a health maintenance organization (HMO), a
type of managed-care system. In exchange for being admitted into the provider
network and agreeing to accept referrals by being part of the HMO roster, the
professional agrees under contract to provide services for a previously negotiated fee
(usually significantly lower than the customary rates of fee-for-service providers in
the community) and to abide by the managed-care organization’s explicit provisions.
Managed-care groups believe that by monitoring practitioner decisions and insisting
on time-limited interventions, they are increasing provider accountability and
ensuring efficient and effective treatment. Critics argue that the quality of care is
frequently sacrificed by organizational decisions based primarily on financial rather
than clinical considerations.
In an attempt at cost containment, managed-care plans typically call for
preauthorization before the therapist may begin treatment and further authorization
after a previously approved number of sessions (with annual and lifetime cost caps).
Typically, only a limited number of sessions per designated period are approved, and
the client’s choice of therapist is restricted to providers on the managed-care roster.
Managed-care programs may limit services and require use of treatment manuals for
short-term interventions. Managed mental healthcare programs usually include a fixed
number of mental health practitioners (individually or as part of a provider network);
others are excluded when the panel of providers is full—a particular problem for
newly licensed practitioners attempting to enter the field. Referrals are made to
providers within defined geographic areas; in many plans, the practitioner must be
available for emergencies on a 24-hour basis.
Whether a client can be seen, for how many visits, at what fee, covering what
services, for what problems or conditions—all are negotiated with the managed-care
organization. Peer reviewers or case managers (usually but not always professionals)
act as “gatekeepers,” carrying out utilization reviews, the conclusions of which often
conflict with the practitioner’s ideas about how best to manage the case. Such
utilization reviews, ostensibly directed at determining the necessity and
appropriateness of the practitioner’s services, occur at regular intervals throughout
treatment. They may thus represent an implicit threat of termination of benefits before
the practitioner believes the client or family is ready to stop treatment. Justifying the
continuation of treatment for an additional number of sessions often requires
considerable supporting documentation or lengthy telephone conversations with a
managed-care reviewer (Davis & Meier, 2001). It is the therapist’s responsibility to
explain why services are necessary and to account for procedures carried out; the
lengthy paperwork and frequent reimbursement conflicts with reviewers are often a
source of stress and potential burnout for clinicians with heavy managed-care
caseloads.
Many practitioners become frustrated with managed-care organizations
because of the amount of paperwork required, the low fees received, and time spent
arguing for payment. As a result, some opt out of the network. These therapists
require that their clients pay them directly at an agreed-upon rate that can be
negotiated and to assume their own responsibility in working with the managed-care
or other insurance organization to possibly arrange for some coverage. Indeed, some
organizations do offer subscribers some reimbursement for sessions with out-of-
network providers, but the amount is generally less than it would be if the subscriber
used an in-network provider. Managed-care plans support short-term, directive,
problem-solving therapy aimed at returning clients to previous levels of functioning.
These plans limit treatment to whatever it takes to return clients to a functional level
as soon as possible but nothing more. A secondary goal is to prevent recurrence of the
presenting symptoms. Just how much treatment is enough remains debatable, argued
between case managers and therapists.
Most managed-care organizations require subscribers to sign an information
release form, permitting their therapist to disclose private information ordinarily kept
confidential. Thus, while the therapist traditionally seeks to protect the clients’
privacy, as an HMO provider, he or she is called upon to share information—
diagnosis, types of services provided, duration of treatment—that compromises all
previously determined ideas regarding confidentiality. Because therapists can no
longer assure clients of confidentiality, clients may withhold vital information from
the therapist or, in more extreme cases, refuse to seek treatment when needed (Acuff
et al., 1999). The current challenge involves training therapists in time-limited
interventions and engaging family therapists in outcome research that measures
clinical effectiveness and cost effectiveness. Managed care requires therapists to
reexamine their professional ethics, rethink how best to allocate professional
resources, account for what they do with clients, and develop short-term effective
interventions.
Every practitioner is exposed to the possibility of financial liability—the
possibility that the therapist intentionally or unintentionally harmed a client in some
specific manner and consequently may be financially accountable. While such suits
are still relatively rare, there remains the possibility, especially in an increasingly
litigious society, that clients may file a legal malpractice suit against a therapist for
one or more of the following reasons: breach of confidentiality, sexual misconduct,
negligence, breach of contract (regarding such items as fees, promised availability),
failure to protect clients from a dangerous person’s conduct, or even for exercising
undue influence over a patient.
When clients or their families bring malpractice charges against therapists into
civil court, the legal landscape becomes multifaceted, encompassing not only
compensatory damages but also punitive damages, adding layers of complexity to the
proceedings and potential outcomes.
Compensatory damages serve as a means of redress for the tangible losses
suffered by the plaintiff as a result of the therapist's alleged malpractice. These losses
may include medical expenses, loss of income, pain and suffering, and other
quantifiable damages incurred as a direct consequence of the therapist's actions or
omissions. Assessing the extent of compensatory damages requires a meticulous
examination of the plaintiff's injuries, the economic impact of those injuries, and the
degree to which the therapist's conduct contributed to the harm suffered.
In addition to compensatory damages, plaintiffs may seek punitive damages as
a form of punishment for the therapist's egregious or reprehensible behavior. Unlike
compensatory damages, which aim to compensate the plaintiff for their losses,
punitive damages are intended to deter future misconduct and hold the therapist
accountable for their actions. To warrant punitive damages, the plaintiff must
demonstrate that the therapist's conduct was not merely negligent but rose to the level
of recklessness, wantonness, or malice. This necessitates a showing of intentional
wrongdoing or a conscious disregard for the rights and safety of the client.
The assessment of punitive damages involves a nuanced analysis of the
therapist's conduct, including any aggravating factors such as a pattern of misconduct,
deliberate deception, or exploitation of the client's vulnerability. Courts may consider
various factors in determining the appropriateness and amount of punitive damages,
including the severity of the harm caused, the degree of reprehensibility of the
therapist's conduct, and the therapist's financial resources.
Moreover, the pursuit of punitive damages introduces additional complexities
and uncertainties into the legal proceedings, as plaintiffs must meet a higher burden of
proof and navigate potential challenges from the defense. The determination of
punitive damages is often subject to judicial discretion, further underscoring the need
for a thorough and compelling presentation of evidence and legal arguments.
In light of these complexities, the prospect of punitive damages underscores
the importance of diligent preparation and strategic advocacy for both plaintiffs and
defendants in malpractice litigation. Plaintiffs must effectively demonstrate the
egregiousness of the therapist's conduct and the need for punitive measures, while
defendants must vigorously defend against allegations of misconduct and mitigate the
risk of punitive sanctions.
Ultimately, the pursuit of compensatory and punitive damages in malpractice
litigation reflects the dual objectives of seeking redress for the plaintiff's losses and
holding therapists accountable for their actions. By navigating these legal challenges
with diligence, integrity, and a commitment to justice, plaintiffs and defendants alike
can strive to achieve a fair and equitable resolution that upholds the principles of
accountability and restitution within the mental health profession.
Malpractice, either deliberately or through ineptitude or carelessness, is the
most likely form of alleged wrongful behavior to produce client litigation. Here the
therapist is accused of failing to render professional services or exercise the degree of
skill ordinarily expected of other professionals in a similar situation. That is,
professional negligence is said to have occurred; the claim is that the therapist
departed from usual practices or did not exercise sufficient care in carrying out her or
his responsibilities. (One important note: Practitioners are not expected always to
make correct judgments or predict the future, but they are expected to possess and
exercise the knowledge, skills, and standards of care common to members of their
profession.)
When therapists face allegations of malpractice, the legal process they undergo
is not only arduous but also emotionally taxing, regardless of the outcome. While the
legal standard for assessing malpractice hinges on the actions deemed appropriate for
therapists with similar qualifications and duties, the ramifications of such lawsuits
extend far beyond the courtroom.
From the moment allegations are levied, therapists often find themselves
grappling with a whirlwind of stress, uncertainty, and financial strain. Mounting a
defense against malpractice claims entails a significant investment of time, energy,
and resources, as therapists must collaborate with legal counsel, compile evidence,
and prepare for litigation. Moreover, the emotional toll of navigating the legal process
can be profound, as therapists contend with feelings of vulnerability, shame, and self-
doubt in the face of professional scrutiny.
Even in cases where therapists are ultimately exonerated and the lawsuit fails,
the repercussions linger long after the legal battle concludes. The stigma associated
with being accused of malpractice can cast a shadow over their professional
reputation, eroding trust and confidence in their clinical abilities. Additionally, the
financial burden of legal fees and related expenses can take a substantial toll on
therapists, jeopardizing their financial security and impeding their ability to sustain
their practice.
Furthermore, the psychological impact of defending against malpractice
claims cannot be understated. The experience of being subjected to legal scrutiny and
questioning of one's professional judgment can trigger feelings of anxiety, depression,
and burnout, undermining therapists' well-being and resilience. Moreover, the
lingering psychological distress resulting from the ordeal may impede therapists'
capacity to effectively support their clients, further exacerbating the collateral damage
of malpractice litigation.
In light of these challenges, it is imperative for therapists to prioritize self-care
and seek support from colleagues, mentors, and mental health professionals during
and after the legal process. Cultivating a strong support network and engaging in
proactive strategies for coping with stress can help therapists navigate the emotional
aftermath of malpractice allegations and safeguard their well-being.
Additionally, institutions and professional organizations have a responsibility
to provide robust support and resources to therapists facing malpractice claims,
including legal assistance, peer consultation, and advocacy on behalf of their
members. By fostering a culture of support and solidarity within the mental health
community, these entities can help mitigate the adverse effects of malpractice
litigation and promote the resilience and professional integrity of therapists.
In conclusion, the experience of defending against malpractice claims is
fraught with challenges, both practical and emotional, that extend far beyond the
courtroom. By acknowledging the profound impact of malpractice litigation on
therapists' well-being and professional identity, and by implementing measures to
support and protect therapists facing such challenges, we can foster a more resilient
and compassionate mental health community.
One common ground for a malpractice suit is sexual contact (Pope & Vasquez,
2010), and many states have now declared such activity to be a felony. As attorneys
Stromberg and Dellinger (1993, p. 8) note, “for therapists who have engaged in sexual
intimacies with patients, a finding of liability against the therapist is highly likely”
(italics theirs). All mental health professional ethics codes prohibit sexual contact with
clients. Any initial consent by the patient is not a defense, since it is assumed that the
client may be experiencing emotional distress, feel low self-esteem, and thus be in a
position of greater vulnerability to sexual exploitation than under normal
circumstances. A history of emotional or sexual abuse may increase vulnerability and
compound the subsequent damage inflicted (Pope & Vasquez, 2010).
Under such circumstances, the courts reason that refusing the overtures of an
unscrupulous therapist, whose motives the client wants to trust, may be difficult—
especially if the therapist labels such advances as “therapeutic” for relieving the
client’s problems (Welfel, 2013). Such clients are likely to experience impaired ability
to trust, confused roles and boundaries, emotional lability, suppressed rage,
ambivalence, increased suicide risk, and cognitive problems. If the therapist is found
guilty by the court, the likelihood of a suspended or lost license is substantial, as is the
probability of losing a malpractice suit with major financial consequences.
Beyond lawsuits for sexual misconduct, claims of malpractice are likely to
involve participating in nonsexual dual or multiple relationships (such as going into a
business venture with a client) or performing incorrect treatment (incompetence in
choosing a treatment plan; see Pope & Vasquez, 2010). Failure to prevent suicide by a
client and breaches in confidentiality are also frequent causes for malpractice suits
(Welfel, 2013). Assessing the risk of suicide typically involves inquiring about
previous suicide attempts, about thoughts or impulses regarding killing oneself, prior
incidents of self-harm, the development of a specific suicide plan, or a family history
of attempted or completed suicides (Baerger, 2001).
In general, for a malpractice suit to succeed, four elements must be present: (a)
a professional relationship existed so that the therapist incurred a legal duty to care;
(b) there is a demonstrable standard of care that was breached when the practitioner
performed below that standard; (c) the plaintiff suffered harm or injury, physical or
psychological; and (d) the professional’s breach of duty due to negligence or injurious
actions was the direct cause of the harm done to the plaintiff. The plaintiff must prove
all four elements exist in order to win the malpractice litigation.
The matter of suicide within the context of therapy is one of profound
complexity, where ethical, legal, and clinical considerations intersect. When
evaluating the potential liability of a practitioner in cases of suicide, it necessitates a
thorough examination of the practitioner's duty of care, the adequacy of risk
assessment and management strategies, and the documentation of their actions.
At the crux of this issue lies the question of foreseeability: could the
practitioner have reasonably anticipated the risk of suicide based on a comprehensive
assessment of the individual's psychological state and documented findings? This
demands not only a meticulous evaluation of the client's presenting symptoms and
history but also an understanding of the myriad factors that contribute to suicide risk,
including psychiatric diagnoses, life stressors, substance abuse, and access to means.
Furthermore, assessing whether the practitioner took reasonable care or
precautions to prevent the self-destructive act requires a nuanced analysis of their
clinical interventions and risk management strategies. This encompasses not only the
formulation of a robust treatment plan tailored to the individual's needs but also the
implementation of specific interventions aimed at mitigating suicide risk, such as
safety planning, crisis intervention, collaboration with other healthcare providers, and
mobilization of support networks.
The documentation of these efforts assumes paramount importance, serving as
a record of the practitioner's diligence, adherence to professional standards, and
commitment to client safety. Thorough documentation not only provides insight into
the practitioner's decision-making process but also serves as a safeguard against
potential legal liability, demonstrating that reasonable care was taken to address the
client's suicidal ideation and mitigate the risk of self-harm.
However, despite the practitioner's best efforts, the tragic reality is that suicide
is not always preventable, and individuals may still choose to take their own lives
despite the interventions undertaken by their therapist. In such cases, liability may
arise if it can be demonstrated that the practitioner failed to take appropriate action or
engaged in conduct that contributed to the suicide attempt.
Navigating the delicate balance between supporting client autonomy and
ensuring their safety in the face of suicidal ideation underscores the profound ethical
challenges inherent in mental health practice. Practitioners must strive to uphold the
highest standards of care, continually reassessing and adapting their approach to meet
the evolving needs and risks of their clients while recognizing the limitations of their
ability to prevent all instances of self-harm.
In conclusion, the issue of liability in cases of suicide demands a
comprehensive examination of the practitioner's duty of care, the adequacy of risk
assessment and management strategies, and the documentation of their actions. By
adhering to professional standards, exercising diligence in their clinical practice, and
engaging in ongoing education and self-reflection, practitioners can mitigate the risk
of liability while prioritizing the safety and well-being of their clients.
Professional liability insurance is necessary for all family therapists (unless the
organization for which they work carries malpractice insurance covering them). Most
professional organizations, such as the APA, the NASW, and the AAMFT, offer group
professional liability (malpractice) insurance for purchase by their members.
Therapists are also called into court to be witnesses in cases that involve clients. In
these instances, the therapist is not the target of a suit but a participant providing
testimony in support of someone else’s suit. Marriage and family therapists might, for
example, be called to court by divorcing parents suing each other for child custody to
testify about a child’s home environment, the quality of her or his emotional
development, the emotional stability of one or the other parent, and on various
custody practices.
Indeed, the intersection of therapy and legal proceedings can present complex
ethical dilemmas, particularly concerning confidentiality. When therapists engage
with couples grappling with the possibility of divorce or custody battles, the issue of
confidentiality takes on added significance. While confidentiality is a cornerstone of
the therapeutic relationship, there are circumstances where the therapist may be
compelled to disclose information, albeit with careful consideration and adherence to
ethical guidelines.
In situations where legal proceedings are imminent or ongoing, therapists must
navigate a delicate balance between respecting client confidentiality and fulfilling
legal obligations. For instance, if a court issues a subpoena requesting the disclosure
of therapeutic records or testimony from the therapist, it can pose a formidable ethical
quandary. In such cases, therapists are duty-bound to weigh the imperative of
maintaining trust and confidentiality against the legal mandate to disclose
information.
Furthermore, the therapist's obligation to maintain confidentiality extends not
only to their clients but also to other individuals involved, such as children or third
parties affected by the proceedings. This adds another layer of complexity, as
therapists must carefully consider the potential impact of disclosure on all parties
concerned.
One approach therapists may employ to address these challenges is to
proactively discuss confidentiality and its limitations with couples at the outset of
therapy. By clarifying the circumstances under which confidentiality may be
breached, therapists empower clients to make informed decisions and mitigate
potential conflicts down the line.
Additionally, therapists can collaborate with couples to establish boundaries
and develop strategies for safeguarding sensitive information. This may involve
exploring alternative means of resolving disputes or engaging in mediation to mitigate
the need for formal legal intervention.
In instances where disclosure is unavoidable, therapists must adhere to legal
and ethical standards governing confidentiality, ensuring that any disclosure is limited
to the extent necessary and accompanied by appropriate safeguards to protect client
privacy.
Ultimately, the complex interplay between therapy and legal proceedings
underscores the importance of ethical sensitivity, clear communication, and a nuanced
understanding of the therapist's role. By navigating these challenges with integrity and
professionalism, therapists can uphold the trust of their clients while fulfilling their
obligations within the broader legal framework.
These situations may lead to ethical considerations on the part of the therapist.
The first instance—to report abuse—does not generally raise ethical issues, as the law
explicitly commands the therapist to report abuse. Sometimes an ethical issue arises in
the other cases as, for example, when a therapist who had been called to court as a
“fact witness” to provide general information about research or typical professional
practice is also asked to provide opinions about a case. There might be a tension
between providing facts on the one hand and personal professional opinion on the
other. As Woody (2000) advises, when the therapist has to decide “whether or not to
issue an opinion about an ultimate legal question, the mental health practitioner
should consider the empirical research that in fact exists; and without a substantial
amount of research directly applicable to the question, the mental health practitioner
should readily admit that his or her opinion, although steeped in knowledge about
human behavior in general, would not be an expert opinion”
In the delicate realm of couples therapy, particularly when the specter of
divorce or custody battles looms, transparency and clarity from the therapist are
paramount. Before embarking on the therapeutic journey with a couple navigating
such tumultuous waters, it is advisable for the therapist to candidly address their
stance regarding involvement in potential legal proceedings.
By openly expressing their position on participation in court matters, the
therapist affords the couple an opportunity to make informed decisions about the
therapeutic process. This upfront approach allows individuals to assess whether the
therapist's stance aligns with their expectations and needs. Moreover, it establishes a
foundation of trust and clarity, fostering a more productive therapeutic alliance.
A therapist who unequivocally states their commitment to impartiality,
refraining from taking sides in any potential legal battles, provides couples with
assurance that the therapeutic space remains a neutral ground for exploration and
resolution. Conversely, a therapist who possesses the requisite expertise to serve as a
forensic expert in court proceedings can offer couples reassurance of their
competency to navigate such complex legal terrain if required.
The significance of establishing neutrality and transparency at the outset of
therapy cannot be overstated. By articulating their position regarding involvement in
legal matters, therapists empower couples to make informed decisions about their
therapeutic journey. This proactive approach not only minimizes the likelihood of
conflict arising later in the process but also fosters an environment conducive to
constructive dialogue and resolution.
Furthermore, should a couple opt to seek therapy elsewhere based on the
therapist's stance, this early clarification prevents unnecessary friction and ensures
that both parties can pursue alternative avenues that better align with their
preferences.
In essence, the principle of forthrightness regarding the therapist's willingness
to engage in legal proceedings underscores the importance of ethical conduct, clear
communication, and client autonomy in the realm of couples therapy. By adhering to
this guideline, therapists can uphold the integrity of the therapeutic process while
empowering couples to navigate their challenges with confidence and clarity.
b. Maintaining Ethical Standards
Beyond legal regulation through licensing or certification, professions rely on
self-regulation through a variety of procedures—state-mandated continuing education
as prerequisite for license renewal, peer review, consultation with colleagues, and so
forth—to monitor the professional activities of their members. Codes of ethics offer
standards whose potential violation may provoke both informal and formal discipline.
The former involves peer pressure exerted upon violators through consultations
regarding questionable practices; the latter may involve censure by professional
associations, in some cases barring violators from continued membership.
Every major organization devoted to providing psychotherapy has its own
code of ethics to guide professional practices and uphold professional standards.
These codes are periodically updated as community standards and technologies
evolve (such as electronic records or therapy offered over the Internet). Beyond those
codes, governmental regulatory agencies, state licensing boards, specialty
organizations, and local professional associations offer their own guiding principles
for acceptable professional conduct. The national organizations also publish
recommendations for working with specific populations (e.g., guidance on cultural
diversity, on gay and lesbian clients, on accurate record keeping). Each organization
typically has an ethics committee to monitor the conduct of its members, protects the
public from unethical practices, and considers alleged violations of its code by one of
its members.
Should an ethics committee, in response to a colleague or client complaint,
determine that a practitioner has violated the code of ethics of the profession, a range
of sanctions may be imposed. Generally, the degree of seriousness of the violation is
the major determinant of the level of sanction an ethics committee might impose.
Code violations range from behavior reflecting poor judgment compared with
prevailing standards but without malicious intent (e.g., advertising infractions;
inappropriate public statements), which calls for educative resolutions, to those cases
where substantial harm to others has resulted from the practitioner’s behavior, and
that person is not prone to rehabilitation (defrauding insurance carriers; sexual
exploitation), which calls for expulsion from the professional organization. Ethics
committees may be lenient toward a nonmalevolent first offender, ordering an
educative solution; that same offense, committed repeatedly by an experienced but
recalcitrant practitioner, would be met with more severe sanctions.
Ethical codes define standards of conduct subscribed to by members of the
profession, aiding members in their decision making with clients whenever possible
areas of conflict arise. Members pledge to abide by a set of ethical standards that
helps reassure the public that they will demonstrate sensible and responsible behavior.
The codes do not cover all situations but offer general guidelines for responsible
behavior. As Fisher (2012) notes, the competency and judgment gained through
education, training, supervision, experience, and consultation with colleagues
represents the linchpin for fulfilling one’s ethical responsibilities.
Some unique and complex ethical issues arise as therapy shifts from an
individual focus to one that involves a couple and family system. For example, to
whom and for whom does the therapist have primary loyalty and responsibility? The
identified patient? The separate family members as individuals? The entire family?
Only those members who choose to attend family sessions? Suppose different family
members have conflicting goals or conflicting self-interests. Is the primary goal one
of increasing family harmony or maximizing individual fulfilment.
Wilcoxon and colleagues (2013) offer a compelling perspective on the role of
therapists in addressing the complex dynamics within family systems, advocating for
a balanced approach that prioritizes the collective interests of all family members
while facilitating constructive dialogue and negotiation around shared values.
Central to their approach is the emphasis on focusing treatment on the family
system as a whole, rather than privileging the needs or perspectives of any one
individual or subgroup within the family. By adopting a systemic lens, therapists can
gain insights into the interplay of relational patterns, communication styles, and
power dynamics that shape the family's functioning and resilience. This holistic
perspective enables therapists to identify systemic strengths and challenges, paving
the way for targeted interventions aimed at promoting cohesion, resilience, and
adaptive coping strategies.
At the same time, Wilcoxon and colleagues underscore the importance of
assisting families in negotiating among the values they collectively wish to conserve,
modify, or reject. Families are diverse microcosms of cultural, generational, and
personal values, each member bringing their unique perspectives, beliefs, and
priorities to the table. Navigating these differences requires therapists to adopt a
collaborative stance, facilitating open dialogue, fostering empathy and understanding,
and co-creating solutions that honor the diversity of values within the family while
promoting fairness and harmony.
Furthermore, Wilcoxon and colleagues' approach highlights the dynamic
nature of family systems, wherein values, roles, and relationships evolve over time in
response to internal and external influences. Therapists must remain attuned to these
ongoing processes of change, continually reassessing and adapting their interventions
to meet the evolving needs and goals of the family. This may involve revisiting shared
values, renegotiating boundaries, and supporting the family in navigating life
transitions and challenges with resilience and adaptability.
Importantly, the therapeutic process outlined by Wilcoxon and colleagues is
not prescriptive but rather collaborative and client-centered, reflecting a commitment
to honoring the agency and autonomy of families in defining their own path to growth
and healing. Therapists serve as facilitators and guides, empowering families to draw
upon their inherent strengths and resources to forge meaningful connections, cultivate
resilience, and chart a course toward greater harmony and well-being.
In summary, Wilcoxon and colleagues' approach offers a comprehensive
framework for therapists working with families, emphasizing the importance of
systemic perspective, collaborative negotiation of values, and responsiveness to
change. By embracing these principles, therapists can play a vital role in supporting
families in navigating the complexities of their relationships, fostering mutual
understanding and respect, and promoting resilience and harmony in the face of
adversity.
Most family therapists struggle at one time or another with the ethical
dilemma of family needs versus individual needs. More than academic hairsplitting is
involved here. Early feminist thinking represented by Hare-Mustin (1980, p. 935)
warned that “family therapy may be dangerous to your health”; that is, the changes
that most benefited the entire family were not always in the best interests of each of
its members. Hare-Mustin was especially concerned that therapists might influence
female family members to subjugate their individual rights for the sake of family
needs, further perpetuating society’s oppressive gender roles. Margolin (1982) too
was concerned that family therapists might endorse—and thus perpetuate—some
familiar sexist myths concerning women: that remaining in a marriage is usually best
for women, that a woman’s career deserves less attention than her husband’s, that
child rearing is a mother’s sole responsibility, and in general that a husband’s needs
are more significant than a wife’s. Now three decades after these warnings, one would
hope that family therapists have become more gender sensitive and informed and are
better trained from the start to address gender issues.
Ethical issues may also arise in working with families from ethnic
backgrounds whose values would appear to conflict with those articulated by the
profession. Cole (2008, p. 425) asks, “How do therapists deal with the dialectic
between doing what they are trained to do in their profession versus doing what is
culturally appropriate and potentially most beneficial for clients?” She offers the
example of a Latino family who, deeply valuing family connections, asks the therapist
to their home for dinner and to meet extended family members. Professional ethics,
she notes, would strongly caution against accepting the invitation, but to decline
would be to risk losing the clients’ trust and damaging the relationship with them. She
offers as a possible solution the notion that since the therapist–client relationship is a
value of paramount importance in all therapy relationships, this clinical and
theoretical dimension should be included in any conceptualization of multicultural
competency. She also suggests that therapists maintain a respectful curiosity and a
professional openness and receptivity to cultural difference. And finally, her view is to
allow the client’s worldview to have greater influence on our interpretations and
constructions of our ethics and theory.
Family therapists inevitably engage in an active valuing process with families,
whether intentionally or not. Wilcoxon and colleagues begin their text on ethical
issues in marriage and family therapy with on values as the context for therapy
(2013). They maintain that family therapists take value positions continually in their
thinking as well as in their interventions with families. As the authors put it, values
permeate ethical decision making throughout life and become our life context. For
therapists, as for everyone else, values are the cherished beliefs and preferences that
guide human decisions.
Because specific therapist values (attitudes toward divorce, extramarital
affairs, nontraditional lifestyles, cross-cultural issues, gender-defined roles in the
family or society at large) may be enormously influential in the process of marital or
family therapy—guiding decision making— therapists must examine their own
attitudes closely. The danger here is that the therapist might be biased against families
whose attitudes, culture, and sexual orientation differ from his or her own or might
side with one family member (say, a father) against the behavior and stated attitudes
of other members (an adolescent), not by situation but by identification with being a
parent. In another scenario, a family therapist—deliberately or unwittingly,
consciously or unconsciously—may attempt to sustain a failing marriage when one or
both partners wish to divorce.
Whether the family therapist’s values are such that he or she chooses to be
responsible to the individual as opposed to, say, the marriage may have significant
consequences. To cite a common problem described by Bodin (1983), suppose a
husband is contemplating divorcing his wife, an action his wife opposes. The husband
may feel his individual happiness is so compromised by remaining in the marriage
that he hopes the therapist attaches greater importance to individual well-being than to
maintaining some abstraction called the “family system.” The wife, on the other hand,
hopes the therapist gives higher priority to collective well-being, helping individuals
adjust their expectations for the sake of remaining together. Many therapists caught in
such a situation take the position that a strife-torn marriage all but guarantees
unhappiness for everyone, including the children. Others argue that the stress and
uncertainty of separation and divorce may do damage to the children, and thus the
maintenance of family life, imperfect as it is, is preferable to the breakup of the
family. As Bodin observes, the therapist’s position may have a profound impact not
only on the rapport established with the various family members but also on the
therapist’s formulation of the problems, goals, and plans for treatment.
How should therapists deal with family secrets? Should parental secrets (e.g.,
sexual problems) be aired before the children or be brought up in a separate couple’s
session? How should an extramarital affair—hidden from the spouse but revealed to
the therapist in an individual session— be handled by the therapist? What about
family secrets—incest between the father and teenage daughter or inferred physical
abuse of the wife or young children or child neglect? Here the therapist has legal
responsibilities that supersede confidentiality; he or she must report the suspicion of
abuse or neglect to the police or child welfare authorities, even in the absence of
proof. In such a situation, the therapist must carefully observe family interactions,
formulate an ethical course of action, and take steps to ensure the safety and well-
being of family members. Undertaking therapeutic work with a family, then, poses a
variety of complications with respect to the therapist’s professional responsibilities.
The help offered to one family member may temporarily deprive or disturb another,
especially in a rigid family system.
When a client enters a professional relationship with a therapist, the latter
takes on the ethical responsibility of safeguarding the former from revealing what was
discussed during the therapeutic relationship. Confidentiality, protecting the client
from unauthorized disclosures of personal information by the therapist without prior
client consent, has long been a hallmark of individual psychotherapy. Its rationale is
based on encouraging clients to develop the trust necessary for them to make full
disclosures without fear of exposure outside the consultation room. In marital and
family therapy, some therapists take the position that they must ensure that
information given to them in confidence by a family member will be treated as it
would be in individual therapy and thus not be divulged to a spouse or other family
member (although the therapist may encourage the individual to share his or her
secret in a subsequent conjoint session).
Other therapists, in an effort to avoid an alliance with a family member, refuse
to see any member separately, in effect insisting that secrets be brought out into the
open to the marital partner or family in sessions together. Still other therapists, if they
individually see—or talk to by telephone or receive a written message from—a family
member tell the informant beforehand that whatever is divulged may be
communicated to the others if in the therapist’s judgment it would benefit the couple
or family. Whatever the procedure, it is essential to ethical practice that the therapist
makes his or her stand on all aspects of confidentiality clear to each family member
from the outset of therapy.
If the therapist should use material about a family in teaching, writing, or
lecturing, he or she is obligated to preserve the clients’ anonymity. As we observed
earlier in this, the increased use of third-party payors for therapeutic services often
calls for disclosure of personal information to an insurance company or managed-care
organization. This loss of privacy may become a therapeutic issue—clients holding
back information—when peer reviews or utilization reviews of therapeutic procedures
require therapists to inform clients that some information may be revealed (Miller,
1996). Regarding the limits of confidentiality. The duties of protecting clients from
harming themselves and protecting others from potentially dangerous clients are
especially important professional responsibilities (Ahia, 2012). In the former,
therapists must intervene—call in family members and/or the police or get the client
to a hospital emergency room—if they believe a client is seriously considering
suicide. A therapist who determines that there is clear and imminent danger to
someone the client vows to harm must take personal action and inform the responsible
authorities; the therapist also has a duty to warn and protect the intended victim,
because the courts have ruled (Tarasoff decision) that “the rights of clients to privacy
end where the public peril begins”. Adopted in California in 1976, the ruling has
become a national standard of practice.
However, in practice it often poses a serious dilemma for therapists—how to
determine when a client is sufficiently dangerous to an identifiable victim (not just
letting off steam about someone) that reasonable steps to warn that person must be
taken, thus breaching confidentiality (Bersoff, 2014). While no therapist is expected
to make perfect predictions of calculable danger, care is necessary in making the
assessment of risk to a potential victim; good written records should be kept, and
discussions with supervisors, consultants, or even attorneys are advisable (Monahan,
1993). Some states protect therapists from malpractice lawsuits for breaching
confidentiality if they can establish having acted in good faith to protect third parties
(Welfel, 2013).
Similarly, mandatory reporting laws, while they differ from state to state, all
require therapists to disclose suspicions of incest or child abuse to the proper child
protective agency. A therapist is held liable for failing to do so if he or she has reason
to suspect (or a child discloses) abuse or neglect. Once again, states provide immunity
from civil lawsuit for reporting suspected abusers. Sometimes problems arise because
the therapist has previously failed to inform clients of this limitation on
confidentiality, and sometimes therapists, in violation of the law, choose not to report
suspected abusers for what they consider to be therapeutic reasons. The limits of
confidentiality should be spelled out by the therapist at the start of therapy, lest family
members agree to proceed while operating under wrong assumptions.
Matters of informed consent and the right to refuse treatment have become
critical ethical issues in the practice of marital and family therapy. Most family
therapists agree that before families enter therapy, they must be adequately informed
concerning the nature of the process they are about to undertake (Haas & Malouf,
2005). The purposes of the sessions, typical procedures, risks of possible negative
outcomes (divorce, job changes), possible benefits, costs, what behavior to expect
from the therapist, the limits of confidentiality, information provided to third-party
payors, the conditions that might precipitate a referral to another therapist or agency,
available alternative treatments—these issues all require explanation at the outset,
before each client agrees to participate. Many clinicians ask their clients to sign an
informed consent form to ensure that clients understand and agree to these various
requirements. Two principles are operating here (Welfel, 2013)—full disclosure by the
therapist so the client can decide whether to proceed and free consent (deciding to
engage in an activity without coercion or pressure). In some cases, therapists provide
written documents (“Patient’s Rights and Responsibilities”) to accompany their oral
presentations, to be read, signed, and retained for future reference.
How should a therapist deal with family members who refuse treatment?
Doherty and Boss (1991) focus on the issue of coercion regarding reluctant adults or
children, as in the case in which therapists insist that all members attend before family
therapy can get under way. Willing members are thus in a position of being coerced
by denying them access to treatment unless they successfully persuade the others to
participate. They suggest that a therapist with such a policy would do well to have a
list of competent referral sources to which the family members willing to take part
might go for help.
Children present another thorny issue. Family therapists need to inform
children, at the child’s level of understanding, what is likely to transpire in family
therapy and then ask for their consent to participate. Consent should also be obtained
before videotaping, audiotaping, or observing families behind a one-way mirror. The
issue of informed consent is important and aligns with concerns for patient and
consumer rights.
The advent of e-therapy, therapy that involves the use of the Internet or SMS
texting, has implications for informed consent. For some, the question of whether to
even use the Internet for therapy is an ethical question; those who do must address
related matters involving informed consent. Initial research indicates some
effectiveness with telemental health services, and family therapists are just beginning
to use various forms of e-communication as part of therapy (Hertlein, Blumer, &
Smith, 2014). To limit one’s liability and to protect the client, e-therapy providers are
advised to disclose both the possible risks and benefits and engage with the client in
an active dialogue about both (Recupero & Rainey, 2005). A thorough and informed
consent procedure enables the client to make an educated decision about whether to
engage in e-therapy.
The procedure should include a discussion of the therapeutic risks and
benefits, the security risks regarding online confidentiality, and, for the therapist, any
licensure limits, such as providing services to clients in another state. Questions of the
confidentiality of online therapy increasingly are extending to the growing networks
of digital medical record keeping (Richards, 2009). Mental health practitioners who
work as part of a multidisciplinary team in institutional settings may be expected to
maintain their notes within an electronic system. Clearly, the system immediately
broadens the limits of what ethically constitutes confidentiality, since people other
than the therapist and the client have access to the client’s file.
The tension between preserving confidentiality and promoting collaboration in
therapeutic settings underscores the evolving landscape of mental health care, where
the traditional boundaries of therapeutic practice are being redefined in light of
emerging treatment modalities and interdisciplinary approaches.
On one hand, the sanctity of confidentiality has long been regarded as a
cornerstone of the therapeutic relationship, providing clients with a safe and
confidential space to explore their thoughts, feelings, and experiences without fear of
judgment or disclosure. Therapists have historically adhered to strict confidentiality
protocols, safeguarding the privacy of their clients' disclosures and ensuring that
sensitive information remains privileged and protected from unauthorized access.
However, as the field of mental health continues to evolve, there is growing
recognition of the potential benefits of collaboration and interdisciplinary teamwork
in enhancing treatment outcomes and addressing complex clinical challenges.
Increasingly, treatment protocols emphasize the value of a multidisciplinary approach,
where therapists work collaboratively with other healthcare professionals, such as
psychiatrists, social workers, and medical specialists, to provide comprehensive and
integrated care.
In this context, the notion of allowing access to client information may be
warranted, particularly when it facilitates coordination of care, information sharing,
and continuity of treatment across multiple providers. By breaking down silos and
fostering communication and collaboration among members of the treatment team,
therapists can leverage collective expertise and resources to better meet the diverse
needs of their clients and optimize treatment outcomes.
Moreover, some therapeutic modalities, such as collaborative and integrative
approaches, explicitly emphasize the importance of teamwork and shared decision-
making in the therapeutic process. In these models, therapists work collaboratively
with clients and other professionals to co-create treatment plans, set goals, and
monitor progress, empowering clients to take an active role in their own care and
promoting a sense of partnership and empowerment.
However, the decision to allow access to client information must be
approached with careful consideration and adherence to ethical and legal standards.
Therapists must weigh the potential benefits of collaboration against the risks to
confidentiality and privacy, ensuring that any disclosure of client information is
justified, proportionate, and conducted with the client's informed consent whenever
possible. Additionally, therapists must take appropriate measures to safeguard the
security and confidentiality of client information, including implementing robust
privacy policies, encryption technologies, and data protection protocols.
In conclusion, while the prospect of allowing access to client information may
challenge traditional notions of confidentiality, it also reflects the evolving nature of
mental health care and the growing emphasis on collaboration and integration in
treatment. By striking a balance between preserving confidentiality and promoting
collaboration, therapists can harness the collective expertise and resources of the
treatment team to enhance the quality and effectiveness of care while upholding the
rights and dignity of their clients.
Privileged communication offers clients even more protection from forced
disclosure of private matters discussed with their therapist than does confidentiality. A
legal right to privacy, privileged communication protects a client from having prior
confidences revealed by a therapist from the witness stand during court proceedings
without his or her prior consent (Glosoff, Herlihy, Herlihy, & Spence, 1997). Thus,
therapists cannot be forced to produce client records in court, or in general to answer
questions about private matters revealed to them by clients, without client permission.
However, since the privilege belongs to the client, the client’s waiving that privilege
of privacy leaves the therapist with no legal grounds for withholding the information.
All states have some form of therapist–client privilege statute, although the
specific details vary by state. The issue, however, is less clear in couple or family
therapy; indeed, these therapeutic activities are not subject to privileged
communication in many states, and clients and therapists alike need to be informed of
their state’s laws regarding both confidentiality and privileged communication at the
start of treatment. One sticky problem is, exactly who is the client: the individual, the
couple, the family? In the case of a divorcing pair, suppose one spouse seeks
testimony from the therapist while the other does not wish the information revealed?
Generally speaking, the therapist, careful about protecting client privacy, should
always demand permission in the form of a written release from a client before
revealing any information to others.
In cases of suspected child or elder abuse, therapists are bound by legal and
ethical obligations that supersede considerations of privileged communication,
highlighting the paramount importance of protecting vulnerable individuals from
harm and ensuring their safety and well-being.
Mandated reporting laws impose a duty on therapists to promptly report any
suspicions or allegations of abuse or neglect to the appropriate authorities, such as
child protective services or adult protective services. These laws are rooted in the
recognition of society's collective responsibility to safeguard those who are most
vulnerable and to intervene swiftly to prevent further harm. By mandating reporting,
legislators and policymakers seek to create a robust safety net for children and elders
at risk of abuse or neglect, ensuring that allegations are thoroughly investigated and
appropriate interventions are implemented to protect the safety and dignity of those
involved.
The legal mandate to report suspected abuse or neglect extends to therapists
regardless of the nature of their professional relationship with the individual or family
involved. This means that the rules governing privileged communication, which
typically protect the confidentiality of information shared within the therapeutic
context, do not apply in cases where abuse or neglect is suspected. Therapists are
obligated to set aside concerns about confidentiality and prioritize the safety and well-
being of the individual at risk, even if doing so may strain the therapeutic relationship
or entail legal repercussions.
Moreover, the duty to report suspected abuse or neglect is not solely a legal
obligation but also an ethical imperative grounded in the fundamental principles of
beneficence, nonmaleficence, and justice. Therapists are guided by professional codes
of ethics that underscore their responsibility to act in the best interests of their clients
and to prevent harm whenever possible. By reporting suspicions of abuse or neglect,
therapists fulfill their ethical duty to uphold the rights and dignity of those they serve,
even in the face of challenging ethical dilemmas and conflicting loyalties.
Nevertheless, the decision to report suspected abuse or neglect is not taken
lightly, and therapists must exercise discernment and judgment in evaluating the
evidence and circumstances surrounding their suspicions. This may involve
consulting with colleagues, seeking supervision or guidance from professional
organizations, and considering the potential impact of reporting on the individual and
their family. Therapists must also be mindful of the potential consequences of
reporting, including the possibility of exacerbating tensions within the family,
triggering legal proceedings, or jeopardizing their professional relationships.
In conclusion, the legal mandate to report suspected child or elder abuse
underscores the primacy of protecting vulnerable individuals from harm and ensuring
their safety and well-being. While the rules regarding privileged communication may
not apply in these circumstances, therapists must navigate the complexities of
reporting with sensitivity, integrity, and a commitment to ethical practice. By
upholding their legal and ethical obligations, therapists play a vital role in
safeguarding the rights and dignity of those at risk and contributing to the broader
effort to combat abuse and neglect in society.
Whether a novice or widely experienced in working with couples and families,
all therapists need periodic upgrading of their clinical skills. Continuing education is
required to keep abreast of new developments in the field, for example, neuroscience
(Celano, 2013), and multicultural approaches to therapy (Rober & DeHaene, 2014),
and new populations served (undocumented immigrants, substance abusers, the
homeless). Belonging to professional organizations, attending lectures at local and
national conventions, taking workshops, consulting with colleagues, keeping up with
family therapy clinical and research literature—all are part of the lifelong learning
needed to remain a competent professional.
Exceeding the bounds of one’s competence and experience in assessing and
treating marital or family problems is considered unethical. Therefore, therapists must
know the boundaries of their own competence and refer to fellow professionals those
clients who require services beyond the therapist’s professional training or experience.
Reaching a prolonged therapeutic impasse with a family should also alert a therapist
that a reassessment is in order and that a referral or a consultation with a peer who has
expertise in the particular troublesome area might help move the therapeutic process
forward.
Clients with whom therapists experience serious and irresolvable conflicts in
values should also be directed to other therapists competent to deal with their
problems. Even highly experienced family therapists seek the input of a consultant for
purposes of verifying diagnostic impressions or confirming therapeutic strategies. In
addition, psychiatric consultants may be called upon for medication evaluation (e.g.,
antidepressant drugs) or to hospitalize a client if the family therapist lacks hospital
privileges or has not dealt with hospitalization in his or her training..
