By Elisabeth Shaw MAPS, psychologist in private practice

Couple and family therapists arguably face more ethical challenges than individually oriented therapists, yet codes of conduct and ethics have not always been of direct assistance. Often it seems that the principles lack the specificity to really attend to the issues at hand. Further, couple and family therapy presents challenges which are often erroneously assumed to be covered under general principles about counselling and psychotherapy. A significant values difference between couple and family therapy and other mental health services is an appreciation of context, which is grounded in the foundational premise of the family as a system. This means that it is the relationship that is the focus of study, and all relationships are seen to exist within multiple other systems, including the therapeutic system (Wilcoxon et al., 2007).

Relationship issues and the values we hold about relationships are completely entwined with their social and historical context. We are constantly exposed to theories about effective relationships and relationship pathology, whether they be evidence-based or common folklore. We cannot help but be influenced by these ideas, nor by our own experience of relationships. New and emerging issues such as internet pornography, surrogacy, same-sex parenting and working with perpetrators of abuse, offer groundbreaking moments in the therapy room. Couple and family therapists have a unique view into the complexities such circumstances bring and need to be able to respond effectively ... or to know when and who to report matters when it all goes belly up. Without an awareness of the potential ethical challenges in the work, psychologists can be insufficiently prepared to face them. This article provides an overview of some of the significant practice issues couple and family therapists face, and outlines some of the considerations required for ethical reflection and decision making.

Competency to practise

A core ethical responsibility to clients is the promotion of beneficence: doing good on the client's behalf. This is reflected in a number of professional areas, but starts with the therapist's competence to practise. Interestingly, couple and family therapy is quite commonly practised by therapists with little or no specific training. It seems to be thought that if one is individually trained, then it is not a great stretch to see other family members (Shaw, 2001). Nothing could be further from the truth. Issues surrounding relationships (violence and abuse, family law matters, sexual concerns, infidelity and other betrayals, severe attachment disruptions) all render this work highly complex and specialised. Without core training, duty of care is potentially breached (refer to the professional standards of the Australian Association of Relationship Counsellors and the Australian Family Therapy Association). If you were seeking assistance for your own relationship, what qualifications would you seek in your therapist? We often provide less for our clients than we would require for ourselves.

Informed consent

The very act of asking the initial caller to gather other family members for an appointment raises questions about the forms of ‘social coercion' that this might involve (Wilcoxon et al., 2007; Ramisch, 2010). There are different levels of power and opportunity in families. One member can decide for the group, while others can be unfairly excluded from key decision making. How the therapist is positioned within this is crucial to consider. Further, there are complexities around informed consent with people across ages and circumstances, and about how one might consider sending therapeutic letters or other communications. Are the adults always the best gatekeepers for other family members? Not uncommonly, I have had children say to me that they have ‘no idea' about why they are in my room, despite my parental preparation.

Confidentiality

Arranging for individual consultations within relational work raises a myriad of difficulties. While it can be important for assessing dynamics such as abuse, it also provides opportunities for disclosures that will significantly shape the work ahead. Further, issues of confidentiality and privacy are often confused, and therapists can find themselves unwittingly silenced and compromised through promises they have made in good faith. There are certain principles about moving between individual and couple or family sessions, but these are not articulated within accessible guidelines, leaving therapists to work things out on their own. It is not uncommon for well intentioned therapists to find themselves in breach of confidentiality by juggling too many agendas and finding themselves the ‘fall guy'.

Neutrality and dual relationships

Frequently couples will ask for assistance when on a covert level they want a referee or a judgment about the behaviour of the other. Individual sessions and phone calls can be invitations to take sides, and neutrality can be called into question. There are complex issues around being engaged to ‘save relationships' and then having notes subpoenaed for divorce proceedings. Besides the feelings this can evoke for the therapist, there are invitations into conflicting roles, e.g., couple/family therapist versus advocate in court.

Working with relationships involves managing multiple alliances. It is not always possible to have everyone on side at the one time. Members of the family may have conflicting or competing needs which they want equally acknowledged. Even trying to develop a focus for the work is fraught with challenges, as you question: whose voice will prevail? Improvement for one member must not occur at the expense of another.

Commonly relationship therapists will think it might be a good idea to offer individual therapy to one family member, and may well be pursued to do so by the client. This is not considered good practice, but it can be tempting to do. Really good relational work can be brought asunder by selecting/engaging in work with one member. What might be defendable reasons (not justifications) to take on individual work in this context?

The individual versus the collective

Working with systems means being able to hold the relationship in mind over and above individual contributions: the notion that the sum is more than its parts. However, one still has to attend to:

  • Individual responsibilities for pain and suffering, and for the stressors of addiction, mental health or family of origin trauma for example. How to address this in a relational context without pathologising one member and getting them off-side can
    be tricky.
  • Perceived inequities in the tasks for therapy. For example, perpetrators of hurt have different tasks and responsibilities than those who have been hurt.
  • Different ages and life stages
  • Ensuring that safety is attended to, and knowing how to take a position when necessary, for example with mandatory reporting.

Further important issues in the field which involve specialised ethical and practice considerations include:

  • The perennial question of working with whoever can come to sessions or insisting that all must attend sessions
  • Working effectively and respectfully with culturally diverse clients and communities
  • Working with gay and lesbian clients and same-sex parents (Negash & Hecker, 2010).
ETHICS CHECKLIST 
  • Are you trained in couple/family intervention?
  • What is your role going to be? Individual or relationship therapist, not both.
  • How are you going to communicate effectively with all family members? How are you going to obtain informed consent?
  • What is your plan to manage multiple alliances and diverse needs?
  • Have you organised specialised professional development to support your work, especially on emerging social issues for families?
  • How often do you take ethical issues to supervision? 

Interventions and case management

Couple and family therapy has advanced different models of practice. Over time, therapeutic strategies (e.g., use of paradox, strategic manoeuvres, prescriptions, triangulation) have been critically analysed in terms of how much stress is acceptable in achieving change (Wilcoxon et al., 2007) and a post modern framework has been adopted as more respectful. In terms of our role, while we may have preferences for therapeutic intervention, we have to be prepared to also be advocates, to take positions (on abuse and violence for example) and to be strategic in our case management. We need to enhance growth and positive relationships, not act as social control agents or gatekeepers of community values not in keeping with the client's own (notwithstanding where people are at risk).

Ethical practice

As is evident, ethics is as much about critical and responsible reflection as it is about compliance with a professional code. Reason, intuition and experience all play a role in developing effective and justifiable responses (Shaw, in press). Finding opportunities for professional development and rigorous debate about ethical issues in practice is crucial. Ask yourself: how often do I reflect on ethical challenges in supervision?

There are some valuable decision making models for therapists (e.g., Gilligan (1982) in Newfield et al., 2000; Kitchener, 1984; Hecker, 2010). It behoves effective therapists to establish frameworks to support their practice ahead of needing them! Finally, our best work will occur when we are also in the best possible shape. Self care is foundational to good ethical practice, and something we can tend to under emphasise.

The author can be contacted at elisabethshaw@optusnet.com.au.

References

Hecker, L. (Ed.). (2010) Ethics and professional issues in couple and family therapy. New York: Routledge.

Kitchener, K.S. (1984). Intuition, critical evaluation and ethical principles: The foundation for ethical decisions in counselling psychology. Counselling Psychologist, 12(3) 43-55.

Negash, S.M., & Hecker, L.L. (2010). Ethical issues endemic to couple and family therapy. In Hecker, L. (Ed.), Ethics and professional issues in couple and family therapy. New York: Routledge.

Newfield, S.A., Newfield, N.A., Sperry, J.A., & Smith, T.E. (2000). Ethical decision making among family therapists and individual therapists. Family Process, 39(2), 177-188.

Shaw, E. (2001, May). The Anxiety in Maintaining the Couple Relationship. Psychotherapy in Australia.

Ramisch, J. (2010). Ethical issues in clinical practice. In Hecker, L. (Ed.), Ethics and professional issues in couple and family therapy. New York: Routledge.

Shaw, E. (in press). Relational ethics and moral imagination in contemporary systemic practice. Australia and New Zealand Journal of Family Therapy.

Wilcoxon, A.A., Remley, T.P.;Gladding, S.T., & Huber, C.H. (2007). Ethical, Legal and Professional Issues in the Practice of Marriage and Family Therapy (4th ed.). New Jersey: Pearson.

InPsych February 2011