Ethics and Moral Principles in Psychotherapy

Ethics / Moral Principles in Psychotherapy

The underlying principles therapists adhere to in doing psychotherapy are:

FIDELITY: Fidelity involves issues of loyalty, faithfulness, and promise-keeping – these are essential for trust and honest communication between client and therapist. According to research on effective therapy outcomes, a good therapeutic relationship is highly correlated with positive change – this is true across multiple counseling methods. A positive alliance reported by the client is the strongest predictor of outcome.
JUSTICE: In its broadest sense, this is “fairness” and the foundation for therapists to treat all clients “equally well”. For example, an ethical therapist does not treat a sliding scale client differently from a full fee client; both clients should expect and receive the same treatment, consideration, and logistical conveniences, regardless of the fee he/she is paying.
AUTONOMY: Each client, as an autonomous person, has freedom of choice and responsibility for decision-making and behavior. The concepts of unconditional worth and tolerance for individual differences reflect therapists’ respect for clients to make their own decisions. This principle of autonomy is also the basis of the right to privacy and confidentiality.
BENEFICENCE: This involves therapists’ commitment to contributing to the health and welfare of clients; mental health professionals are members of the “helping professions”, reflecting the obligation to promote positive growth.
NONMALEFICENCE: This is a concept rooted in medicine meaning “above all, do no harm”. Therapists are responsible for knowing what attitudes, behaviors, etc. have potential to cause harm. Specific applications of this principle include: not misusing assessment results, respecting clients’ civil rights, practicing only within the boundaries of the therapist’s competence, maintaining competence and furthering knowledge through continuing education/proactive learning, avoiding dual relations, etc.

An example of the “do no harm” principle is therapists setting boundaries, e.g. avoiding dual relationships. Therapists recognize that dual relationships erode and distort the professional nature of therapy. Even after termination, there are three reasons why the therapeutic relationship does not end: 1) It is the therapist’s continued responsibility to maintain confidentiality, release notes, etc.; 2) Client and therapist may still occasionally contact each other; and 3) The client typically internalizes the therapist.

Common dangers of dual relationships are:

Role-theory explains that social roles contain inherent expectations about how a person in a particular role is to behave, as well as the rights and obligations pertaining to that role. Role conflicts arise when the expectations attached to the one role, call for behavior that is incompatible with another role.
If the therapist is also the client’s friend, employee or employer, landlord, etc. the crux of the therapeutic relationship is no longer healing and the nature of the interaction is compromised.
A dual relationship creates a conflict of interest so that the intentions and investment of client and therapist are distorted.
Dual relationships negatively affect the cognitive and emotional processes that research has shown to play in the beneficial effects of therapy, e.g. recalling positive memories of therapy and internalizing the therapist’s voice.
The power differential inherent in client and therapist roles prevents the client from entering into another egalitarian relationship with the therapist; the power dynamic here is also related to the therapist being privy to intensely personal information about the client.
The fundamental nature and sanctity of psychotherapy would be changed if the therapy office became a place to meet friend, lovers, business partners, social contacts, etc.
If the therapist has an additional secondary relationship with the client, testimony and reports in courts, schools, and other forums would be compromised.

Confidentiality

Consider these definitions:

Privacy:
The right to decide how to live one’s own life. Constitution of the United States; Article 1, Section 1 of the California Constitution; Information Practice Act of 1977
Confidentiality:
The client’s right to have communications kept within the bounds of the professional relationship. The California legislature provides a comprehensive right to privacy, covering all medical relationships and patient communications. your right to privacy is absolute. This is the Confidentiality of Medical Information Act (CMIA), where all health service providers must maintain the confidentiality of all medical information (Civil Code 56 and Welfare and Institutions Code 5328).

Your right to privacy is absolute – the value underlying privacy reflects our society’s belief in individual autonomy, that we have a right to live our lives as we choose, given that our choices do not harm others in a shared society. Confidentiality is a subset of this overarching privacy principle. Confidentiality guarantees that you are free to decide for yourself with whom you share what is most personal to you. You have the legal and ethical right to expect your therapist to maintain utmost confidentiality; without your explicitly written consent your therapist cannot share your information with anyone. In keeping all communications confidential, the therapist treats clients with respect and dignity, paving the way for building trust in the therapeutic relationship. Trust is the foundation for you and your therapist to work on mutually agreed upon goals. It is crucial for you to know and trust that everything you say to your therapist is kept private, your feeling that your discussions are kept safely contained is key for effective psychotherapy.

There are some legal exceptions to confidentiality when, in the interest of society, a mental health professional has a duty to disclose what the client reveals. If, in the course of treatment, the need to disclose information arises, your therapist should be up front and honest about it, discussing with you in advance his/her intention to disclose specific content. You should not have to be unpleasantly surprised that your therapist has shared information.

The exceptions are:

If abuse/neglect of a child, elder, or physically/mentally handicapped person is occurring
If you are a danger to yourself or others, the therapist is required to report this to the appropriate authorities.
If you want your therapist to communicate with another professional about your treatment, e.g., your M.D.
Third party insurance payment – your therapist may be required to give diagnoses and/or treatment information so that you get reimbursed. You have the right to expect that your therapist will discuss beforehand with you the details to be shared with your insurance company.
In the event of a malpractice case, e.g. if a client sues the therapist, the therapist may disclose details of treatment for the purpose of defense.
The Patriot Act of 2001 (Section 215) requires therapists and others to provide the FBI with information related to an investigation to protect against international terrorism or clandestine intelligence activities. The Act also prohibits therapists from disclosing to clients that the FBI sought such information.

Confidentiality and Group Therapy

Therapists treating clients in a group typically develop a group confidentiality agreement where not only is the therapist’s duty of confidentiality to the group established, but also each group member agrees to keep all information in session confidential – this would be a condition for participation in the group.

Confidentiality and Conjoint Couples Therapy

The therapist typical adopts a “no secrets” policy where the therapist will not allow him/herself to be put in the position of holding the secret(s) of a client in couples therapy. Each member of the couple should be informed of and agree to this policy. Couples therapy cannot be effective (and may be destructive) if either or both clients find out the therapist has been privy to information from their partner and has been in collusion with their partner. In such a scenario, it would be a profound betrayal by the therapist of the client. Ideally, a conjoint confidentiality agreement would state that the therapist may disclose relevant information to both partners at the therapist’s discretion. An example of doing couples therapy without the “no secrets” policy: if a client tells the therapist in a private session that he/she is having an affair and/or planning to leave the partner, it would be unethical and counter productive for the therapist to continue to work with the couple knowing that one partner is not honest and has a hidden agenda.

Confidentiality and Third Parties Who Attend Therapy

When clients bring visitors to one or a few of their therapy sessions, e.g. relatives and friends, the therapist should inform the visitor the he/she is welcome to attend the session but is not considered a client and therefore is not entitled to confidentiality under the law. Obviously, the therapist will respect the confidential nature of the sessions(s), but the visitor should not expect to receive the same legal protection received by the client.