Ethics in Psychotherapy and Counseling. Kenneth S. Pope

and how to teach themselves new behaviors after therapy ends. They can question what they always believed was a given. They can find out what matters most to them, and how to stop wasting time. They can become happier, or at least less miserable. They can become better able, as Freud noted, to love and to work. They can learn how to accept and love themselves just as they are and accept others who are different from them.

Our ethics acknowledge and affirm our profession’s responsibilities. This book was written to help strengthen, deepen, and inform ethical awareness and the sense of personal ethical responsibility. Its job is to help you hold onto the ideals—including ethical ideals—that called you into the profession to begin with, to help you develop and fulfill those ideals. There will be so much—trust us on this—that tends to dull ethical awareness, to make ethics drift out of focus, to create barriers between you and your ideals, to replace ethics with pseudo-ethics and ethics placebos. Fatigue, endless paperwork, unrealistic expectations, illness, family crises, not being able to make ends meet, burnout, threats of job loss, insurance coverage that doesn’t come close to meeting the needs of our clients, biases that have not been addressed, and so many other forces can pressure us into cutting ethical corners. This book is intended to help you develop a strong and healthy resistance to such forces, to help you weather them without losing your ethical awareness and ideals.

      We can often help, but if our ethics slip, we can needlessly hurt. Mishandled, the process of therapy and counseling can waste time and opportunity. It can betray clients’ hope, good faith, hard work, and trust. It can leave them worse off than before they reached out for our help. It can erode trust in the health system and prevent people from seeking help in the future.

      Realizing how much our ethical decisions can affect the lives of those who come to us for help is central to our ethical awareness. What we do can make a difference in whether a client loses hope and commits suicide or chooses to live, whether a battered partner finds shelter or returns to a toxic and dangerous relationship, whether a teenager with anorexia gets help or starves to death. Such stark examples tell only part of the story. So many people come to us facing what seem to be minor, hard-to-define problems, yet the hard, risky, unpredictable twists and turns of their therapy can lead to more meaningful, effective, and fulfilling lives.

      Few therapists take these responsibilities lightly. Few forget about a suicidal client between sessions. Few sit unmoved while a client talks, perhaps for the first time, about what it was like to survive an atrocity. Few turn away untroubled when a managed care company refuses to authorize treatment for someone in desperate need of help, someone who lacks enough money to put food on the table, let alone to pay for therapy.

      Recognizing these responsibilities as they appear in our day-to-day work and deciding how to respond can be stressful, sometimes overwhelming. We may feel short of time, resources, or wisdom. We may feel pulled in different directions, stretched to or beyond the breaking point. The responsibilities can weigh us down, make us feel discouraged, rattle us, and make us want to run and hide. They can make us more vulnerable to other sources of stress and leave us prone to make flawed ethical decisions.

Uncertainty causes stress for some of us. We can’t find that magical book that will tell us what to do, especially in a crisis. Research, guidelines, manuals, our own experience, and consultation help, but we can’t know the best course in all situations, or even how the “best” course will turn out. We are constantly thrown back on our own judgment. If we believe a client might kill someone but there is no explicit threat or other legal justification under the state’s law to hospitalize the client or breach confidentiality, what do we do? What diagnosis should we write down if we know that the insurance company won’t cover treatment for the client’s condition and believe that the client’s need for treatment is urgent, a matter of life or death? Will using stress-reducing imagery techniques help a client (reducing stress and increasing the client’s effectiveness) or cause harm (enabling the client to adapt to an abusive job or relationship) is a question without an instantly clear, infallible answer. Does informed consent make sense if all it accomplishes is to cause a patient to turn away from life-saving treatment or stop them from sharing information critical to their treatment? The inescapable responsibility of making careful, informed professional judgment regarding issues of enormous complexity and potentially life-and-death implications can push even the most resourceful therapists to and beyond their limits.

      Fearing that formal review agencies will hold us accountable, after the fact, scares, stresses, and distresses some of us. Some agencies focus specifically on the ethical aspects of our work. Others, such as state licensing boards and the civil courts, enforce professional standards of care that may reflect ethical responsibilities. The prospect of review agencies second-guessing us—and perhaps falling prey to both outcome bias and hindsight bias—can make difficult judgments a nightmare for some therapists. They may suffer debilitating performance anxiety, dread going to work, and discover that the focus of their work has changed from helping people to avoiding a malpractice suit.

      Managed care stresses some therapists. For example, capitation contracts provide a limited sum of money to cover all services for a group of patients (e.g., a business that has contracted coverage for its employees with an agency). The agency providing services, having estimated the average number of sessions needed for each patient, must limit the total number of sessions to make a profit. Strict guidelines may limit how many sessions a therapist can provide. Therapists may feel pressure to terminate before the limit, even if they think services are still needed. Even if clinicians follow agency procedures, they may face charges before an ethics committee, licensing board, or malpractice court for patient abandonment, improper denial of treatment, or similar issues. Therapists may fear not only that a formal review agency will sanction them but also that the limited sessions fall far short of what their clients need.

      Teaching or learning therapy is practiced on the living—this can stress us. As supervisors, we may grow uncomfortable with how the supervisee responds to the client differently from how we would, with our responsibility to evaluate the supervisee’s work, and with the demands of our role as teacher, mentor, and gatekeeper. As supervisees, we may doubt our ability to carry out clinical responsibilities (especially when they involve suicidal or homicidal risks), dread making mistakes, feel uneasy about differences in values or theoretical orientation between ourselves and our supervisor, wonder if racial (or gender or sexual orientation or religious or political, or, or, or) differences between us and our supervisor are causing us to be viewed in a negative light, and figure that if we are completely honest in describing to our supervisor what we actually thought, felt, and did with our clients, we might be advised to look for another line of work.

Learning to work competently with clients from various identity groups can be challenging. Understanding and integrating racial and cultural issues and context is fundamental to our professional responsibilities. We can complete workshops, read, get supervision, take continuing education courses, but the challenge in gaining knowledge about various social groups will be an ongoing task. Knowledge about the various social identities that our clients represent will be necessary in assessing the degree to which we integrate various values, behaviors, and expectations in the course of treatment. Those potential identities include but are not limited to race, ethnicity, generation, gender, ability status, sexual orientation, gender identity, caste, religion, spirituality, immigration, employment, and the like. Working competently requires awareness, knowledge, and skills about people’s identities and the ways in which overlapping forms of oppression (e.g., gendered-racism, gendered anti-Semitism) impact people’s lives (for further reading on the theory of intersectionality as originally created by Black Women see Combahee River Collective, 1995; Crenshaw, 1991; for intersectionality in clinical practice see Adames et al., 2018; Chavez-Dueñas et al., 2019).

      WHAT DO I DO NOW?

      A fundamental stress that confronts therapists is the urgent, complex, inescapable question: “What do I do now?” Consider these scenarios:

       I’m staring at this insurance form, wondering if I should get creative with the diagnosis. They won’t cover this new patient’s condition, but they can’t get the help they desperately need without the coverage.