Ethics in Psychotherapy and Counseling. Kenneth S. Pope

“It is important to note that, for the purposes of the Multicultural Guidelines, cultural competence does not refer to a process that ends simply because the psychologist is deemed competent. Rather, cultural competence incorporates the role of cultural humility whereby cultural competence is considered a lifelong process of reflection and commitment” (Hook & Watkins, 2015; Waters & Asbill, 2013). This current iteration of the Multicultural Guidelines also recognizes the contributions of other culturally competent models of practice such as the American Counseling Association’s (ACA) Multicultural and Social Justice Counseling Competencies: Guidelines for the Counseling Profession (Ratts et al., 2016); the American Psychiatric Association’s Cultural Formulation Interview (American Psychiatric Association, 2013); and the Standards and Indicators for Cultural Competence in Social Work Practice (National Association of Social Workers, 2015, pp. 8–9).

      The ethical requirement of competence recognizes that the therapist’s power and influence (see Chapter 5) should not be handled in a careless, ignorant, and thoughtless manner. The complex, hard-to-define nature of therapy tends to cloud why this requirement makes sense. It becomes clearer by analogy to other fields. A physician who is an internist or general practitioner may do excellent work, but would any of us want that physician to perform coronary surgery or neurosurgery on us if they did not have adequate education, training, and supervised experience in these forms of surgery? A skilled professor of linguistics may have a solid grasp of a variety of Indo-European languages and dialects but be completely unable to translate a Swahili text.

      COMPETENCE AND CONFLICT

      Pulled by patients holding exaggerated beliefs about our abilities and pushed by our own impulse to step in and help, our humility may fail us and we may resist admitting to ourselves and the client that we lack competence for a particular situation. We may need new clients to pay the bills and fear shutting off a valued referral source. Managed care may require us to take the patient. Nevertheless, extensive education, training, and supervised experience in working with adults does not qualify us to work with children; solid competence in providing individual therapy does not qualify us to lead a therapy group; and expertise in working with people who are profoundly depressed does not qualify us to work with people who have developmental disabilities.

      At times, complex situations require great care to determine how to respond to a client’s needs while staying within our areas of competence. For example, a counselor may begin working with a client on issues related to depression, an area in which the counselor has had considerable education, training, and supervised experience. Much later the therapeutic journey leads into a problem area—bulimia—for which the counselor has little or no competence.

Alternatively, a client starts meeting with a counselor to deal with problems concentrating at work. Soon, the client says they suffer from agoraphobia. Can the counselor ethically assume that the course on anxieties and phobias that they took 10 years ago in graduate school makes them competent? The counselor must decide whether they have the time, energy, and interest in gaining competence through continuing education, study, or consultation to provide up-to-date treatment for agoraphobia or whether they need to refer the client or find some other way for the client to get competent help for agoraphobia.

      Clinicians who work in isolated or small and rural communities often face this dilemma. They take workshops, consult long distance with experts, and come up with creative strategies to make sure that their clients receive competent care. Despite the clear ethical and legal mandates to practice only with competence, some of us suffer lapses. A national survey of psychologists, for example, found that almost one-fourth of the respondents indicated that they had practiced outside their area of competence either rarely or occasionally (Pope et al., 1987).

      INTELLECTUAL COMPETENCE: KNOWING ABOUT AND KNOWING HOW

      Intellectual competence involves one’s fund of knowledge or “knowing about.” In our graduate training, internships, supervised experience, continuing education, and other contexts, we learn about the research, theories, interventions, and other topics that we need to do our work. We learn to question the information and assess its validity and relevance for different situations and populations. We learn to create and test hypotheses about assessment and interventions. We find ways to keep up with the latest therapy research.

      Part of intellectual competence is learning which clinical approaches, strategies, or techniques show evidence or promise of effectiveness and for whom do such techiques work. If clinical methods are to avoid charlatanism, hucksterism, and well-meaning ineffectiveness, they must work (at least some of the time). The practitioner’s supposed competence means little if their methods lack competence. In his provocative article The Scientific Basis of Psychotherapeutic Practice: A Question of Values and Ethics, Jerry Singer (1980) emphasized the ethical responsibilities of clinicians keeping up with the emerging research basis of the methods they use.

      Intellectual competence also means learning what approaches have been shown to be invalid or perhaps even harmful. George Stricker (1992) wrote:

      Although it may not be unethical to practice in the absence of knowledge, it is unethical to practice in the face of knowledge. We all must labor with the absence of affirmative data, but there is no excuse for ignoring contradictory data (p. 544).

Intellectual competence is not frozen in time. David Barlow showed how quickly well-designed research can change our views of which interventions are effective, worthless, or even detrimental. “Stunning developments in health care have occurred during the last several years. Widely accepted health-care strategies have been brought into question by research evidence as not only lacking benefit but also, perhaps, as inducing harm” (Barlow, 2004, p. 869; see also Sue, 2015).

      Intellectual competence also means admitting what we do not know. We may know about depression in adults but not depression in kids. We may be familiar with the culture of one Asian population but not others. We may understand the degree to which the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) can assess malingering among criminal defendants but not whether it can identify leadership strengths among job candidates in the tech industry.

      Intellectual competence also involves knowing how to do certain clinical tasks. We gain this kind of competence, the development of skills, through carefully supervised experience. We can’t learn how to do therapy just by reading a book or sitting in a classroom; therapy is a set of skills that is learned through practice. The APA Ethics Code Standard 2.01c (APA, 2017a) encourages properly trained psychologists planning to provide services new to them to achieve competence in those new services through relevant education, training, supervised experience, consultation, or study. Both the APA Ethics Code (Standard 2.03) and the CPA’s Ethics Code (Standards IV.3 and IV.4) recognize that knowledge becomes obsolete and that psychologists don’t stop developing and maintaining competence when they become licensed.

      EMOTIONAL COMPETENCE FOR THERAPY: KNOWING YOURSELF

      Emotional competence for therapy, as described by Pope and Brown (1996), reflects our awareness and respect for ourselves as unique, fallible human beings. It includes self-knowledge, self-acceptance, and self-monitoring. We must know our own emotional strengths and weaknesses, our needs and resources, our abilities and our limits for doing clinical work.

      Therapy can stir strong emotions in both therapist and client. Some clinical work places great emotional demands on us. For example, working with people who survive torture can evoke intense reactions that can lead to secondary trauma, despair, helplessness, and burnout (Allden & Nancy Murakami, 2015; Comas‐Diaz & Padilla, 1990; Long, 2020; Pope, 2012; Pope & Garcia-Peltoniemi, 1991).To the degree that we are unprepared for the emotional stressors and strains of therapy, our attempts to help may be futile and perhaps even harmful.

Table 6.1 presents research findings about intense emotions experienced in therapy. The numbers indicate the percentage of therapists in each study who reported at least