Ethics in Psychotherapy and Counseling. Kenneth S. Pope

The first question in each sequence is a variant of “What do you feel?” Emotional competence leaves little room for denying, discounting, or distorting how we respond emotionally to the challenges of clinical work.

To the extent that these scenarios and questions form the basis of class or group discussion in graduate school courses, internships, in-service training, continuing education workshops, or other group settings, their value may be in direct proportion to the class’s or group’s ability to establish as safe an environment as possible in which participants are free to disclose responses that may be politically incorrect or “psychologically incorrect” (Pope, Sonne et al., 2006) or otherwise at odds with group norms or with what some might consider the “right” response. Only if participants are able to speak honestly with each other about responses that they might be reluctant to speak aloud in other settings and to discuss these responses with mutual respect, will the task of confronting these questions likely prove helpful in developing emotional competence (Pope, Sonne et al., 2006).

      Learning to discuss these sensitive topics and our personal responses to them with others can help to strengthen our emotional competence and develop resources for maintaining competence throughout our careers (see Pope, Sonne et al., 2006, for a more thorough discussion of understanding taboos that hurt therapists and clients). Our colleagues also constitute an invaluable source of help to avoid or correct mistakes, identify stress or personal dilemmas that threaten to overwhelm us, and provide fresh ideas, new perspectives, and second and third opinions. A national survey of psychologists, in fact, found that therapists rated informal networks of colleagues as the most effective resource for prompting effective, appropriate, and ethical practice (Pope et al., 1987). Informal networks were seen as more valuable in promoting ethical practice than laws, ethics committees, research, continuing education programs, or formal ethical principles. Our colleagues can help sustain us, replenish us, enrich our lives, and play an important role in our self-care (Chapter 17).

Chapter 7 CULTURE, CONTEXT, AND ETHICS IN PSYCHOTHERAPY AND COUNSELING

      In the last few decades, the United States (US) and Canada have become more multiracial, multiethnic, and multilingual. As of 2019, 40% of the US population was Black Indigenous and People of Color (BIPOC) including: 18.5% Latinxs, 13.4% African American, 5.6% Asian American, and 1.3% American Indians (U.S. Bureau of the Census, 2019). Approximately 20% of the US population or 40 million are immigrants (Pew Research Center, 2020). In Canada, 22.3% of the total population in 2016 identified as People of Color and 21.9% of the population as immigrant. The largest ethnic minority community in Canada was composed of people of South Asian descent (5.6%), followed by Chinese (4.6%), First Nations (4.4%), and people who identify as Black (3.5%; Statistics Canada, 2016).

In the field of mental health, several foundational publications (see Comas-Díaz, 2012; Helms & Cook, 1999; Sue et al., 2019; Vasquez, 2007; White & Henderson, 2008) and professional guidelines (see American Psychological Association [APA], 2017b, 2019c; Canadian Psychological Association [CPA], 2017b) underscore the importance of ethnicity and culture in the therapeutic process. These important documents aim to assist therapists in providing culturally responsive services to individuals and communities. Culture, defined as the “complex constellation of [learned] mores, values, customs, traditions, and practices that guide and influence people’s cognitive, affective, and behavioral response to life circumstances” (Parham et al., 1999, p. 14) is an important aspect of the work that we do as therapists. Culture shapes how clients: (a) narrate and make sense of their presenting problems, describe the causes, signs, and symptoms of their problems; (b) discuss what they believe heals or prevents the problems from getting worse; and (c) envision their relationship with healthcare providers including their therapist (Adames & Chavez-Dueñas, 2017; Gallardo et al., 2012; Kleinman et al., 1978; Vasquez, 2007). Culture always shapes how therapists view problems and issues, as well as what we consider to be healthy and unhealthy processes and functional and dysfunctional coping strategies (Vasquez & Johnson, in press). Culture is always in the therapeutic space, even when we fail to honor its presence and significance.

      The concept of culture is sometimes misleadingly used interchangeably with race. However, the consensus among scientists, including social scientists, is that both concepts are distinct, albeit closely related (see Alvarez et al., 2016; Chavez-Dueñas et al., 2019; Helms & Cook, 1999). Specifically, race describes how individuals are grouped according to their shared phenotype (e.g., skin-color, eye-color, hair texture) and the social, educational, health, and political implications of this method of grouping (e.g., choosing to divide people up according to the color of their skin; see Bonilla-Silva, 2014; Carter & Pieterse, 2005; Chavez-Dueñas et al., 2014; Gannon, 2016; Helms & Cook, 1999; Ifekwunigwe et al., 2017; Jones, 1997). Said differently, race is a social construct and not a biological one. However, this social construct has real life and social consequences such as its impact on health and access to opportunities. The role of race, racism, colorism, and other forms of oppression (e.g., anti-Semitism, sexism, heterosexism) in ethics will be discussed in Chapter 23. In this chapter we focus on culture and its implications for our work as therapists—we provide some steps to recognize and overcome barriers to ethical practice in the context of different cultures.

      CULTURE HAS ALWAYS BEEN A PART OF HEALING

      Psychotherapy as a healing practice has existed for centuries in different cultures. However, the current practice of psychotherapy is often rooted in a Western philosophy with origins in Europe and the United States. Wampold (2001) explains that

The idea of sitting in a room with the healer, confiding in the healer, responding to questions, and following the implicit or explicit ritualistic expectations of the psychotherapeutic protocol, whether it is expressing one’s feelings, monitoring one’s thoughts, forming a contingency contract, or looking at the rapidly moving hands of the therapist, would be an absurdity in 99% of the societies past or present. On the other hand, participating in some healing practice is universal. As a healing practice, psychotherapy shares commonalities with medicine, but also with laying-on-of-hands, theriac, and shaman rituals. Psychotherapy is not universal; it has existed, in widely different forms, in some (but not all) Western cultures for about 100 years (p. 79).

      There is also evidence that the Indigenous people of the Americas were using talk as a form of treatment for mental illness centuries before colonization. Padilla (1984) describes how the Aztecs had a well-developed system of public health that included healing services for mental health-related concerns where conversation was used to heal and care for others. He also wrote that

      In essence it was believed that the tonalpouhqui [healer] had the knowledge and more authority to assist the patient by means of lengthy conversations designed to liberate them [from their ailments]. The personal characteristics and language of the tonalpouhqui were the major determinants for a successful outcome…The tonalpouhqui possessed concepts of ego formation and catharsis, as well as techniques of dream interpretation and psychotherapy similar to those developed later by Freud and Jung (p. 7).

      These two passages exemplify the ways in which distinct cultural groups around the world used dialogue and other methods to connect and build relationship to address the problems of living. However, the common ways in which psychotherapy is currently practiced are not culturally universal. Consider current counseling practices prevalent in the US, Canada, and many other Western countries: 45 to 55-minute sessions, once a week, often taking place in an office setting or using a Zoom connection, typically between two people. Few would argue that these practices are universal or free of cultural influence. To a great extent, they reflect Western standards and values. If so, how do we form healing relationships with clients of other cultures for whom such practices are a barrier? What do we need to learn about ourselves, the groups we belong to, and other cultures in order to communicate and work more effectively with those from other cultures? The following sections provide some ways to address these complex, arduous, but crucial questions.

      CULTURAL