NURS 6650 Week 1: Legal and Ethical Considerations for Group and Family Therapy

NURS 6650 Week 1: Legal And Ethical Considerations For Group And Family Therapy

Week 1

Members of a cohesive group feel warmth and comfort in the group and a sense of belonging; they value the group and feel in turn that they are valued, accepted, and supported by other members.

—Irvin D. Yalom, The Theory and Practice of Group Psychotherapy Laureate Education (Producer). (2017).

Group and family therapy offers a unique sense of community and support that may not be achieved through other therapeutic approaches. As you help clients effect change within themselves, they are able to in turn help others within the group change. Although many clients thrive in this environment, it is important to recognize that group and family therapy is not appropriate for everyone. Like any other therapeutic approach, group and family therapy has limitations that must be considered.

This week, as you begin exploring group and family therapy, you examine legal and ethical considerations of this therapeutic approach. You also prepare for your practicum experience by examining counseling theories and developing goals to guide your practice.

Discussion: Legal And Ethical Considerations For Group And Family Therapy

Considering the Health Insurance Portability and Accountability Act (HIPAA), the idea of discussing confidential information with a patient in front of an audience is probably quite foreign to you. However, in group and family therapy, this is precisely what the psychiatric mental health nurse practitioner does. In your role, learning how to provide this type of therapy within the limits of confidentiality is essential. For this Discussion, consider how limited confidentiality and other legal and ethical considerations might impact therapeutic approaches for clients in group and family therapy.

Learning Objectives

Students will:

• Compare legal and ethical considerations for group and family therapy to legal and ethical considerations for individual therapy
• Analyze the impact of legal and ethical considerations on therapeutic approaches for clients in group and family therapy
• Recommend strategies to address legal and ethical considerations for group and family therapy

To Prepare:

• Review this week’s Learning Resources and consider the insights they provide on group and family therapy.
• View the media, Legal and Ethical Issues for Mental Health Professions, Volume I, and reflect on legal and ethical considerations for group and family therapy and individual therapy.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Post to Discussion Question link and then select Create Thread to complete your initial post. Remember, once you click submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking Submit!

By Day 3

Post an explanation of how legal and ethical considerations for group and family therapy differ from those for individual therapy. Then, explain how these differences might impact your therapeutic approaches for clients in group and family therapy.

Support your rationale with evidence-based literature.

By Day 6

Respond to at least two of your colleagues by suggesting strategies to address the legal and ethical considerations your colleagues discussed. Support your responses with evidence-based literature.

Legal And Ethical Considerations For Group And Family Therapy Essay Paper

Group counseling offers multiple relationships to assist an individual in growth and problem solving. Groups are an excellent treatment choice for numerous intrapersonal and interpersonal issues, and in helping people to change. Groups provide a sense of community to its members allowing them to see that they are not alone. 

In group therapy sessions, members are encouraged to discuss the issues that brought them to therapy openly and honestly. It is the responsibility of the counselor to work to create an atmosphere of trust and acceptance that encourages members to support one another.

It is the responsibility of the counselor to respect the basic rights of all members. Because of this responsibility, counselors must carefully select members and hold individual consultations with each member to discuss informed consent. This dialogue must also include the risks and benefits of group work (Israel, 2002). During this time it is important for the counselor to stress the importance of confidentiality within the group.

A counselor cannot prevent a group member from speaking out during their personal lives, however a counselor must stress the importance of maintaining confidentiality as a way of demonstrating respect for protecting the disclosures of others in the group (Corey et al., 2010). It is a difficult task for the therapist to uphold the legal rights of each individual within the group especially since they have no control over the activities of members outside of the group.

Therapists also may interact with group members away from the group setting and have to toe the line of what is and is not appropriate to discuss outside of the group setting (Israel, 2002).

Ethical issues in a counseling practice lay the foundation of a therapist in practice. Ethics are at the center of how the counseling process functions and operates in a successful manner for the clients who seek help in such a setting. In order for the counseling profession to be ethical and hold professional recognition, there are many facets that need to be examined and outlined to make sure all counselors and practitioners are functioning at the highest level and withholding their duties required by the counseling profession. 

The first introduction so to speak of the area of ethics also happens to be one of the first steps in counseling, which is informed consent. The informed consent provides the basis of what happens or will be. Why is this important in counseling? The informed consent process involves establishing the basic framework between a therapist and their client that serves as an ethical and legal requirement as well as the formation of a basic working partnership between a therapist and their client.

 The informed consent is essentially an informational exchange between a therapist and a client that outlines the process of therapy. It also allows the client to be informed of their rights in order to make conscientious and thoughtful decisions related to their therapy. An interesting fact about informed consent is that it can be provided in written and oral form, or a combination of the two (Corey, 2013).

If done orally, the counselor must document what was addressed in the informed consent. The information that must be presented to clients, first and foremost, are their rights and responsibilities as a client working with a particular therapist. Beyond this, an informed consent should outline the goals of the counseling relationship, the responsibilities of the client as well as the therapist, expectations of the client, limitations of the counseling relationships, fees involved.

The purpose of this paper is to discuss and evaluate what ethical requirements that are current “hot topics” therapists must employ when working in group and individual settings, respectively. There are subtle differences in ethical considerations but at the same time, there are many similarities. For this purpose, these ethical considerations have been narrowed down to conflict of interest (dual roles), when to refer clients to group or individual counseling or even to another more qualified therapist and when clients need to share and when they don’t. In addition, the discussion of what a therapist must share about the group; what the group is about, what rules are necessary for a successful outcome and the rationale of the group – why they are there.

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 value 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.

Ethics are a set of moral principles or rules of conduct for an individual or group. The term ethics comes from the Greek ethos meaning custom, habit or character. Ethics determine choices made. In counselling, ethics underpin the nature and course of actions taken by the counsellor. Counsellors and others in helping professions are expected to behave in an ethical manner.

We believe it is important to become familiar with the basic ethical guidelines that therapists should follow before you begin therapy with a new therapist, and we encourage you to do so. Unfortunately, media portrayals of therapy do not always provide examples of ethical, effective therapy experiences and many myths about therapy persist.

Although all the therapists and counselors listed in GoodTherapy.org certify that the therapy they provide accords in orientation and attitude to the Elements of Good Therapy, GoodTherapy.org does not provide a specific code of ethics for therapists to follow. However, ethical codes have been developed by mental health associations for the purpose of setting professional standards for appropriate behavior, defining professional expectations, and preventing harm to people who go to therapy. Mental health professionals have an obligation to be familiar with their professional code of ethics and its application to their professional services.

We provide links to ethical codes below because we feel it is important for consumers of psychotherapy to know the difference between ethical and unethical behavior. Most therapists intend to “do no harm” and strictly follow ethical guidelines. Overall, mental health professionals are a good bunch. However, not only do good therapists make mistakes, there are some providers who, unfortunately, are careless and unaware of the importance and purpose of some ethical guidelines. We believe it is in everyone’s best interest to become familiar with basic        ethical guidelines before beginning psychotherapy.

By nature of the profession, counsellors are to act in the best interest of their client, promoting client goals, protecting client rights, maximising good and minimizing harm (Stein, 1990). This expectation broadens due to the inherent power of the relationship between client and counsellor. Ethics including ethical codes and principles aim to balance the power and ensure that the counsellor operates for the good of the client and not for self.

Primarily, counsellors’ duty of care is to their clients. When making ethical choices, counsellors must consider not only themselves, but also the agency or organisation (if not self-employed), their profession and the greater community (Axten, 2002). Counselling does not occur in a vacuum therefore it is important that counsellors acknowledge all facets of their practice both internally and externally.

Ross (2002) draws on this further by asking counselors to look at ethics from a holistic perspective — body (the environment, structures, systems, policies, laws, regulations, moral codes, and societal norms), mind (ethical thinking, philosophy), heart (relationships, emotions, values) and spirit (unknowing, unconscious). A complete awareness of the ethics of a situation can occur when all are taken into consideration.

Code of Ethics

The concept of ethics relates to moral consideration. The challenge lies in what is considered moral or ethical. Each counsellor comes to the profession with their own set of values and standards. Individual principles and how they were used to interpret dilemmas would be universally different. Therefore, a Code of Ethics — a general standard that counsellors and therapists adhere to and use co jointly with legal standards to provide ethical practice and work through ethical dilemmas — is required.

Ethical codes offer counsellors an outline of what are considered acceptable and unacceptable behaviours. In a region (such as Australia) where counselling is not regulated through licensing, ethical codes provide a valuable tool for developing and maintaining ethical conduct.

Numerous professional associations have developed their own Code of Conduct and Ethics. Codes may adopt similar principles whilst also covering behaviours specific to an area of counselling. Professional counselling organisations provide Codes of Conduct and Ethics to members and the inability to stick to these Codes may result in removal of membership.

A professional may belong to more than one organisation and thus have access to additional ethical codes. When faced with an ethical dilemma, a counsellor is to consider all available and applicable codes. It is counsellors’ responsibility to familiarise themselves with relevant codes and regulations governing their area of practice.

Clarkson (2001) contends that all members of a professional association subscribe (at least in principle) to their profession’s Code of Ethics for the sake of protecting the public. The degree to which this ‘protection’ occurs is based on four factors:

• Client awareness and knowledge of the Code of Ethics and the complaints procedure
• The degree to which the client feels they can discuss his or her feelings about a violation with the counselor
• The fairness of the Codes
• The client’s ability to manage the Code or gain assistance in negotiation

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.

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 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.

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’.

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 same 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 defensible reasons (not justifications) to take on individual work in this context?

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 pathologizing 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)

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 postmodern 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).

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.

Ethical considerations in group counseling

Ethics are parameters by which professionals in different fields use (Jacobs, Masson, Harvill, & Schimmel, 2012). They are, in a sense, the rules that professionals follow to be fair to their clients, their profession and to themselves. While not all ethical considerations are the same for every profession, there are similarities. 

This also holds true for different situations in counseling. The scope of this paper is to discuss the “hot topics” of ethical considerations for group therapy and individual therapy; and to compare them accordingly. Also, to answer why a therapist may choose individual counseling over group therapy or vice versa.

There are many ethical considerations for therapists who choose to counsel on an individual and group basis. For this context however, the focus is on the conflict of interest, when to refer clients on to other professionals or from individual counseling to group counseling and whether forcing clients to share their deepest, darkest sorrows and secrets is ethical.

A conflict of interest in counseling can range from too much therapist self-disclosure to having dual relationships, or relationships with clients outside of the therapy sessions (Jacobs, et al., 2012). These ethical dilemmas may be seemingly innocent enough and may, in some cases be unavoidable (i.e. in rural communities where there are not many therapists) (Gonyeah, Wright & Earl-Kulkosky, 2014; Gottlieb, 1993) but when the therapist and client are in a situation where knowing each other’s lives outside of the office setting, certain rules and ethical considerations come into play. 

Attending functions together may require a lot of thought on both sides to determine the safety of both the client and therapist. In a group therapy setting, the stakes for safety and protection are even higher because of the many lives and families involved (Burian & O’Connor Slimp, 2000).

Therapists must be aware and mindful of when a client needs to move on to other more qualified therapists or from an individual setting to a group session. Knowing the time to move on is the responsibility of the therapist as is knowing when they are not qualified to do their client justice with their own limitations (Jacobs, et al., 2012). 

This is when the therapist should refer the client to a more qualified therapist who has the experience required to further help the client. With groups, it is the therapist’s job to know when being in a group setting is more beneficial and will challenge the client to move on in their recovery. If the client within a group setting is struggling in the group and can’t seem to connect, it is the job of the therapist to refer them back to individual counseling or a group setting that is more suited to the clients issues.