Ethical Challenges in Group and Personal Therapy

Abstract

This paper investigates the ethical issues that characterize group therapy and personal therapy. It shows that both types of therapies have unique ethical challenges that affect counselor-client relationships. Evidences from this paper also show that confidentiality, informed consent, and dangerous group behaviors are some ethical issues that characterize group therapy. Similarly, based on empirical studies, this paper highlights the lack of autonomy, nonmaleficence, and boundary issues as the main ethical challenges in personal therapy. Based on the efficacy of both types of therapies, and their nature, this paper shows that many therapists prefer to use group therapy as opposed to personal therapy.

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Introduction

In counseling, people require therapists to show ethical principles when they undertake their duties. Counselors do not only have a duty to act ethically, but also update their practices, according to the latest ethical standards (Delgado-Romero, Galván, Maschino, and Rowland, 2005). Although these ethical standards outline what the counselors should (or should not) do, breaking ethical rules may have serious ramifications for therapists and their clients. However, different types of therapies have unique ethical challenges that define these ramifications. This paper investigates them and outlines their relationships with group therapy and personal therapy. It also shows how such ethical challenges affect a therapist’s choice about whether to use individual therapy or group therapy.

Ethical Issues in Group Therapy

Group therapy has unique ethical challenges that affect the efficacy of the intervention. This section of the report talks about different ethical issues that emerge in such therapies. They include confidentiality, informed consent, and dangerous behaviors from group members.

Confidentiality

Confidentiality is a serious problem that different types of therapists face. However, Bodenhorn (2006) says that it affects group therapy more than it does individual therapy. He explains this fact through the ethical challenges that exist in group therapy. For example, he says, some group members may know information about some members and not others. The same is true for couple’s therapy where one partner may disclose (to the therapist) that he is HIV positive, while the spouse does not know. Similarly, one partner may disclose to the therapist that he has had a series of affairs that are unknown to the spouse. These disclosures expose several ethical issues that the therapist face (to tell, or not to tell).

The APA code of ethics is unclear about how therapists should handle such issues of confidentiality. However, standard 4.02 suggests that the therapists and their clients should discuss the limits of confidentiality before starting their sessions (American Psychological Association, 2009). Principle “A” of the same code of ethics outlines the need for therapists to safeguard the interests of their clients (American Psychological Association, 2009). Comparatively, Koocher, and Keith-Spiegel (2013) suggest several ethical remedies that the therapists may pursue when they encounter the above-mentioned ethical challenges. They say these remedies are in three forms.

First, therapists may protect all of their clients’ secrets (Koocher and Keith-Spiegel, 2013). This strategy presents them as trustworthy people. However, its main disadvantage is its ability to put partners in a precarious position when they tell the therapist about a (potentially) damaging piece of information and still act as if everything is normal. In such cases, therapists may witness cases where people act one way, privately, and another way, publicly.

Secondly, therapists could also choose not to hold any secrets between group members and adopt an “open information” policy. Although this strategy is useful in creating group harmony, it may prevent members from sharing information, confidentially. The third strategy involves an intermediary solution where therapists choose the kinds of information to share with other group members, and which ones to keep confidential. Usually, therapists use their discretion to decide the kinds of information to disclose and the ones to keep secret.

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For example, revealing information about an abusive partner (in a couple’s therapy) may put one partner at risk of further abuse. Therefore, therapists may use their discretion to keep such information private. However, Koocher and Keith-Spiegel (2013) say there are situations where people need therapists to breach confidentiality clauses. For example, they say they can do so when the group participants pose a danger to themselves or to others. Many people understand this breach as the “duty to protect.” Nonetheless, to avoid any misunderstandings, Koocher and Keith-Spiegel (2013) tell therapists and their clients to develop policies that guide such breaches.

Confidentiality issues may also occur when therapists have to share information from the counseling session with a third party. Particularly, this ethical issue emerges when group participants are minors and their guardians, or parents, want to know the details of the counseling sessions. Concerning this ethical dilemma, Bodenhorn (2006) says that although it is prudent to explain the need to uphold confidentiality, therapists still have a duty to tell the third parties about what happened during the counseling sessions. Overall, these dynamics show that confidentiality is a serious ethical issue in group therapy.

Informed Consent

Consent is an important ethical issue for therapists. However, many of them do not realize this fact. For example, Qian, Gao, Yao, and Rodriguez (2009) say many Chinese therapists do not follow this ethical principle in their practice. Particularly, this is true for group therapists. Indeed, since group therapy requires members to interact with one another, informed consent is an important ethical issue because it makes sure that group members make informed decisions to take part in the therapy.

However, before group members can engage in such productive discussions, Sarkar et al. (2010) say it is important for the counselor to tell them about their rights. Furthermore, they add that group counselors should tell all the members about the format and ground rules of the discussions (Sarkar et al., 2010). Such modalities may clash with the cultural beliefs of the clients, but as Miller & Wendler (2006) say, group counselors, have to take this risk. Overall, these factors outline the ethical issues that all group members should know before the discussions start (informed consent).

However, within the limits of informed consent, therapists are also required to follow some ethical principles after the discussions have started. For example, therapists should tell group members of their right to leave the group discussions. The group members should also know any research that should occur in the group discussions, and if the therapist would tape the group sessions (Miller & Wendler, 2006). Similarly, group members should understand their freedoms from group pressure, the modalities of processing information, and any expectations that group members have of them. Broadly, these provisions outline the ethical obligations of group therapists. Counselors should make sure they do not breach them because doing so would compromise the therapy sessions.

Dangerous Behaviors

There is a consensus among researchers that group members may engage in activities that are dangerous to themselves and to others (Sarkar et al., 2010). In such circumstances, Sarkar et al. (2010) say it is important for therapists and group members to develop policies that protect them if such situations arise. However, many counselors often experience situations where participants give threatening remarks, which prevents them from acting because they do not know if such threats are real or not. If they ignore them, they may give members an opportunity to harm themselves or other members. However, if they act on them, they may escalate an “innocent” issue, thereby distorting group harmony. This is the main ethical issue that arises in such situations.

Ethical Issues in Individual Therapy

Individual therapy has several ethical issues that closely guide the relationship between counselors and their clients. This section of the paper outlines three such ethical issues – autonomy, nonmaleficence, and counselor-client boundaries.

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Autonomy

The lack of client autonomy is a serious ethical concern for individual therapy because clients sometimes develop a strong attachment to their therapists. In such cases, they are unable to act independently. However, it is important to uphold client autonomy because personal therapy should reflect the wishes of the client, and not those of the therapist (Rogers, 2002). If a client were constantly dependent on the therapist, it would be difficult for the counselor to withdraw his support because it could negate all the gains made in the therapy. Similarly, it is untenable for the client to depend on the therapist, always.

Nonmaleficence

Nonmaleficence is an ethical need for counselors to “do no harm” to their clients. Indeed, many professional bodies warn counselors from engaging in acts that could be injurious to their clients (Hoyt & Bhati, 2007). For example, through a case study, the Continuing Psychology Education (2010, p. 7) narrated the experiences of one therapist, Susan Forward, who revealed information about her private therapy sessions with O.J Simpson’s deceased wife. She said, her client allegedly claimed that O.J battered her. Observers said publicizing this information was injurious to the wife.

In fact, the California Board of Behavioral Science Examiners barred the therapist from her practice, for a specified time (Continuing Psychology Education, 2010, p. 7). Therefore, many ethical organizations need their members to act in the best interest of their clients. Particularly, they emphasize the need for therapists to tailor their craft to appeal to the cultural interests of their clients. This means that therapists should not exploit their powers (Hoyt & Bhati, 2007).

The boundary between Counselors and Clients

Unregulated counselor-client relationships are likely to create an ethical dilemma in individual therapy because of the possible attachments that may emerge when therapists and clients spend too much time together. Sexual relationships between clients and their therapists are often common issues that emerge in such ethical dilemmas, especially when therapists and the clients are of different sexes (Halter, Brown, and Stone, 2007). Such outcomes could strain the therapist-client relationship, thereby undermining the therapy.

Many therapists encounter situations, which need them to make choices about whether to cross the client-therapist boundary or not. However, unclear lines outline what therapists and clients should engage in. Indeed, Continuing Psychology Education (2010) says there are no clear answers regarding boundary issues between therapists and their clients. Similarly, after searching several electronic databases, Halter et al. (2007, p. 5) say the ambiguities surrounding the definitions of “sexual boundary violations” and “professionalism” complicate this ethical issue.

However, abundant literatures from western research have explored this issue. For example, Halter et al., (2007) have investigated location issues in individual therapy (the places where clients and therapists should meet). Indeed, since individual therapies are personal, therapists and clients could be tempted to change their therapy venues to “inappropriate” locations, such as a client’s house, or a hotel. Halter et al. (2007) describe such an ethical dilemma by narrating one therapist’s experience with a female client.

The therapist was very welcoming to the client because he gave her a drink during the counseling sessions and maintained a close body contact when talking with her. Although he committed these acts without any malice, people often thought he was unethical (Halter et al., 2007). Such are the issues that some therapists encounter in individual therapy.

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People who say the counselor-client boundary is rigid borrow their ideas from Freud (an independent researcher) (Continuing Psychology Education, 2010). However, based on the thin line that divides friendliness and “inappropriate” behavior, many authors agree that all people should judge a counselor’s behavior based on whether they occur during the analytical sessions, or outside the therapy sessions (Continuing Psychology Education, 2010). However, Halter et al. (2007) say if both parties (therapists and clients) overcome boundary issues, they are likely to enrich their therapy experience.

Group Therapy vs. Individual Therapy

This paper already shows the ethical issues that emerge in group therapy and individual therapy. These differences affect the choice of therapy that the counselors prefer. For example, therapies that have many ethical issues discourage many counselors from pursuing them. Such is the case with individual therapy. In fact, many researchers have said that group therapy has a higher impact on a client’s progress than individual therapy does (Hoyt & Bhati, 2007).

Given the fact that it influences many people at one time, counselors perceive it as a cheaper and more cost-effective therapy. The extra support that most clients get from being in a group supports this efficacy. Concisely, in group therapy, clients get genuine support from people who share the same issues as they do and can offer valuable help to them. Moreover, hearing the experiences, challenges, and problems that other people face may give group members a stronger impetus to change their circumstances.

Although individual therapy is simple to conduct, it strains the counselors by stretching their imagination about how they manage different clients. Indeed, different clients have unique demands and challenges that need different approaches. The pressure is for the counselor to show creativity and address these concerns. Therefore, interacting with three, or more, such clients, daily, may stretch their resources.

Individual therapy also creates unique ethical challenges that may discourage many therapists from adopting such methods (Hoyt & Bhati, 2007). For example, individual therapy gives a lot of power to counselors. Often, such powers may create “tempting” situations where they feel the need to overstep their mandate. There are high numbers of ethical challenges that arise from such situations. This paper has already explained some of them (lack of autonomy, nonmanafelence, and unregulated client-therapist boundaries).

Such ethical dilemmas do not exist in group therapy because the latter creates a neutral environment for clients and counselors to interact. Moreover, since group therapy has many members, therapists can also get support from them when they want to defend themselves in an ethical debate. This support does not exist in individual therapies because if ethical issues emerge, therapists do not have witnesses. Overall, these dynamics explain why many therapists prefer group therapy for individual therapy.

Summary

After weighing the findings of this study, it is crucial to point out that the ethical challenges of group therapies and personal therapies depend on multiple human relationships (or the lack of it). It also shows that both types of therapies have unique ethical challenges that inform a therapist’s decision about the type of therapy to use. Evidences from this paper show that confidentiality, informed consent, and group formation principles are some ethical issues that characterize group therapies. Similarly, based on empirical studies, this paper shows that the lack of autonomy, nonmaleficence, and boundary issues pose the greatest ethical challenges in individual therapy.

Based on the efficacy of both types of therapies, and the severity of their ethical issues, many therapists prefer group therapy as opposed to individual therapy. Indeed, group therapy is superior to individual therapy because it allows group members to discuss, openly, the issues that drive them to seek counseling. This environment reduces the severity of ethical challenges that face counselors who pursue the therapy method. Since some of these ethical issues may overlap between individual and group therapies, future research should investigate the implications for common ethical dilemmas in both therapies.

References

American Psychological Association. (2009). Publication Manual of the American Psychological Association. Washington, DC: American Psychological Association.

Bodenhorn, N. (2006). Exploratory Study of Common and Challenging Ethical Dilemmas Experienced by Professional School Counselors. Web.

Continuing Psychology Education. (2010). Ethics And Boundary Issues: Case Studies. Web.

Delgado-Romero, E., Galván, N., Maschino, P., & Rowland, M. (2005). Race and Ethnicity in Empirical Counseling and Counseling Psychology Research: A 10- Year Review. The Counseling Psychologist, 33(4), 419-448.

Halter, M., Brown, H., & Stone, J. (2007). Sexual Boundary Violations by Health Professionals – an overview of the published empirical literature. Web.

Hoyt, W., & Bhati, K. (2007). Principles and Practices: An Empirical Examination of Qualitative Research. Journal of Counseling Psychology, 54(2), 201–210.

Koocher, G., & Keith-Spiegel, P. (2013). What Should I Do? – 39 Ethical Dilemmas Involving Confidentiality. Web.

Miller, F., & Wendler, D. (2006). The Relevance of Empirical Research in Bioethics. Schizophr Bull, 32(1), 37-41.

Qian, M., Gao, J., Yao, P., & Rodriguez, M. (2009). Professional Ethical Issues and the Development of Professional Ethical Standards in Counseling and Clinical Psychology in China. Ethics & Behavior, 19(4), 290-309.

Rogers, W. (2002). Whose autonomy? Which choice? A study of GPs’ attitudes towards patient autonomy in the management of low back pain. Family Practice, 19(2), 140-145.

Sarkar, R., Sowmyanarayanan, T., Samuel, P., Singh, A., Bose, A., Muliyil, J., & Kang, G. (2010). Comparison of group counseling with individual counseling in the comprehension of informed consent: a randomized controlled trial. BMC Medical Ethics, 11(8), 1-6.

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