Transparency & Integrity, and Honesty: Ethics in Therapy Sessions

Ethics is not only about written guidelines, rules, and specific regulations; ethics is also a stance and attitude towards a particular situation

Ethics is one of the most important topics that has been studied by many disciplines and has been the focus of researchers for centuries. Therefore, all evidence-based frameworks rely on core ethical principles like respect for autonomy, beneficence, non-maleficence, and justice. These principles also apply to psychotherapy modalities. Given that therapeutic relationships inherently involve numerous dynamics, the dynamics of the therapist-client relationship may include dozens of ethical dilemmas and questions that need to be addressed (Opoczyńska-Morasiewicz et al., 2015). This situation has led to the need to establish some rules that can protect both therapists and clients over time. Furthermore, an increased focus on ethical principles, as well as recent publications, demonstrates the essential role these principles play in the psychotherapy field, serving as the foundation not only for the therapist but also for the person receiving therapy. In this regard, the APA (American Psychological Association) (1992) has established a general framework of ethical rules and provided a roadmap for addressing ethical dilemmas that may arise. Consideration of these defined ethical rules in psychotherapy is crucial to ensure the delivery of high-quality psychological interventions (Vyskocilova et al., 2013). However, we can say that ethics is not only about written guidelines, rules, and specific regulations; ethics is also a stance and attitude towards a particular situation. Therefore, it is crucial for psychotherapists to prioritize ethical issues at the center of all their practices. In this therapy sketch, we will examine the topic of ethics in our therapy sketch, pointing out its importance for both therapists and clients.

What is Ethics in terms of Psychotherapy?

Even though there are many psychotherapy modalities defined in the literature, APA offers a broad definition for psychotherapy as treatments that help individuals with various mental health issues and emotional difficulties (APA, 2016). These different psychotherapy modalities can be rooted in very different theoretical perspectives; for example, cognitive-behavioral therapy (CBT) focuses on how thoughts, emotions, and behaviors are interconnected. In contrast, psychodynamic therapy focuses more on unconscious processes and how early relationships influence current emotional experiences. On the other hand, they all share a common foundation and principles. The most important, and perhaps the most widely shared, of these is ethics. Let's explore what ethics encompass in the context of psychotherapy with examples.

Principle 1. Beneficence and Nonmaleficence

Effective psychotherapy should maximize client benefits and minimize potential harm. Regardless of the approach, therapists must prioritize clients' well-being because even well-intentioned actions can cause harm. Practices such as maintaining boundaries, using informed consent, providing information about the process, using evidence-based methods, being fair and honest about professional skills and using them appropriately, and supporting client autonomy are essential to protect clients and ensure ethical practice.

Let's say that Anna wants to start therapy. Explaining how the process works, informing her about the duration of the sessions, the limits of confidentiality, what she can get help with, and what areas the therapist can assist with is part of transparency. Additionally, discussing how to communicate outside the session and openly clarifying roles during therapy is crucial for maintaining boundaries. Explaining the assessment process, including the methods or modalities that will be used and the reasons behind them, helps clarify the process. If any of these are not included in the therapy session, it can cause Anna to feel not safe, or hesitant about whether she can trust the process or even her therapist. This might lead to harming Anna, even though interventions or therapy methods are appropriate.

Principle 2. Fidelity and Responsibility

Therapists are responsible for resolving the ethical dilemmas they encounter in a manner that achieves beneficial results for both the client and themselves. Adhering to ethical principles and making informed decisions based on these principles, consulting with more experienced and knowledgeable individuals, such as supervisors, is part of the responsibility principle (Ackley, 1972).

Continuing Anna’s example, over time, Anna benefited from therapy. She began to trust her therapist, and a therapeutic relationship developed between them. One day, she sent a follow request to her therapist's personal social media account. Although this behavior may seem common, it can be considered an ethical dilemma in the therapeutic realm, as a social media account can disclose personal information about the therapist to Anna and impact the therapeutic process. Solving this ethical dilemma within the principles of fidelity and responsibility is part of the solution. Therapists can utilize several guides and ethical codes to resolve ethical dilemmas, such as these, or further discuss them with their supervisor.

Principle 3. Integrity

This principle provides therapists with an outline for avoiding making misleading, false, deceptive, or unfounded statements. According to the integrity principle, therapists should also refrain from creating unrealistic expectations for their clients and avoid exploiting them financially and emotionally. Moreover, to prepare the ground for integrity, therapists need to carry out their practice through training, practicing, attending licensing or certification programs, receiving supervision or consultation to use therapy modalities or techniques effectively (Hartman et al. 2012).

Let's say that Anna’s therapist decided to use EMDR techniques after finalizing the assessment process. Informing Anna about the process, clarifying competence in the modality and technique, and not setting unrealistic expectations are part of the integrity principle. Skipping any part could lead to the violation of ethical principles and cause harm.

Principle 4. Justice

In practicing their profession, therapists recognize that everyone has an equal right to support. This means that a person's identity, including their age, gender, ethnicity, religion, sexual orientation, or socio-economic status, should not influence the quality of therapy. Each individual should benefit from therapy with the same care and respect.

This principle also includes being aware of biases as mental health professionals. For example, if they have strong personal views on an issue or lack sufficient knowledge and experience, they take precautions to prevent this from harming the client. If necessary, they seek supervision or refer the client to a more appropriate specialist. In short, therapists are obliged to treat everyone fairly and respectfully. While providing services, they should be aware of their own limitations and exercise caution to avoid doing injustice to anyone, even unintentionally. This is crucial for the therapy process to be safe, inclusive, and effective.

For example, during the therapy, Anna shared that she struggled with reading and following written material due to a learning disability. She shared that long texts tiring her quickly, and sometimes she has difficulty remembering the information provided during psychoeducation. Considering this, when developing a treatment plan, it is important to tailor methods and techniques to her condition. This includes using more visual support instead of written material, simplifying information, and reiterating key points. Such practices align with the justice principle, as Anna has equal rights to care and support.

Principle 5. Respect for People’s Rights and Dignity

Every person is valuable, and everyone has the right to privacy, confidentiality, and autonomy. So when a person comes to therapy, the therapist respects their personal boundaries, lifestyle, and right to make decisions about their own life. However, some people may not be able to make their own decisions independently or may be more vulnerable, for example, children, older people, and people with disabilities. Therapists are trained to tailor the therapy process to meet each client's individual needs. Therapists also respect individual and cultural differences, as mentioned in the justice principle. They take these differences into account in the therapy process and ensure that their own prejudices do not affect the therapy, tailoring it to meet the clients’ needs.

After a while, Anna started to bring up some issues related to her cultural background in her therapy sessions. She realized how her family values, the environment in which she grew up, systemic oppression, and her beliefs influenced her current relationships and sense of self. Including cultural identity in the therapy process in an equal and respectful way, without judgment, is a part of both justice and respect for people’s rights and dignity principles. Obtaining supervision on this topic and gathering information from other sources to take a more culturally sensitive approach related to the justice principle is crucial, as overlooking this might violate ethical codes.

In short, ethics rely on some core principles; however, it is not limited to only five core principles. Only these four principles provide an outline, stance, and attitude towards a particular situation. Furthermore, you can see from the examples above that one principle is not independent of the other. They are all interrelated; violation of one can lead to another breach in the practice. Additionally, they share a specific purpose: maximizing the benefits from the psychotherapy process and minimizing potential harm to both mental health professionals and clients.

How to apply these principles in the therapy room?

As mentioned above, dozens of ethical dilemmas can emerge from a therapeutic relationship, which might be unavoidable. The question here is how to handle them, considering the core ethical principles in the therapy room. The answer is to employ an ethical decision-making model during the therapy process for the professionals. An ethical decision-making model has been discussed and introduced by various researchers, including Forester-Miller and Rubenstein (1992), Haas and Malouf (1989), Kitchener (1984), Stadler (1986), and Van Hoose and Paradise (1979). Based on the research and literature, the American Counseling Association (ACA) published “Practitioner’s Guide to Ethical Decision Making.” They introduce a 7-step roadmap for therapists to follow. These steps are designed to protect both clients' and therapists' rights, ensuring that the process is conducted safely and respectfully.

1. Identifying the problem: The First step starts with clarifying what the problem is. Is it an ethical issue, a legal issue, a system issue, or a private life issue? The therapist gathers information and evaluates all aspects of the situation so that everything is clear.

2. Applying the Code of Ethics: The therapist refers to the code of ethics. These rules are established to protect the client's rights and maintain a safe and professional relationship. Multiple psychotherapy associations have published their own codes of ethics. Here are some of the key organizations:

   1. American Psychological Association,

   2. American Counseling Association,

   3. National Association of Social Workers

   4. National Board for Certified Counselors

If the problem is described in these rules, the solution is usually explained in the code of ethics.

3. Determine the nature and dimensions of the dilemma: In this step, the therapist shapes their decision by considering values such as your right to choose (autonomy), treating everyone fairly, prioritizing your well-being, doing no harm, and maintaining a therapeutic relationship. If the guidelines in the code of ethics do not address the dilemma, therapists can consult with their supervisor and utilize current information from the literature.

4. Generate a potential course of action: To find the safest and most suitable way to resolve an ethical dilemma, the therapist generates possible scenarios and solutions that can help you. They will also use the code of ethics and supervision to develop possible solutions to these scenarios.

5. Consider the potential consequences of all options and determine a course of action: As mentioned in the fourth step, therapists brainstorm and generate a potential course of action. After that, the implications of each option are considered for you, the therapist, and others to select the most beneficial or least harmful one.

6. Evaluate the selected course of action: At this stage, the therapist reassesses the appropriateness of the chosen course of action by asking themselves some questions. These are questions such as whether the chosen solution is fair (justice), whether it is understandable by others (publicity), and whether it can be reapplied in a similar situation by another therapist (universality).

7. Implement the course of action: The last step is to put the decision into practice. However, it doesn't mean that the ethical decision-making model is limited to taking action only. Therapists actively monitor the outcome of their decisions to see how they reflect on you as a client.

Although ethical decision-making is often considered necessary for therapists, it is not only about the therapist's professionalism, but also about the client's feeling safe, respected, and that the therapeutic relationship is beneficial for them. Decisions made during the therapy process are thus based on certain principles. As a result, what you need and under what conditions you may be harmed are taken into consideration.

Takeaways

• Different psychotherapy modalities stem from diverse theories but share a common foundation: ethics.

• Increased focus on ethical principles and recent publications highlight their essential role in psychotherapy, serving as the foundation for both the therapist and the person receiving therapy.

• Associations such as the ACA, APA, and NASW have established a code of ethics and provided a roadmap for addressing ethical dilemmas that may arise.

• Beneficence and Nonmaleficence, Fidelity and Responsibility, Integrity, Justice, and Respect for people’s rights and Dignity are core principles for therapeutic relationships.

• An ethical decision-making process is introduced alongside the code of ethics to handle dilemmas during therapy, protecting rights, ensuring quality care, and avoiding harm.

• Ethical codes and decision-making aren't just about professionalism; they also ensure clients feel safe and respected, and that therapy benefits them.

References:

• American Counseling Association. (2014). ACA code of ethics.

• Ackley, D. (1972). Counseling ethics: Issues and cases. Brooks/Cole Publishing Company.

• American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. https://www.apa.org/ethics/code

• American Psychological Association. (2016). Understanding psychotherapy and how it works. https://www.apa.org/topics/psychotherapy/understanding

• Forester-Miller, H., & Rubenstein, R. L. (1992). Ethical decision making: A practitioner’s guide. American Counseling Association.

• National Association of Social Workers. (2021). Code of ethics of the National Association of Social Workers. https://www.socialworkers.org/About/Ethics/Code-of-Ethics

• Hartman, L. I., Anderson, R. E., & Bird, S. M. (2012). Professional integrity and ethical decision making. Training and Education in Professional Psychology, 6(4), 202–210. https://doi.org/10.1037/a0032053

• Opoczyńska-Morasiewicz, M., Sękowski, M., & Świtaj, P. (2015). Ethical dilemmas in psychotherapy: Experiences of Polish therapists. Psychoterapia, 3(174), 5–18. https://doi.org/10.12740/PT/60435

• Vyskocilova, J., Prasko, J., & Slepecky, M. (2013). Ethical aspects of psychotherapy. Activitas Nervosa Superior Rediviva, 55(3–4), 111–117.