In 1964, Supreme Court Justice Potter Stewart famously remarked about obscenity, “I can’t define it, but I know it when I see it.” Defining ethics in therapy can feel just as tricky. For example, would you accept a thank-you card or a bunch of flowers from a client?
Most therapists would say yes. But what if it were a Rolex watch, a week in their Spanish villa, or even the flowers if they were pointedly delivered on Valentine’s Day? And if you said the card was in and the villa was out, where exactly in between would you draw the line?
You see what I mean? We feel we know what ethics are but pinning them down to specifics is tricky because they depend on interpretation, social and professional context, personal beliefs, and many other factors.
The Challenge of Making Ethical Decisions in Therapy
A Code of Ethics, of course, is vital and your professional body will provide you with one for formal guidance. But a written Code can’t anticipate every real-world situation.
Supervision is another source of support and getting that second opinion can be very useful. However, some ethical dilemmas (like clients turning up with gifts) arise in a session and have to be dealt with immediately.
You can hardly ring your supervisor for advice while the client is sitting in front of you, and they might not be available if you did. So even inexperienced or student hypnotherapists can be faced with making potentially complex ethical decisions in the moment.
Kitchener’s Five Principles
You'll be happy to hear that there is a framework you can fall back on when you need to make these decisions. Kitchener [1] set out five general principles to apply to ethical decision-making when you don’t have a specific rule to follow. These are:
- Autonomy – allowing clients freedom of choice to make their own decisions where possible and to stay consistent with their own values.
Autonomy has to be balanced against the client’s ability to make sound decisions (for example, if they are a minor or a vulnerable adult) and on how their values are likely to be seen in the society in which they live (for example, a nudist who prefers to be naked in settings where others would consider it inappropriate). - Nonmaleficence – the medical principle of ‘do no harm’, where it’s important to balance the pros and cons of each possible course of action and take them into account in your decision-making.
It’s also similar to the philosophical principle used by many therapists of ‘the greater good. For example, breaking confidentiality to report a risk of harm may prevent greater harm to the client or others. However, see footnote [2] on that specific issue. - Beneficence – acting in the client’s best interests, for example referring them to a GP or more experienced therapist if you need to, offering a safe place to explore difficult situations and feelings, not unnecessarily prolonging therapy, offering reasonable adjustments for disabilities, and so on.
- Justice – treating all clients fairly, so being aware of transference and countertransference, following the law that protects certain groups from prejudice, and even having a clear and open pricing structure.
Justice is not about treating everyone the same, but about adapting to everyone’s needs equally where you can, especially where a vulnerability or disability applies. Kitchener called it ‘“treating equals equally and unequals unequally but in proportion to their relevant differences’ [3]. For example, having a chaperone with a client who might be considered vulnerable. - Fidelity – being honest and trustworthy in your dealings with clients.
This isn’t just about building rapport, although that comes into it, but also ensuring your clients trust you, whether that’s by keeping your word, maintaining professional boundaries, or demonstrating respect for their time and needs (e.g., not constantly moving appointments about without giving good reasons).
Sometimes, the principles might conflict, for example, the recent debate over assisted dying. Is someone making that decision expressing autonomy, or do they need protection from themselves? I’m not going to provide an answer to that one, by the way, because I don’t want to go too far off-topic, but context is key, and you might come to different decisions in different situations.
Tips For Ethical Decision-Making
When faced with a real-time ethical dilemma, having a framework for clear thinking is essential. These questions can help guide you.[4]
- What is the ethical dilemma?
- What does your professional body’s Code of Ethics say about this?
- What guidance might you draw from previous experience or supervision?
- What are your choices?
- What are the likely consequences of each option, and how do they fit with Autonomy, Nonmaleficence, Beneficence, Justice and Fidelity? If you have problems remembering the five principles, this will help … Act Now, Be Just and Fair
Then choose and implement the one that you feel will lead to the least harm and most good. I’d also recommend a consultation with your supervisor as soon as possible, to ensure there are no options that you’ve overlooked or actions which need to be taken later.
Growth and Development as a Therapist
Ethical dilemmas are part of running a therapy practice, and even experienced practitioners are sometimes unsure about the best course of action. It’s why we have a support system of reflective practice including supervision, continuous professional development training and even, now and then, social media groups (the good ones that aren’t going to make you feel about an inch high for asking a question). [5]
Reflective practice isn’t just about identifying things you could have done better. It’s also about understanding your decision-making process and learning to address future dilemmas with greater confidence.
Ethical decisions made 'in the moment' are rarely perfect, and hindsight often highlights areas for professional development. Remind yourself that ethical decision-making improves with practice, reflection and support.
In the end, if you act with compassion and ask yourself what you would want if your role and the client’s were reversed, you’ll rarely go astray.
References
[1] Kitchener, K. S. (1984). Intuition, critical evaluation and ethical principles: The foundation for ethical decisions in counselling psychology. Counselling Psychologist, 12(3), 43-55.
[2] The legal basis of your work with a client is set out in your contract or terms and conditions. All clients should be asked to read it and sign to say they have done so. Should there be a query, anything not covered is judged on what a reasonable person would expect. So, since most reasonable people would arguably expect a therapist to keep their work confidential, you must mention in your T&C any limitations, such as you being obliged by law to part with information (e.g., the Terrorism Act, if a court order or warrant is issued), or if you feel that someone is at risk of harm. Some therapists have broken confidentiality for what they thought was a good reason (e.g., to protect a client bent on self-harm,) and have later been sued for breach of contract because no exceptions were listed in their paperwork.
[3] Kitchener, K. S. (1984). Intuition, critical evaluation and ethical principles: The foundation for ethical decisions in counselling psychology. Counselling Psychologist, Page 49.
[4] Adapted from Forester-Miller, H. and Davis, T. (1996). A Practitioner’s Guide to Ethical Decision Making. [online] Available at: https://www.counseling.org/docs/default-source/ethics/practitioners-guide.pdf?sfvrsn=df2de618_4. Pages 2.4.
[5] I recommend Meeting of Minds. Counselling and Hypnotherapy Tips and Resources on Facebook, https://www.facebook.com/groups/therapymeetingofminds
----------------------------
Author: Debbie Waller is an experienced hypnotherapist and hypnotherapy trainer. She is the author of Anxiety to Calm: a Practical Guide to a Laid-Back Life, The Hypnotherapist's Companion, Their Worlds, Your Words, and The Metaphor Toolbox, all available from Amazon or direct from the author. Find out more about Debbie's services on
Yorkshire Hypnotherapy Training - multi-accredited hypnotherapy practitioner training, taster days and foundation levels.
CPD Expert - accredited CPD and other therapy training (online and workshops options), expert and qualified hypnotherapy supervision
Comments
Post a Comment