Special ethical considerations when the "patient" is the relationship
While the focus of individual therapy is solely on the individual, marriage and family therapy shifts the focus from any one individual to the unit as a whole entity. This broader perspective is based on the fundamental principles of systems theory which considers any dysfunction in an individual’s behavior to be a symptom of the larger dynamics operating within the group. As Corey, Corey and Callanan (2002) indicate, “Actions by any individual member influence all the other members, and their reactions have a reciprocal effect on the individual” (p. 396). This requires that the process of analysis and change be a more comprehensive and collaborative effort involving all parties. Consequently, managing this process is a delicate and complex task in which the therapist must sensitively manage the needs and emotions of the individuals in balance with the functioning of the unit.
While the nature of the ethical issues that arise in couple and family therapy mirror those that occur in single client contexts (i.e., confidentiality, roles and responsibilities, etc.) the issues become more complex and multi-faceted with the involvement of multiple clients having differing perceptions, goals and orientations. Specifically, for example, by nature of the context, many issues that do not compromise confidentiality in individual therapy may present dilemmas in multi-person therapy. Therapists often disagree on the proper way to handle confidentiality in a multiple-client situation. Some practitioners in the midst of the couple or family therapy still maintain strict individual confidentiality with each member and even engage in some level of separate individual therapy sessions. This approach has the advantage of eliciting more critically relevant information than typically revealed in joint sessions, thus giving the therapist more in-depth insight into situation from several perspectives. However, it also runs the risk of the presence of or the appearance of collusion with a certain member or members, thus compromising trust in the therapeutic relationship. It may also serve to perpetuate an atmosphere of secrecy which is contributing to the dysfunction, thus exacerbating the problem rather than facilitating more open communication.
An alternative approach prohibits instances of individual confidentiality, treating the couple or family exclusively as a group and promoting fully open communication. This approach avoids potential problems of real or perceived alliances on the part of the therapist and forces the issues into the collective sessions, where the therapist can model effective patterns of disclosure and response. Therapeutic progress in this context may move forward at a slower pace as families may tend to remain entrenched in their dysfunctional non-communicative patterns and avoid the relevant issues.
Yet another alternative to the aforementioned strict confidentiality or cull disclosure perspectives is a hybrid approach based on the experience and judgment of the therapist. Birchler and Schwartz (1994) propose this model of “limited confidentiality” (p. 277) whereby individual disclosure of relevant issues to the therapist is encouraged to enhance a fuller understanding of the issues, promote progress and develop appropriate interventions. The information is shared with all members in conjoint sessions at the discretion of the therapist based upon his/her assessment of its therapeutic relevance. While this approach is more complex and dependent upon the skill of the therapist, Birchler and Schwartz (1994) consider it to possess significant advantages over the more straightforward and absolute techniques of all-or-nothing confidentiality.
Regardless of the approach therapists choose to deal with the complex issue of confidentiality in a multi-client situation, ethical mandates of informed consent must be followed. Perhaps because the relationships are more complex in these settings, clear and complete disclosure of the ground rules (i.e., policies regarding confidentiality) becomes essential. Issues of confidentiality should be openly discussed and understood by all participants to avoid potential difficulties which would cause setbacks in therapeutic progress. Couple and family therapy is often a highly charged and dynamic process with the potential to facilitate great change in the lives of many. As such, it also can present therapists with intense and complex ethical issues. By firmly establishing their professional values and grounding themselves in their therapeutic and ethical orientations therapists can better prepare themselves for handling the complexities of the therapy situations.
Birchler, G. R. & Schwartz, L. (1994). Marital dyads. In M. Hersen & S. M. Turner (Eds.), Diagnostic interviewing, 2e, 277-303. New York, NY: Plenum.
Corey, G., Corey, M. and Callahan, P. (2002). Issues and ethics in the helping professions (6th ed.). Pacific Grove, CA: Brooks/Cole Publishing Company.