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Navigating Ethical Dilemmas and Establishing Boundaries in Therapeutic Setting


Muskaan Kalaria

26th June 2024




“Without a code of established ethics, a group of people with similar interests cannot be considered a professional organisation” - Allen, 1986

Practising psychology requires an extensive understanding of the ethics involved, forming the basis for effective treatment. Ethics refers to people's moral decision-making ability and social interactions. Often confused with morality, which involves judgement and evaluation, ethics is connected to human conduct. The APA dictionary defines ethics as ‘The principles of morally right conduct accepted by a person or a group considered appropriate to a specific field’ (APA Dictionary of Psychology, 2018). These regulations guide practitioners, safeguard the clients' rights, inculcate fairness, and provide a systematic framework for the profession which eventually enhances the quality of work (Ray, 2001). After all, therapists are humans, and thereby are fallible. Ethical regulations provide accountability. It not only tells us what needs to be done and what needs to be avoided, but it also forms the therapist's belief system that helps them acknowledge their biases and form intentions that are further carried out as actions in the therapeutic settings. 


Estabrook et al. (2010) suggest that the role of ethics begins right at the first therapeutic junction, when the therapist informs the client about their right to withdraw, fees, location, informed consent, limits to confidentiality, required documentation, and the circumstances under which the therapy can be terminated. Each therapeutic setting differs from another therefore requires the right examination of the situation and the application of the right ethical code. Sometimes ambiguous, these codes require correct interpretation and application based on the problem at hand. To ensure this one must be well versed with the core ethical principles that outline any therapeutic setting. 


Ethical Principles and Concepts in Therapy

Welfel (2016) believes that the effectiveness of counsellors is directly proportional to their ethical knowledge and competence. The book ‘Counselling, A Comprehensive Guide Profession’ states six ethical principles that develop the ethical choices of a counsellor (Gladding, 2018). The first is Beneficence. Therapists should be guided by an intent to protect clients from harm and foster growth. This ethical principle highlights the need to prioritise positive contributions to the client's mental health and prevent them from any further harm (Gladding, 2018). Psychologists need to be aware of the challenges they might face due to their own mental and physical health that could affect the people they work with. If conflicts occur, they need to be handled professionally while ensuring minimal harm to the client. 


Next comes Nonmaleficence. Professionals must ensure the avoidance of actions that inflict harm on their clients. Before therapy, a careful assessment of potential risks warrants minimal damage during therapeutic interventions. A therapist is supposed to ensure that the therapeutic interventions do not exacerbate a client’s problem at hand. 


During therapy, the client has the right to autonomy. This marks the third principle of autonomy. Clients have the freedom of choice and the right to make decisions for themselves. Their independent choices are to be acknowledged and supported by the professional. By providing the necessary information to the client, the therapist provides a pathway for them to form informed choices about their treatment. It includes respecting the client’s culture, preferences and personal values (Gladding, 2018). 


One of the most important aspects in therapy, and in life itself, is justice. Therapy should be fair and equal no matter who the person is. Clients have a right to access equal opportunities, resources, and services offered by the therapist. This profession thrives on discarding discrimination and personal biases and treating each client with humanity. Regardless of a person’s background, they deserve equal care and attention. A client, when concerned about social injustice and discrimination should not be disregarded due to the therapist’s personal opinions. These issues could be the very factor that enhances the problem at hand. Mindfulness and an open ear go a long way in this profession. Psychologists strive to provide reasonable judgement and precautions to avoid biases and maintain healthy boundaries to prevent discriminatory practices. 


A client pours his trust into the therapist's hand as they begin the therapeutic journey. The therapist needs to uphold this relationship with integrity and confidentiality. Honouring honesty and transparency leads to a shared bond of trust between the two that provides the client with a safe space to express themselves. This principle requires the therapist to maintain confidentiality and ensure the maintenance and advancement of the therapeutic plans. 


The sixth principle is veracity or truthfulness. Professionals need to be truthful while communicating with clients and others. They have to provide their correct qualifications to the client. Veracious professionals ensure trust and support from their clients. This helps build a safe environment where the client isn't deceived about the therapist’s ability to handle him. In case the therapist is doubtful regarding his ability to handle the client he needs to express this concern right away and provide a reference to the client. This prevents the client from harm and protects his well-being. The American Psychological Association (APA) also mentions these principles in their code of conduct (Ethical Principles of Psychologists and Code of Conduct, 2002). 


Apart from these guidelines, therapists must take informed consent before a therapy session. Counsellors are required to inform their clients regarding the nature of the therapy and answer any doubts that they may have. Clients have the right to know about the risks, nature and purpose of therapy. If a client denies to provide informed consent the therapist needs to respect this decision. In the case of minors, parents or legal guardians are consulted for the same. Counsellors are also responsible for maintaining professional competence and having the required education, training, and qualifications to provide therapy in the first place. 


Unethical practices can unknowingly or knowingly occur during therapy. American Counseling Association (2014) suggests some behaviours that are prevalent forms of ethicality. These include negligent practice, developing dependency on the client, sexual relations with the client, harm to confidentiality, conflicts of interest, claiming expertise that one does not possess, or dual relationships where the counsellor’s role is intertwined with another relationship that exceeds professional boundaries (American Counselling Association., 2014). 


These professional codes are implemented to protect the profession from the government, help organise internal arguments and protect the practitioners from malpractice suits (Van Hoose & Kottler., 1985). 


How to Practise Ethically

To practise ethically one needs to be well-versed in the above-mentioned ethical guidelines. Sound ethical judgement is an important part of professional practice (Jordan & Meara, 1990). Professional psychology values both conscious and virtuous decision-making, emphasising preferred outcomes above permitted ones. It is important to follow established therapeutic codes to ensure safety from law and legislature and to uplift the client without exposing them to harm. This includes maintaining confidentiality apart from situations that demand a breach of it. State legislatures have certain confidentiality disclosure agreements that every therapist needs to be aware of. Break of confidentiality usually occurs in situations where the client may be an immediate danger to themselves or the people around him. Breach also occurs when the client endangers someone who can't protect themselves as in the case of abuse or child neglect. A lot of grey areas are encountered during therapy that need sound judgement and quick yet planned decision-making that ensures the upholding of the client's rights while also protecting the therapist. One such incident could be when a client is a danger to themselves. If the client experiences suicidal ideation one might not breach confidentiality unless they intend to act on those thoughts. Hospitalisation of a client is never done against their will unless they plan on harming themselves.


A therapist practices ethically only when he is competent enough to do so. He needs to provide therapy only in the area of his expertise. When in doubt, it is best to refer the client to another professional that can better handle the case. To ensure proper advancement in the field, even competent counsellors need to keep on gaining further knowledge regarding the current trends and use this knowledge in their training and practice. A good therapist regularly assesses his client's outcomes and adjusts the treatment plan to focus on maximising the positive outcomes for him. Enhancement of quality of life and overall well-being is the goal at hand. Through the help of the risk-benefit ratio, a good therapist weighs the benefits against the risks and then makes sound decisions regarding the treatment.


Therapy begins with empathy. Professionals need to work empathetically with their clients to ensure they work collaboratively towards the combined goal of overall well-being. A compassionate therapist understands the client’s problem and demonstrates genuine concern that enhances client trust which leads to openness. But this doesn't mean that clients need to be cradled into change. A client has the right to autonomy that needs to be addressed and accepted by the therapist. Their experiences need to be acknowledged with genuine empathy. When considering the client’s circumstances all perspectives ranging from socio-cultural to economic factors need to be considered when making the treatment plan. A competent counsellor needs flexibility to adapt to clients' needs (Gladding, 2018). They should possess the capacity to encourage clients to make their own decisions and boost independence. Effective counsellors prioritise advocacy and social justice work alongside other personal and professional skills. It involves speaking up for marginalised people and promoting ways to uplift their rights and treat them with respect. 


According to Remley and Herlihy (2016), ethical rules are often vague and lack specificity. They just provide guidelines for how one should act but they too have their flaws. Some therapeutic issues can’t be resolved using a code of ethics. Often enforcing these ethics can be difficult. They are historical and require constant updation that fits the situation at hand. Counsellors need to be aware that ethics won't always provide them with the guidance they need and that experience and a better understanding of the client leads to the application of the ethical codes when necessary. Ethical decision-making is never easy and requires characteristics such as integrity, morality and courage. 


A study by Hayman & Covert (1986) identified five common ethical dilemmas among university counsellors. These were confidentiality, role conflict, counsellor competence, conflicts with employers or institutions, and degree of danger. Situational issues involving danger were the easiest to resolve, while those regarding counsellor skill and confidentiality were the most challenging. Surprisingly, less than one-third of respondents reported using public professional standards of ethics to resolve difficulties. Most professionals employ "common sense," which might be unethical and unwise (Gladdings, 2018). While making decisions, counsellors should act based on careful reflection of their thoughts based on those mentioned six ethical principles: beneficence, nonmaleficence, autonomy, justice, fidelity and veracity. These principles help guide the reflection process of an effective counsellor. 


Other guidelines according to Swanson (1983) include acting with professional honesty. Unacknowledged feelings and agendas would affect the therapeutic relationship. This can be tackled by receiving supervision so that one is responsible for his actions  (Kitchener, 1994). Swanson (1983) mentions that counsellors should act in the best interests of the client. Accidentally counsellors could impose their values and biases on the client without considering what is best for them. These things need to be tackled with patience, thorough understanding and reflection. Next Swanson talks about how therapists should act without malice or the need for personal gain. Errors in judgement occur when the counsellor’s self-interest becomes a part of the relationship with a client (St. Germaine, 1993). Lastly, counsellors should be able to justify an action as the best judgement based on the current state of the profession (Swanson., 1983). 


Keeping these pointers as well as one’s own biases at bay, therapists can work ethically as well as mindfully to provide the right help to those in need, upholding the profession’s integrity. 


Boundary Setting

Boundaries are the cornerstone of a good, ethical therapist. It refers to the professional limits between the therapist and the client that are essential elements of a therapeutic setting. They provide an effective counselling environment that ensures a safe and respectful exchange of ideas, problems and conversations. Not limited to just therapy, boundaries are necessary in daily life as well. It helps form relations that aren’t burdening. These relationships are based on mutual respect and acknowledgement of the party's needs. 


Establishing Healthy Boundaries

Boundaries help form the structure of therapy and maintain the integrity of the therapist-client relationship. These could include session timing, fees, gifts, confidentiality, and contact outside the therapeutic setting to name a few (British Association for Counselling and Psychotherapy., 2023). It can also take the form of interpersonal issues like dual relationships, touch, non-professional practice and practitioner competence. A therapist is responsible for holding these boundaries in place. What is an important boundary varies from counsellor to counsellor yet certain boundaries have been predetermined by therapeutic associations that need to be followed. 


Firstly, therapists need to clearly define their preference for location, timing and number of sessions (British Association for Counselling and Psychotherapy., 2023). Therapists need to inform their clients regarding the counselling sessions, the frequency of sessions, what happens if the counselling doesn’t work out, and how to cancel a session. This clarity helps reduce clients' ambiguity and vulnerability while providing them with a safe environment. Transparency leads to clear and profound growth. When conducting therapy online or through telephones a secure and confidential environment for both the client and the practitioner should be maintained. 


Next comes confidentiality. Therapists need to ensure that clients understand the limits to confidentiality. This discussion should occur at the very first session. Some counselors also offer an open form of communication outside the therapeutic setting. This could occur via text or email. These topics and the extent to which out-of-session contact is allowed to the client need to be established so that there is a boundary between the personal and professional life of the counselor. One must also take into account the extent to which self-disclosure occurs in a therapeutic session. When used appropriately it can foster depth in the therapeutic relationship (British Association for Counseling and Psychotherapy., 2023). Nonetheless if not monitored self-disclosure can shift focus from the client's problems. 


Contradicting opinions have been applied to the use of touch in a therapeutic setting. Some do use this tool in its appropriate manner but it all depends on the comfort level of the client. In humanistic therapies, non-sexual contact like hugs or a comforting hand on the shoulder is seen as an essential part of acknowledging the client. The same approach is highly frowned upon in psychodynamic therapies and is regarded as crossing boundaries (British Association for Counseling and Psychotherapy., 2023). 


Sometimes clients might want to offer gifts to their therapist as a way to show gratitude. Various therapists have differing views regarding the acceptance of gifts. The client should be well aware in the initial stages of therapy of what the therapist deems appropriate and what needs to be avoided. 


Some boundaries like dual relationships should never be crossed between a client and his therapist. These are relationships that are ongoing outside the therapeutic setting. These could be in the form of friends, family, colleagues, or the same religious congregations. This also involves sexual relations within the professional relationship. Countries like the United Kingdom might consider it to be a criminal offense when a therapist makes sexual advances towards their clients (British Association for Counseling and Psychotherapy., 2023). 


If these boundaries are broken or blurred it can lead to an unethical practice which could compromise the safety of the client as well as the therapist. If in a situation of boundary ambiguity, practitioners need to inform their clients of the harm they are exposed to, offer an apology if appropriate, take immediate action to minimize or stop the harm, discuss the matter at hand with superiors and seek help at the earliest possible (British Association for Counseling and Psychotherapy., 2023). 


Identifying and Working with Ethical Dilemmas

Identification of ethical dilemmas is a skill that is necessary for a good therapist. Mental health counselors deal with various ethical dilemmas during their careers. One way to avoid a breach of ethical codes is to be well aware of the professional guidelines of the organization a therapist is working for. Organizations like the American Psychological Association (APA) have ethical frameworks in place that provide professionals with guidelines on how to conduct therapy and protect their as well as the client’s rights. Another step towards a better understanding of ethical dilemmas is to gain more experience and keep on educating oneself. When in doubt, seek supervision to gain different perspectives that could help one make better ethical decisions. 


It is important to respect boundaries and prevent dual relationships or any other conflicts of interest. The client’s best interests need to be prioritised like autonomy, beneficence and justice. Professionals at the end of the day are humans. They need to acknowledge their needs to ensure they have optimal emotional, physical and mental well-being. Participation in peer support groups and superior assistance can help relieve pent-up stress. This way they can discuss challenging cases while also getting the required emotional help. Personal therapy can help the practitioner heal. This can be used for various issues like burnout, personal issues interfering with professional work etc. 


When facing any ethical dilemmas the first step according to the ACA is to document the dilemma (American Counseling Association, 2013). This helps in further legalities if required. Then one should reach out to the authorities and seek professional advice on how to approach a problem. Most of the time ending the counsellor-client relationship is the best possible decision to avoid further harm. The best strategy to avoid problems from arising during ethical dilemmas is to seek help from professionals. It ensures both client-therapist safety. 


Conclusion

In conclusion, ethical dilemmas are often encountered while practising therapy. It is best to keep oneself updated about the ethical codes and boundary regulations when one specialises in the field of psychology. This knowledge helps one avoid legal action and safeguards the client’s rights. Continuous self-reflection and vigilance are necessary to ensure that the therapist upholds his ethical standards and doesn’t cross professional boundaries. The entirety of the ethical framework is developed to ensure that the credibility of the profession is upheld and that one practices with integrity. 


 

Muskaan Kalaria is part of the Global Internship Research Program (GIRP) under IJNGP.

 

TAGS ETHICS | THERAPY | BOUNDARY SETTING




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