Questioning the “Slippery Slope”: Ethical Beliefs and Behaviors of Private Office-Based and Church-Based Therapists

Counselors and other mental health professionals whose primary office is in a church building often face unique challenges in maintaining appropriate client-therapist boundaries. A sample of 497 Christian counselors responded to an 88-item survey of their ethical beliefs and behaviors. Of the respondents, 148 reported a church as their primary work setting and 162 reported a private office as their primary work setting. Survey results were factor analyzed, then church-based therapists were compared with private office-based therapists regarding their views of ethical behaviors. Although church-based therapists take greater liberties with multiple-role relationships than private office-based therapists, they appear similar with regard to other ethical beliefs and behaviors. Results suggest that church-based therapists who take liberties in nonsexual multiple-role relationships are no more likely than other therapists to violate other ethical standards.     

When transference isn't transference: Iatrogenesis of multiple role relations between practicing therapists

Charismatic, grandiose and authoritarian senior therapists often develop complicated relationships not only with practicing therapists who are their colleagues, but also their friends, supervisees, as well as patients. The patient/therapist in a multiple role relationship with such a senior person may be extremely vulnerable and very unaware of the true nature of the problem Under certain conditions, some of these patient/therapists have suffered ego dysfunction and decompensation which appeared to be iatrogenic in origin rather than due to the patient's transference resistance. The implications of these issues for the field of psychotherapy, and underlying dynamics in vulnerable patient/therapist's, and in grandiose, narcissistic group leaders, are highlighted, along with ways of identifying the intrapsychic, interpersonal, and institutional roots of this problem An earlier draft of this paper was presented at the 1990 Meeting of the American Group Psychotherapy Association in Boston.     

Treatment with Unethical Practitioners; Caveat Emptors

Therapists who are trained at psychoanalytic institutes often foster unethical relationships between trainees and senior therapists. This practice may pass on the damage to the unsuspecting population of patients at large. One way in which trainees are harmed, at these institutes, is in their failure to develop a clear sense of the importance of boundaries in treatment. In not learning how to develop a secure frame from their own treatment, neophyte therapists are often unable to recognize the need for appropriate boundaries in their treatment of others. As a result, their patients may be in danger. The therapist who does not value the struggle to maintain a healthy balance between independence and dependence in their own treatment will probably not be able to help their patients find the proper balance either. One can only wonder how such a therapist could help their own patients know when the time to end treatment is at hand. My own research seems to indicate that unethical treatment practices at these institutes cut across ideological and theoretical differences within the analytic community. Consequently, the problem is not one of individuals who are poorly analyzed and poorly trained. Rather, the focus is a wider one, in which a serious blindspot seems to be endemic to a system that fosters a lack of regard for appropriate boundaries in treatment.     

The omnipotent clinician: A potential source of iatrogenesis

Clinicians who do not acknowledge their delusions of omnipotence can do harm to their patients when these feelings are acted out in the treatment. In breaking the frame of the therapy these clinicians inadvertently create the potential for iatrogenic treatment reactions. When practitioners knowingly practiced outside the boundaries of the established wisdom and theoretical knowledge of the profession, an ethical problem arises. Under such conditions, it can be said that the practitioner consciously jeopardize his patients emotional, and at time, physical well-being. Justifying their behavior, some therapists ironically assert that they are morally superior to others who adhere to the rules of treatment. As Langs note, when boundaries are blurred therapists often unconsciously dumps their pathology into the patient who must then struggle to contain the toxic feelings of both parties. Resolution to this type of countertransference may come through greater awareness of the therapeutic community at large as to the dangers of acting out feelings of omnipotence in the treatment.     

Sanctions for ethics violations: does licensure of socioeconomic status matter?

Although sexual relationships between therapists and their clients are unethical, such beahviors still occur. This study investigated whether psychologists with applied versus nonapplied training differed in the severity of sanctions advocated for psychologists charged with sexual ethical violations toward high- or low-socioeconomic status victims. Licensed and Nonlicensed psychologists (N=48) viewed a 15-min videotape simulating the adjudication process about an alleged sexual involvement between client and psychologist, then prescribed either: Dismissal of Charges, Educative Advisory, Educative Warning, Reprimand, Censure, Stipulated Resignation, Permitted Resignation, or Expulsion. The alleged victim was described as a college professor of home economics or a hairdresser. Licensed psychologists chose more severe sanctions ("Stipulated or Permitted Resignation") than did Nonlicensed psychologists ("Censure"). Socioeconomic status made no significant difference in sanctions. Apparently, applied therapy training results in more severe judgements toward those who violate American Psychological Association ethical guidelines than other types of psychology training.     

Special perspective: An immodest proposal: should treating mental health professionals be barred from testifying about their patients?

Notwithstanding ethical rules that address therapeutic and forensic role conflicts for psychologists and psychiatrists, overzealous patient advocacy by therapists, tightened reimbursement for therapy, and a growth market for forensic psychology and psychiatry, have led many therapists to appear willingly as forensic experts on behalf of their patients. Existing ethical rules, as well as other proposed approaches to address this problem, assume that it can be resolved by modest changes in existing practice that permit therapists to testify as long as their testimony avoids psycholegal opinions. This essay questions whether these modest changes can adequately address this problem and advances consideration of a more radical proposal to address this problem, prohibiting therapists from testifying about their patients. © 1998 John Wiley & Sons, Ltd.     

The Nazi doctors and the medical community; Honor or censure? The case of Hans Sewering

During the Nazi era, most German physicians abrogated their responsibilities to individual patients, and instead chose to advocate the interests of an evil regime. In so doing, several fundamental bioethical principles were violated. Despite gross violations of individual rights, many physicians went on to have successful careers, and in many cases were honored. This paper will review the case of Hans Sewering, a participant in the Nazi euthanasia program who became the President-elect of the World Medical Association. The appropriate stance for the medical and scientific community toward those who violate human rights and ignore fundamental ethical principles of the healing professions will be considered.     

Beliefs and practices of therapists who practice sexual reorientation psychotherapy

There is currently controversy regarding whether sexual reorientation or conversion therapies are ethical and effective forms of treatment for dissatisfied homosexually oriented people. We present the results of a survey of 206 psychotherapists who practice sexual conversion therapy. 187 therapists said they believed homosexuality is a developmental disorder and that the 1973 decision by the American Psychiatric Association to "depathologize" homosexuality was politically motivated and unscientific. The therapists believe that the majority of dissatisfied homosexually oriented clients who seek conversion therapy benefit from it, experiencing both changes in their sexual orientation and improved psychological functioning. We conclude that therapists who persist in providing reorientation therapy do so because they believe it is an effective and ethical treatment option for their clients.     

Custody Evaluations: Critical Contextual and Ethical Considerations

The area of custody evaluation is fraught with anxiety and tension for parents and children as well as therapists. This article encourages the use of a set of lenses that explores individual and family members' relationships within a variety of contexts. To advance the reader's understanding, a model employing various levels and domains will be presented and described. A variety of critical ethical issues, and challenges often encountered by therapists are also examined.     

Ethical Considerations for Therapists Working With Demographically Similar Clients

The increasing emphasis on multicultural competence within psychotherapy continues to highlight the need for being sensitive to key differences between therapist and client. However, this attunement to the psychotherapeutic impact of therapist–client differences may obscure the equally critical need to evaluate ethical problems associated with therapist–client similarities. It will be argued that therapists treating clients who are demographically similar to themselves encounter a unique set of ethical challenges that warrant careful consideration and caution precisely because of therapist–client matching. The extant research on matching therapists and clients based on demographic similarities is discussed, with a particular emphasis on psychotherapeutic outcomes and client preferences. Attention then turns to the nonrational heuristics and biases that can often cloud therapists’ ethical decision making regarding the appropriate uses versus contraindications for demographically matching therapists and clients. Within the discussion of nonrational heuristics and biases, suggestions are offered for managing related challenges for ethical decision making.     

Joint Effects of Corporate Positions and Prospects on Perceptions of Business Ethics Among Japanese Students: A Reflection of Collectivistic Cultures1

This study was designed to account for inconsistencies between past research indicating that executives in general are more ethically oriented than employees. The reality in Japan's society is that it has been mostly top executives who violate business ethics. Japanese students (N = 201) assumed that they were “executives” or “employees” in a manufacturing company, and their company had “high” or “low” financial prospects. The high‐prospect executives were most ethically oriented, while the low‐prospect executives were least ethically oriented. Ethical orientation did not change across the two prospect conditions for the employees. The findings are interpreted in terms of ethical dissonance created by dual pressures from acceptance of Western global ethical standards and strength of indigenous collectivistic ethical standards.     

Psychotherapy through the Group Process by Dorothy Stock Whitaker and Morton A. Lieberman

Ethics deals with right and wrong behavior. It can be used to check whether group therapists with their patients “abstain(s) from whatever is deleterious and mischievous,” an Hippocratic concern, and whether they safeguard their personhood, a Kantian requirement. Therapists' paternalism weakens the patients' moral agency and challenges their autonomy. Personal therapy lessens this tendency.

The group models Plato's and Socrates' ancient dialectic. Both see the end point, self-knowledge, as a virtue and seek it. Increased care of group members for each other is the modus operandi of treatment. This, with the therapist's clinical input, brings about patient wholeness. Reduction in the distorted treatment relationship returns autonomy to the patient. Group therapy is an ethical way to change patients psychologically. Gratuitously, they become more virtuous.     

Ethics and the forensic expert: a case study of child custody involving allegations of child sexual abuse

Psychologists who participate as forensic evaluators in custody and visitation cases involving allegations of child sexual abuse must possess advanced assessment skills and a thorough knowledge of child development, child sexual abuse, and child interviewing techniques. This case study illustrates the types of problems that are inevitable when psychologists violate the boundaries of their role as an independent evaluator and fail to uphold their ethical obligation to be knowledgeable and competent in the area in which they profess expertise.     

Conflict Between Religious Commitment and Same-Sex Attraction: Possibilities for a Virtuous Response

This article addresses the treatment of individuals who experience conflict between their religious convictions and their same-sex attraction. Recently, attention has been drawn to the ethical issues involved in the practice of sexual reorientation therapy (SRT) with such conflicted individuals. This article reviews the ethical arguments for and against SRT through the lens of the general ethical principles of the American Psychological Association's (2002) ethics code. Practitioners are then challenged to think about how they might respond virtuously (Meara, Schmidt, & Day, 1996) when presented with such a client. Thought questions are presented to assist therapists to develop in virtue while working with religious clients who are conflicted about same-sex desire.     

Intimate boundaries: Therapists’ perception and experience of erotic transference within the therapeutic relationship

Aim: This study explored therapists’ understanding and experiences of erotic transference within therapeutic relationships. Method: A small‐scale qualitative research project was undertaken with six therapists working within different counselling contexts. Data was collected through semi‐structured face‐to‐face interviews, and an Interpretative Phenomenological Analysis used for analysis of individual perception and experience. Findings: All participants had experienced what they understood to be erotic transference and/or sexual and loving feelings within therapy. There was little differentiation between the two phenomena, and both were often referred to interchangeably. There were contradictory views as to whether using the phenomena would be beneficial to client work, but there was a strong motivation to learn more about it. Therapists who encountered sexual attraction within therapy experienced feelings including shame and embarrassment. Supervisory support was seen to be beneficial. Implications/conclusion: The importance for therapists to acknowledge a lack of clarity that exists around the understanding of erotic transference and its relationship to sexual attraction within therapy is noted. Also, a recognition that better access to training regarding erotic transference and sexual responsibility within client relationships might be helpful to therapists in their work.     

Therapists’ self-reported chronic strategies of disconnection in everyday life and in counselling and psychotherapy: an exploratory study

The aim of this study was to explore how therapists believe they may relationally disconnect from other people and their clients, with an overall objective of developing methods for enhancing relational depth in counselling and psychotherapy. Participants were 168 trainee and practicing therapists, who listed their chronic strategies of disconnections (CSoDs) in everyday relationships, and then rated the presence of these CSoDs in their therapeutic work. Thirty-nine categories of self-reported everyday CSoDs emerged, organised into seven domains. Most prevalent were behavioural, passive and intrapsychic strategies. Over half of the CSoDs were rated as being present in therapy to a minimal extent, most commonly passive CSoDs, disingenuous CSoDs and humour. Male therapists, and trainee therapists, were most likely to identify their CSoDs as present in therapy.     

‘Coming out’ in therapy? Perceived risks and benefits of self‐disclosure of sexual orientation by gay and lesbian therapists to straight clients

Primary objective: The study's primary objective was to investigate the experiences of gay and lesbian therapists, when considering self‐disclosure of their sexual orientation to straight (i.e. heterosexual) clients. This qualitative study set out to ascertain the key factors gay therapists take into account when considering this decision and to explore the effects this self‐disclosure may have on themselves, their clients and their therapeutic relationships. Research design: The research design was based on the use of semi‐structured interviews, undertaken with a non‐random, purposive sample of counsellors and psychotherapists (n=8) in current practice. The rationale for this method was to aid exploration of therapists' experiences of the process of self‐disclosure. Methods and procedures: Inclusion criteria were for therapists who self‐identified as being gay or lesbian, and who were experienced in clinical work with straight clients. Transcribed data was analysed using inductive thematic analysis. Main outcomes and results: Some therapists reported being confident with self‐disclosure relating to their own sexual orientation. However, a common theme related to the reportedly high levels of anxiety and vulnerability, which therapists identified. Key themes emerged around: respondents' fears of client judgement; a need for therapist self‐protection; self‐awareness of the potential impact of their own fears and prejudices on the therapeutic relationship; and the potential relevance of internalised homophobia, as an overall constraining factor. Conclusions: Self‐disclosure of their sexual orientation to straight clients is constructed, in this initial survey, as being potentially problematic and risky for some gay therapists.     

Conflict of interest between therapist-patient confidentiality and the duty to report sexual abuse of children

All 51 jurisdictions in the United States require physicians to report suspected child abuse. In most jurisdictions, reporting requirements override both confidentiality and privilege associated with the physician-patient relationship. The authors review the literature relevant to the conflict between privacy and reporting abuse and report the results of a national survey of therapists at sex offender treatment units. They discuss ethical problems experienced under these statutes by therapists who attempt to provide treatment for sex offenders, and by therapists who are required to report past instances of child abuse even when there is no evidence of ongoing abuse.     

A descriptive study of e-counsellor attitudes,ethics, and practice

Introduction: The purpose of this study was to examine questions related to the process, perceived outcomes, and ethics of therapists who provide counselling and therapy online. Method: An online survey was conducted (N=93) with identified e-counsellors with at least a Master's Degree. Questions included demographic information and Likert-type scales related to extent of practice, theoretical orientation, training and supervision, attitudes about appropriate practice, referral, legal and ethical issues, practice difficulties, and therapist satisfaction. Results: Overall, e-counsellors are satisfied with their practice and believe it is effective. They generally do not have formal training or supervision in online practice. Current e-counselling appears to be a part-time, supplemental practice with little overlap to FTF practice. There was little agreement among respondents on attitudes, practice, ethical issues, and knowledge of regulations related to e-counselling. Discussion: Lack of consensus about ethical obligations and practice suggest the need for formal training in e-counselling by professional programmes and international cooperation in formulating practice ethics. Areas for further research are discussed.     

WHY NO GUIDELINES FOR BEHAVIOR MODIFICATION?

This paper reviews the guidelines for behavioral programs published by the National Association of Retarded Children. The review discusses a number of reasons why guidelines should not be enunciated for behavior modification, e.g., the procedures of behavior modification appear to be no more or less subject to abuse and no more or less in need of ethical regulation than intervention procedures derived from any other set of principles and called by other terms. The review recommends alternative methods for protecting the rights of clients who participate in behavioral programs. Specifically, behavioral clinicians, like other therapists, should be governed by the ethics codes of their professions; also, the ethics of all intervention programs should be evaluated in terms of a number of critical issues.