Romanian Journal of Bioethics, vol. 6, nr.

3, July – September 2008 [2]

ETHICAL DIMENSIONS IN COUPLE AND

FAMILY THERAPY
Maria Nicoleta Turliuc∗

Abstract
This paper analyzes in a comparative perspective the main dimensions of ethical codes for
couple and family therapy of some of the most important international professional
associations,
and their origins. It underlines the lack of sufficient ethical guidance for this type of
practitioners
everywhere in the world, the lack of a powerful professional association in the Romanian
context
and of a Romanian specific code of ethics for these therapists. According to many theorists and
practitioners, some of the main ethical dilemmas which generate the most stress and anxiety
are
in the following practical areas: informed consent procedures, confidentiality, fees, billing, and
maintaining clinical and financial records, the duty to warn, protect and report, avoiding
malpractice and multiple relationships. I have chosen to focus more on the first two ethical
dilemmas
Key words:– couple
the informed consent
and family procedures,
therapy, and the confidentiality,
ethical dilemmas, privacy
informed consent, and privileged
confidentiality.
communication – and to present them extensively. Possible signs of some non-ethical situations
are also discussed, together with the steps of intervention planning which allowed the therapist
Traditionally, codes of ethics have professionals, to increase clients’ trust
for couple and family to avoid more easily ethical conflicts.
represented a collection of philosophical and faith in members of the profession,
and behavioural guidelines developed by to specify desirable conduct between
differentprofessionalassociations. professionals”. Mabe and Rollin (1990)
Mappes, Robb and Engels (1985, p.246) believe that a code of ethics serves as a
offer several specific reasons for model for how professionals behave,
establishing a code of ethics: “to protect helps to establish a professional identity,
clients, to provide guidance to and can be viewed as a part of the
professionals, to ensure the autonomy of maturation process of a profession.

∗
Associate Professor, Ph.D., „Alexandru Ioan Cuza” University of Iaşi, Faculty of Psychology and Education
Sciences, e-mail: turliuc@uaic.ro

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Brock (1994) appreciated that a code of
ethics can be the vehicle to enforce
existing professional guideline; to
describe the manner in which
professionals should conduct a safe and
efficient practice; to indicate to the
members of the association, to the clients
and to the entire society that the primary
concern is the client’s interest and well-
being.
Ethical issues and difficulties arise
in the context of any therapeutic
intervention, regardless the theoretic
orientation or the style of the therapist.
In the last 50 years, the most powerful
associations in the field of mental health
have developed, revised, and refined
their ethical code. In each new version,
the changes were made in response to
new legal decisions, to the rapid
development of practice milieu, and as a
reaction to the questions and problems
raised by the members of professional
groups. Given their particular theoretical
orientation, couple and family therapy
practitioners have felt that the existing
guidelinesfromindividual
psychotherapy did not respond always
adequately to their concerns (Margolin,
1982; Vesper and Brock, 1991). In the
countries which have recognized the
distinct professional status of couple and
family therapy, the rapid development
and recognition of this profession has
helped to spur the evolution of specific
professional association, which analyzed
and synthesized the ethical dimensions
ofthisactivity.Recently,the
postmodernism underlined, more than
ever, the importance of analysis and
awareness of ethical issues, of the fact
that their comprehension offers the
advantage for operating in a logically
consistent manner (Becvar and Becvar,
2000).
Historically, the code of ethics of
American therapists for couple and
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family – which represented the model for
all codes of ethics of these professionals,
from all over the world – is inspired
from the codes of psychologists and
social workers. In response to the needs
of the practitioners to have clear rules of
professional behaviour, two largest
couple and family therapy associations,
American Association for Marriage and
FamilyTherapy(AAMFT)and
International Association for Marriage
and Family Counselling (IAMFC), have
elaborated and promulgated their code of
ethics. The main content areas of each of
these codes are presented below (apud
Scalise, 2000) (See Table)
The comparison of these two codes
of ethics reveals a number of similarities.
Both emphasize a strong responsibility to
the clients’ interests and well-being, the
recognition of the critical importance of
the confidentiality, a demand for
competence and professional integrity,
and some guidelines concerning research
participants. Even if some minor
differences do exist, they are more a
matter of form than substance. The
lecture of these codes reveals that their
standards are highly compatible and
almost interchangeable. Many authors
(Margolin, 1982; Veper and Brock, 1991
etc.), who analyzed the ethical dilemmas
faced by couple and family therapists,
have indicated that too often the
guidelines are too general and without
the specificity needed by practitioners. In
other words, despite the changes
occurred in the field of couple and
family therapy, the codes of ethics of
professional association have not kept
the step with the growing need of
practitioners for more guidance.
The Code of deontology for the
profession of psychologist, elaborated by
the Romanian College of Psychologists
is currently the single code which guides
the practice of different types of
psychologists, including that of the
therapists for couple and family. We may
expect that the growing up and
coagulation of Romanian professional
associations’ activity will lead to the
development of professional identity of
couple and family therapists and to the
formulation of their own code of ethics,
capable to assure a better guidance.
Couple and family psychotherapists
must be careful in using the information
obtained, taking into account the power
and potential influence they can have on
clients. For example, until a problem is
perceived and labelled, it does not exist
for the families. The family therapist
usually asks the family and each of its
members in therapy which is the
problem they have, but the answers are
frequently different, and the family
members do not always have the
capacity to identify and label accurately
their real problem. Therefore, the
psychotherapists are confronted with the
difficulty of labelling the clients’
problem,whichwasnever
comprehended or perceived (Becvar and
Becvar, 1996), and which can become an
even greater problem than was intended.
For example, the child and wife abuse
was a reality easily accepted, having
community’s support. What is different
is not the abusive behaviour itself, but
how we perceive this behaviour and the
fact that we now define it as bad, as
being problematic. The ethical principles
create a strong pressure on the therapists
to avoid the pathologizing or the
impression that they have access to the
absolute truth.
Another difficult issue is that of
manipulation which, according to some
theorists, must be avoided at all costs.
However, in the absence of capacity to
influence or to be influenced, the
manipulation does not exist, both
conceptsmeaningmodifyingor
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determining the behaviour of another.
Any therapist’s behaviour in front of a
clientinfluencestheirrelations,
inevitably. “The problem, therefore, is
not how influence and manipulation can
be avoided, but how they can best be
comprehended and used in the interest of
thepatient”,notedWatzlawick,
Weakland and Fisch (1974, p. XVI).
Some of the main ethical dilemmas
which generate the most stress and
anxiety are in the following practical
areas: informed consent procedures,
confidentiality, fees, billing, and
maintaining clinical and financial
records, the duty to warn, protect and
report, avoiding malpractice and multiple
relationships. I have chosen to focus
more on the first two ethical dilemmas
(the informed consent procedures, and
theconfidentiality,privacyand
privileged communication), and to
present them extensively.
The informed consent is a legal
concept based upon the individual’s right
to make a decision referring to any
treatmentprocedures.Themain
characteristics of informed consents are:
competence, information, voluntarism,
understanding, and decision itself (J.
Scalise, 2000). Competence refers to an
individual’s ability to make a qualified
decision about some life-affecting event.
Information implies that the individual,
prior to treatment’s initiation, has been
provided with all of the necessary data.
Voluntarism indicates that person was
free from any coercion or pressure in the
process of decision making. When a
rational person has understood the
information offered by a professional,
we can presume that the legal act of
consentwasinformed.The
understanding refers to the fact that the
individual making the decision process
comprehends the information being
provided. Decision is the last step, the
client having the possibility to accept or
to refuse the treatment. Finally,
Doverspike(1996)proposedan
additional characteristic: the appropriate
documentation of the consent, consisting
of the fact that therapist should have
obtained a signed form by the client
during the first session, indicating that he
or she was provided with the appropriate
information, that all the questions were
answered, and that the consent of
treatment was freely given. This
procedure is not necessary in the case of
an incompetent client to give the consent
(as a person judged legally incompetent
or minor).
The following aspects can serve as
a guide of discussions with couples and
families, as a part of an informed consent
procedure (Vesper and Brock, 1991):
1. Providing a detailed and rational
explanation of all treatment procedures
(e.g., a description of the methods of
therapy, goals, frequency and duration of
session, the length of treatment etc.).
2. Presentation of the role and
professional qualification of the therapist
(e.g., academic studies, formations and
skills, licensure status, academic and
scientific titles etc.).
3. Presentationoflimitsof
confidentialityandprivileged
communication. The Romanian Code of
deontology for the profession of
psychologiststipulatesthat:the
therapists must avoid the disclosure of
the information they have about clients,
colleagues, colleagues’ clients, students,
or members of organisations, with
exception of the following situations:
protection of public health, prevention of
an imminent danger, prevention of a
criminal act etc.; they clarify the nature
of multiple relationships for all the parts
involved before the informed consent;
the results, documentations and notes of
the psychologist can be used only in a
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way whichrigorously assures the
anonymity of the client etc.
4. Explanation of any possible risks or
unconformable situations which can
occur during the treatment (e.g., the
possibility of revealing family secrets, of
provoking highly emotional tensions,
conflicts etc.).
5. Enumeration of any benefit that can
be reasonably expected, without
guarantees for any specific outcomes.
6. Explanation of the availability of
any alternative treatments with similar
benefits (e.g., group therapy, self-help
groups etc.).
7. Presentation of office policies and
procedures (e.g., payment and collection
procedures,chargesformissed
appointments,emergency/after-hours
policies etc.).
8. Explanation to client that the
therapist will answer any question about
the treatment at any time.
9. Explanation of the fact that clients
can withdraw their consent for therapy at
any time.
10. Have all clients’ signed informed
consent to treatment form and give them
a copy. This last aspect it is not
stipulated in the Romanian Code of
deontology for the profession of
psychologist, the therapists having the
possibility to decide if they will use
signed contracts for informed consent.
Even if some therapists have argued
that to discuss information with clients in
a manner required by the procedure of
informed consent compromises the
effectiveness of therapy, in their empiric
research, Walters and Handlesman
(1996) have indicated that clients are
more trusting in the treatment after
havingbeenprovidedspecific
information during this procedure. It is
important to underline that informed
consent cannot be used as a defence for
unethical actions and that, when
treatment involves a minor, children do
not have the right to consent the
treatment (only their parents or
guardians).
We must remember that not all the
family members may benefit from the
therapy equally, and under certain
circumstances, family therapy may
actually be viewed as detrimental for
individualfamilymembers.For
example, when only one spouse is in
therapy and decides, against the wishes
of the other, to divorce, or if the therapist
promotes the disclosure of information
that may be perceived as harming the
future marital relationship or that may be
used later by the more powerful partner.
Another important aspect is the
voluntarism of the consent of family
therapy, not all the family members
being motivated to participate at the
same level. If the therapist refuses to
treat the family unless all members are
present, does he or she deny an
individual family member the right to
refuse treatment? This might be
interpreted as a form of coercion. In this
way, many therapists admit that, even if
the ideal situation is to work with all
family members, they accept to treat the
clients on the manner they come in
therapy (more often, the mother and
child, or the spouses).
Aspects regarding confidentiality
Confidentiality has been considered
the cornerstone of a successful
psychotherapeutic relationship. While
clients assume that what they disclose
during the therapy will not be revealed
without their consent, in reality, the
confidentiality is not absolute. The
English literature operates with concepts
as:confidentiality,privacyand
privileged communication. A clear
explanation of these notions was offered
by Shal (1970): confidentiality relates to
matters of professional ethics, and
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protects clients form unauthorized
disclosure; privacy is a much larger
concept, which recognizes the freedom
of the individual to pick and choose for
himself, the time and the extent to which
he or she wishes to be protected from
unwarranted intrusion; finally, the
privileged communication refers to the
client’s right to be protected from having
his confidences revealed publicly from
the witness stand during legal procedures
without his permission. In the countries
where the privileged communication is
legally recognised, when a therapist
received a subpoena he could ask his
client permission to reveal some
information and if the client does not
grant permission to release the records,
the therapist must determine how to
respond to the subpoena (e.g., he can
assert the privileged communication on
behalf of the client). Even if the concept
does not appear in the Romanian Code of
deontology for the profession of
psychologist, it seems to be a part of
confidentiality. Article VI.2. stipulates:
“The disclosure, by psychologists, of
data revealed by clients or which has
been obtained in professional settings, if
this means denying the right to
confidentiality, is forbidden”, and the
articleVI.4.underlinesthat:
“Psychologists can reveal confidential
information to others only with the
consent of clients, and in such a manner
that clients cannot be identified,
excepting the situation justified by law
or in the imminent or possible
circumstances of physical abuse or
crime”.
In therapeutical situations with
multiple clients, such as couple and
family therapy, the issue of maintaining
confidentiality is even more difficult.
AAMFT indicates that when a therapist
meets more than one person from a
family, without a written document, he
or she does not reveal the information
obtained form one family member (in an
individual session) to the other members
of that family. Discussing this aspect,
Nichols and Schwartz (2000, p.90)
appreciated that “it can be easier to
expose ethical principles in a classroom,
than to apply them in the process of
clinical practice, especially in the
situations which imply strong emotions”.
The Romanian Code of deontology
for the profession of psychologist
stipulates that (art. XII.4.): “If in the
therapeutic process are present partners
or other family members, the
psychologists will clarify from the
beginning the relationships they have
with each person in therapy and will
inform who the client is: a person, the
couple relationship, or the family.
Psychologists will present the limits of
confidentiality”. But, if the client is
family, as we sustain from the systemic
perspective, and not any single family
member, appear the following question:
“Is the information revealed by an
individual member of the family
protected enough by the client’s
confidentiality?” A solution to this
dilemma is offered by Scalise (2000),
who recommends obtaining a written,
pre-treatment contract signed by all the
participants; it may serve to discourage
the legal representative to try to obtain
information about the case.
Confidentiality is hard to maintain
also in the case of child’s custody,
because the premises are that the best
interests of the child superseed the
importanceofmaintaining
confidentiality.Therearemany
concurrent values which can generate a
conflict. For example, the general belief
that a child can gain more attention in his
natural family than in an institution, can
conduct to underestimation, hiding and
maintaining of the child abuse. Another
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example is when a child did not succeed
to adjust himself in his adoptive home,
the therapist can experience the fear that
if he recommends the changing of the
adoptive family this change can be even
more dangerous for the child.
A difficult situation appears also
when the therapist treats a couple and in
an individual session he finds out that
one of the spouses has an extramarital
relationship. For having an efficient
marital therapy, the therapist must insist
in front of the infidel spouse that he or
she must end the extramarital affaire;
otherwise the therapist must tell the other
spouse what is happening. If the infidel
spouse refuses to end his affaire, what
should the therapist do? More than that,
some therapists have recommended the
confrontation in therapy of the betrayed
spouse with the partner’s lover, starting
to the presumption that if the “the third
person” is perceived by the betrayed
spouse as being less attractive that he/she
evaluates him/herself, then the process of
reconciliation can be easier. But, can be
ethical this decision, if the evaluation of
the other person can launch the process
of separation and divorce?
Finally, another delicate problem is
that of family’s secrets. In this matter, at
one extreme are those therapists who
adopt the position that the disclosures of
each individual family member will be
treated as if he or she was client in
individual therapy; at the other,
therapists sustain the idea of not keeping
any secrets from family members.
Regardless of the stance a therapist is
taking, it is important that he remembers
the necessity of maintaining the
confidentiality and that the information
revealed in an individual session must
remain private.
The following situations can
indicate possible non-ethical behaviour,
note Nichols and Schwartz (2000, p.92):
1. To be special. If a therapist starts to
think that he deals with a special case or
with a special person, he risks to believe
that he cannot use the common rules.
2. Attraction. Any kind of intense
attraction, romanticism or produced by
client’s status, culture or attitude.
3. Alterations of the therapeutic
framework. Longer sessions, more
frequent sessions, lending money to the
client or therapist’s incapacity to refuse a
request of a client which missed the
planned session indicates different types
of non-ethical behaviour.
4. Violation of clinical norms.
Deviations from the deontological
clinical rules can imply not sending a
person from individual therapy who is
confrontedwithevidentmarital
problems, to couple or family therapy;
solicitation to or acceptation of personal
counselling by supervisors etc.
5. Professionalisolation.The
permanent refuse to discuss with
colleagues the difficult professional
decisions taken in various cases can be
also the indicator of possible ethical
deviations.
In conclusion, the tensions between
personal and professional beliefs can
create ethical dilemmas and there are not
easy answers to these difficulties, neither
a consensus regarding the type of values
practitioners should prioritize (B.
112
Thomlison, 2002). The Romanian Code
of deontology for the profession of
psychologist does not respond enough to
the guidance need of couple and family
therapists. The decisions based on
professional ethics must take into
account the family’s rights and the
priority of family’s health; ethical
behaviour must be oriented by what it
was already done and by was not yet
tried. Regardless the careful planning,
ethical conflicts can often appear and to
avoid them therapists can follow the next
steps, by answering to the questions:
Which values are implied in the
conflict? Who is involved in the
dilemma? Which are the personal values
and beliefs of the therapist regarding the
family and the case under treatment?
Which are the alternative options in the
case under treatment and their
consequences? Which are the advantages
and disadvantages of the each
alternatives identified? Should be a
certain aspect discussed with the
colleagues, supervisors etc.? Answering
to these questions, taking the full
responsibilityofthetherapeutic
intervention and using a clear language
in the process of informing the family
regarding the services provided and the
risks involved, the couple and family
psychotherapist can more easily resolve
the inherent ethical conflicts.
 Table – The main content areas of each of these codes are presented below
(apud Scalise, 2000)

AAMFT Code of ethics IAMFC Code of ethics

1. Responsibility to clients 1. Client well-being
2. Confidentiality 2. Confidentiality
3. Professional competence and integrity 3. Competence
4. Responsibility to students, employees, and 4. Assessment
supervisees 5. Private practice
5. Responsibility to research participants 6. Research and publications
6. Responsibility to the profession 7. Supervision
7. Financial arrangements 8. Media and public statements
8. Advertising

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