Ethical Issues in Family and Marital TherapyHealth Psychology Program| | Denise A. Bolden-Little| 11/7/2010| Introduction Due to the extremely sensitive nature of marital and family therapy, it is imperative that therapists engage in the ethical, competent treatment of their clients. There are three aspects of marriage and family therapy research that makes it unique from other research fields: 1) multiple family members are involved; 2) it involves extremely sensitive information; and 3) it is performed in conjunction with therapy.
According to Hohmann-Marriott (2001), because of these aspects as well as the researcher’s responsibility to conduct efficient research and to promote client’s welfare, specific guidelines for ethical marriage and family research were prescribed. Guidelines for Ethical Marital and Family Research The primary guideline for the conduction of ethical marriage and family research is to minimize risk to participants. With this injunction in mind, it is the responsibility of the researcher to conceive all possible risks for the participants; and then to make every reasonable effort to minimize those risks.
These potential risks of harm may be physical, mental or emotional. Also, after the research is complete, it is imperative that the participants are debriefed to ensure that no unforeseen harm has occurred to the participants; and if it has, measures can be taken to mitigate damage. Furthermore, researcher should consider the sensitive nature of the family’s private lives and how their family life impacts self-esteem (Hohmann-Marriott, 2001). Next, it is critical that research design is reviewed by an objective, qualified professional prior to the study being implemented (Hohmann-Marriott, 2001).
The professional should be knowledgeable about both the legal and ethical ramifications of the proposed research. The reviewers are mainly advocates for the participants, but also are interested in facilitating researchers with getting their study underway. Balancing these two objectives can prove challenging at times for reviewers. Hohmann-Marriott (2001) states that obtaining informed consent is crucial for researchers. Informed consent literally means that the participant has been informed of the proposed research, and has consented to be a participant.
The informed consent document contains four elements: 1) a statement of voluntary participation; 2) a statement about potential risks of the study; 3) a description of the research study; and 4) a statement of confidentiality and its exceptions. Special ethical consideration of family and marital research is dealing with minors and other individuals who may not be able to consent to participation. It is crucial for the researcher to inform family members, who have consented, that they are not obliged to discuss other family members – especially if it causes them discomfort.
While the use of some deception may be necessary to obtain unbiased results, it is essential to understand that deception can also be unethical and may yield inaccurate results, too. According to Hohmann-Marriott (2001), the researcher should use deception sparingly because it is unfair to the participants. Deception provides participants with “misinformed consent,” and eliminates their autonomy. Additionally, marital and family researchers should account for the vulnerability of this unique population.
Of the utmost importance is the realization that the participants approached the researchers for assistance with personal or familial issues. Another guideline for ethical marriage and family research is ensuring that all participants receive treatment. In other fields of research, it is common to designate an experimental group and a control group. In this method of research, the control group is often given a placebo (denied treatment). Due to the vulnerability and the unique needs of the marital and family population, it would be quite unethical to deny treatment to those who sought assistance.
Hohmann-Marriott (2001) offered a couple of solutions for this dilemma. One alternative is to place the control group on a waiting list for treatment after the experimental group has completed its study. The problem with this option, however, is that it places the family at risk because treatment could be significantly delayed. The more favorable alternative is to offer different treatment options to the control group and the experimental group. If one treatment modality proves more beneficial, then the other group can be offered that treatment upon completion of the study.
It is the responsibility of the researcher to balance the participant’s right to privacy with the scientific need to publish research results (Hohmann-Mariott, 2001). Confidentiality helps the researcher to maintain this balance, which is essential given the highly sensitive information that marital and family researchers encounter. One way to ensure the family’s confidentiality is to ask them to review the research study prior to publication. This allows them to suggest changes in details that may compromise their privacy and confidentiality.
Another imperative to conducting ethical marital and family research is to avoid dual relationships. According to Hohmann-Marriott (2001), when a researcher takes on roles in addition to research, conflict of interest may occur. Some common dual relationships that are likely to result in conflict are: therapeutic relationships; oversight of consent agreements; and sole evaluators of proposed research study. To minimize likelihood of conflict, researchers are urged to only be peripherally involved in therapy with participants, assign a neutral party to attain consent, and to have research reviewed by objective professionals.
Inaccurate data can negatively affect the researcher’s career as well as the overall field of study. It matters not whether the erroneous information was gathered accidently or deliberately. Some measures that can reduce the risk of collecting incorrect data include: asking others to monitor research methods; utilize standardized and practiced procedures; practice diligence in data collection; and stress the importance of honesty in data-collection (Hohmann-Marriott, 2001). As purported in the article by Hohmann-Marriott (2001), the reporting of accurate data is equally important as the collection of accurate data.
Just as collecting erroneous information can negatively impact the researcher’s career and the discipline, so can falsely reporting data. Needless to say, it is unethical to only report data that confirms the researcher’s hypothesis. However, it is also deleterious to report data that result from mistakes or misinterpretation. It is indeed the researcher’s duty to consult experts when necessary (i. e. , statisticians). The final guideline stipulated in the ethical research of marital and family therapy is minimizing the effects of researcher’s bias.
Because all researchers have values and biases about their research, it is vital to understand how these factors can affect research design, methodology, and outcome. One technique to minimize the impact of bias is for the researcher to discuss ideas and values with other colleagues – so that value judgments do not become interpreted as research results (Hohmann-Marriott, 2001). Relational Ethics vs. Individualism A study conducted by Wall, Needham, Browning and James (1999) postulated that unlike many therapists in other disciplines, marital and family therapists value “mutual and caring interpersonal relationships” over individualism.
A majority of therapists in this study reported that their view of a good moral life included being part of loving, caring relationships. Utilitarianism was least favored by therapists who participated in this study. An interesting note in this study is that loving, caring interpersonal relationships were even favored over mutual, equality or “reversibility” as referenced by Kohlberg. Fairness and equality were secondary to “relationality. ” Terms used to describe familial relationhips include mutual, support, and helpfulness. It is also important to cite that these findings were not gender-dependent.
In terms of gender, the study indicated a high value on role flexibility as well as equality. Of course, that is not to say that the respondents believe that men and women “equally suited” for all roles. It is proposed that while both men’s and women’s roles may be equally valued, there needs to be some distinction. While this study (Wall et al. , 1999) clearly indicates that the therapists who participated value relationality, in matters concerning divorce, a vast majority (more than 60%) were neutral on this issue – meaning they were supportive of that which would yield the best therapeutic outcome for the clients.
According to this study, female therapists are more inclined toward neutrality in divorce than male therapists. In relation to child rearing, the research by Wall et al (1999) suggests that most marriage and family therapists value some family forms over others. These findings are gender-significant. More than half of the female respondents indicated that no family form is better for children whereas only a third of male respondents shared this viewpoint. Of those respondents who favored a family dynamic, over 40% believed that the traditional family system (working father, stay-at-home mother) was best-suited for the children.
Homosexual couples were least ranked per the study. Philosophical Context of Relational Ethics As outlined above, relational ethics do not tend toward individualism or strong family systems rather mutual, supportive interpersonal relationships. In the article by Wall et al (1999), the term “relationality” is used by feminists to separate their views from traditional male-oriented ethics. In a philosophical context, feminism proposes that both eros (love of self) and agape (altruistic love of others) should be tempered by the “love commandment: ‘Love your neighbor as yourself. ” Another context reviewed in this study is the Habermasian relational ethic, which evokes that significant value is placed on the family’s communicative relationships. Lastly, some ethicists purport that relationality is fundamental to family justice and equality. Overview of Relational Ethics on Marriage, Depression and Health Contextual theory, which has an emphasis on relational ethics, is suggested by many in the field as the “impetus for change,” (Grames, Miller, Robinson, Higgins, and Hinton, 2008). Because of its ethical foundations, clinicians have found it effective in treating individuals, couples, and families.
Grames et al (2008) studied the relationships between relational ethics and marital satisfaction, depression, and physical health. The authors used the Relational Ethics Scale (RES) to measure these components. It was discovered through their research that there is indeed a significant correlation to high RES scores in vertical and horizontal ethics and marital satisfaction. It was also noted that low vertical RES scores were consistent with participants who reported higher rates of depression and health problems. Working with Parents of Children in Psychotherapy
Research differs on perspectives regarding the roles and degree of involvement of parents during therapy with children. There is an ethical imperative that mandates helping both the children and their parents, Code of Ethics of the American Academy of Child and Adolescent Psychiatry (Ruberman, 2009). It is proposed that the parents’ involvement is determined by the clinical situation, and the child’s developmental phase (or maturation). Generally, it is agreed that younger children will have a higher degree of parental involvement than would adolescents.
A challenging balancing act may be for the therapist to consider an adolescent’s resistance to parental involvement with the client’s best interest. According to Ruberman (2008), some of the roles that the therapist may take on with parents are as a guide and educator about the therapeutic process, but also about coping with the challenges of child rearing. It is important to understand that clinical judgment regarding the presenting issues and the development of the child are essential in helping to determine the parental role during therapy with children.
Infidelity Due to the prevalent and devastating nature of infidelity, it is a common issue in marital therapy. Given the volatility of extramarital affairs on relationships, no wonder the decision whether to facilitate partner disclosure or accommodate nondisclosure during couple therapy is a complex one. According to Butler and Harper (2009), some issues factoring into the decision to disclose versus nondisclosure are relationship ethics, pragmatics, attachment and intimacy consequences, and the prospects for healing.
Of vital importance is the therapist’s reaction or response to the disclosure of infidelity. With this in mind, it is also essential to realize that some of the ethical standards to consider when deciding whether or not to disclose infidelity secrets are beneficence vs. nonmaleficence, and the ethics of justice and equality. First, the ethical imperatives “to do no harm” and “to act in manners that are beneficial to others” would preclude a therapist from withholding information that would be damaging to the individual or couple.
In addition, the standards of justice and equality infer that both parties in the relationship are entitled to all information as it relates to “rights of relationship choice, definition, and circumscription,” (Butler et al, 2009). Other viewpoints state that disclosure should solely be the decision of the offender. Additional factors to consider are the aggrieved individual’s ability to cope with the pain of the infidelity, and that the benefits of disclosure must outweigh the healing challenges that disclosure will bring forth.
Butler and Harper (2009) also suggest that keeping secrets results in a shift in power, privilege and control in the therapeutic relationship. The therapist must also balance the couple’s rights to privacy and confidentiality, as well as any consents made to the exceptions of these rights. Also assessment for possible risks of harm by the aggrieved party or risk of self-harm should be conducted during the decision-making process. Attachment security is relative to well-being (Butler and Harper, 2009).
Because infidelity injures attachment security and intimacy, careful contemplation should occur prior to the decision to disclose. It is argued that both the extramarital affair and keeping the secret of infidelity undermine attachment and intimacy. The authors, Butler and Harper, also review alternative relationship constructions, wherein the couples may not strongly value attachment and intimacy. In these cases, disclosure may not be necessary for the partner or the therapist. Some therapists value pragmatics over principles when dealing with infidelity secrets (Butler and Harper, 2009).
To the pragmatists, it is offered that even if undisclosed, perturbations within the relationship will prohibit maintenance of the infidelity secret. Intuition, anxiety, doubt, and fear all sabotage the attachment security, whether the affair has been disclosed or not. In the end, keeping infidelity secrets are devastating to attachment intimacy and security. The Treatment of Infidelity Infidelity appears to be quite common in America. Some studies indicate that up to 50% of all divorcees report infidelity during their marriage.
Additionally, up to 20% of men and 10 % of women disclose being unfaithful during their marital relationships (Levine, 2005). One reason that makes infidelity such a complex treatment issue is that there are many forms and degrees of infidelity. A primary role of the therapist is to remain clear and objective during treatment. Maintaining a clinical perspective allows the therapist to provide balance during the storm of emotions that emerge upon the discovery of infidelity. Levine (2005) adds that since infidelity is a boundary violation, part of our work as clinicians must be to model healthy boundaries for our clients.
One model for the treatment of infidelity is the Practice-Based Evidence Approach (Dupree, White, Olsen, & Lefleur, 2007). This method is comprised of expertise from clinicians that formulate guidelines for the complex and challenging treatment of couples coping with infidelity. This treatment model is in line with the belief that therapists’ competence is vital in helping couples overcome the pain of infidelity. In developing this model, the authors (Dupree et al, 2007) reviewed literature on infidelity studies to comprise a “map,” guiding therapists through the treatment process.
These treatment guidelines are outlined as follows: a) creating a safe environment for client to explore their relationship, b) provide structure so that clients are validated throughout the therapeutic process, c) examine the reactions to the trauma of the infidelity, d) explore the patterns of the relationship, e) explore expectations and meanings of the relationship, e) provide an environment that facilitates self-disclosure and the rebuilding of attachment and intimacy, and f) explore forgiveness and healing.
According to Dupree et al (2007), other factors that are critical in working with couples on infidelity are treatment engagement, format, assessment styles, types of interventions, and cultural considerations. Another treatment approach is Socio-emotional Relationship Therapy (SERT). Authors, Knudson-Martin & Huenergardt (2010), describe this approach, which uses neurobiology and the social context of emotion to assist clients in developing mutually supportive relationships.
One unique aspect of SERT is that “therapist neutrality is not considered possible or desirable. ” This model involves experiential work that focuses on 4 conditions at the core of mutual support: mutual influence, shared vulnerability, shared relationship responsibility, and mutual attunement. The goal in working with couples dealing with infidelity is to “create new relational experience that equally supports each partner. In this article (Knudson-Martin & Huenergardt, 2010) , the steps to attaining this goal are outlined as: 1) create a mutually supportive context, 2) demonstrate socio-emotional attunement with each partner, 3) collaboratively assess to create a new relational frame for addressing client issues, 4) make the social context real with personal consequences, 5) envision new relational possibilities, 6) deepen relational experience, and 7) maintain new, egalitarian relational model.
Through this model, therapists are able to discover and disrupt the power imbalance which the authors purport are embraced by our society. Authors, Rosenblatt and Rieks (2009), discuss therapeutic interventions that help couples overcome an impasse – coming to a compromise. As defined in the article, compromise is “a settlement in which each side gives up some demands or make concessions. ” First, it is proposed that therapists must realize that compromise is a matter of perception, meaning that it means different things to different people in different situations.
So it is important to discover the meanings that both partners attach to compromise. Next, it is suggested that couples approach compromise from an exchange theory perspective. This means that one person in the relationship exchanges one thing of value for another (maintaining a balance of exchange). Another approach is the “getting-to-yes” model. Through this intervention, the focus for the couple is about working collaboratively for mutual gain – instead of arguing about the conflict, the couple chooses to brainstorm possible options for a resolution.
Finally, the aforementioned authors point out that sometimes a decision is made through the indecision of the couple (Rosenbalatt & Rieks, 2009). Religion and Spirituality in Marital and Family Therapy In this section, the role of religion and spirituality is explored in couple therapy. Because religion and spirituality plays a significant role in the lives of many people, the authors, Marterella and Brock (2008), posit that to be effective, therapists must be competent and knowledgeable about religious and spiritual issues.
It is also suggested that there is a strong correlation between religiosity and marital stability, especially during times of conflict or crises. According to the authors, there are many barriers to addressing religious and spirituality in therapy. Some of these barriers include the perspective that both religion and spirituality hold repressive connotations for society, that they are associated with neurosis or psychiatric disorders, and the exclusion of anything nonscientific for the advancement and legitimacy of the discipline.
Some ethical issues regarding religion and spirituality in therapy is balancing these beliefs with the client’s best interest, the clinician must also be aware of own belief system, and its potential impact on the therapeutic relationship, and also understanding the vast cultural influences of religion and spirituality in the lives of many populations (Marterella & Brock, 2008). Summary As defined in this paper, there appears a strong correlation between ethical competence of marital and family therapists, and their ability to facilitate through the complex dynamics of marital therapy and research.
Because of the extremely sensitive and complex nature of marital therapy, including coping with issues such as infidelity, child rearing, depression, and health problems, one role of the therapist is to assist the couple and families with navigating the decision-making process by collaboratively exploring various choice-consequence relationships. To effectively achieve this task, the clinician must be well aware of one’s own values system, and understand how it may impact therapeutic work with clients. In general, the goal of marital and family therapists is to help clients foster and maintain mutual, aring, and loving relationships. Recommendations In reviewing the literature, it is apparent that many of the authors feel that more research is needed on the treatment of infidelity. Especially limited is information regarding themes, patterns of treatment modalities, and relapse prevention for infidelity. Future research on cultural and religious differences in treatment options would benefit therapists in working with this wounded and challenging population. 149.