A lot of the reality of therapy involves thinking on your feet, particularly when it comes to ethical dilemmas. These situations don’t always arise at convenient times. You may find yourself needing to make a decision then and there, without the chance to ask for help.
When Ethical Boundaries Are Not Clear
In 1964, Supreme Court Justice Potter Stewart said of obscenity, “I can’t define it, but I know it when I see it”. Ethical boundaries in therapy can feel just as difficult to pin down. A lot of the time, the context matters as much as the question. For example, would you accept a thank-you card or a bunch of flowers from a grateful client? I’d guess most therapists would not see this as an ethical dilemma and would say yes.
But what if it were a genuine Rolex watch, or a free week in their Spanish villa? Or even the flowers, if they were pointedly delivered on Valentine’s Day? And if you said the card was in and the villa was out, where exactly in between would you draw the line?
You see what I mean? We feel we know what ethics are but pinning them down to specifics is tricky. They depend on interpretation, social and professional context, personal beliefs, and many other factors.
Common Ethical Dilemmas in Therapy
- Confidentiality vs Safety: if you are concerned for a client’s safety, when and how would you break confidentiality?
- Dual Relationships: do you work with family and friends? What if you meet a client socially at an event? How does that impact the therapy?
- Working with multiple members of a family: how do you ensure confidentiality for each of them?
- Lack of progress: how long should you continue to work with a client if they report no progress is being made?
- Dependency, Transference and Countertransference: could these be affecting your relationship with the client?
- Financial difficulty: a client is struggling to pay for sessions, but wants to continue. How do you handle this?
- Personal values: a client expresses views that conflict with your own beliefs, for example about religion, politics or prejudice. How do you remain professional and client-centred without allowing your own values to interfere?
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The Challenge of Ethical Decision-Making in Therapy
A Code of Ethics, of course, is vital and your professional body will provide you with one for formal guidance. But a written Code can’t anticipate all of the potential ethical dilemmas you could meet.
Supervision is another source of support, and getting that second opinion can be very useful. However, some ethical dilemmas (like clients turning up with gifts) arise in a session and have to be dealt with immediately.
You can hardly ring your supervisor for advice while the client is sitting in front of you, and they might not be available if you did. So even inexperienced or student hypnotherapists can be faced with making potentially complex ethical decisions in the moment.
Kitchener’s Five Principles for Ethical Dilemmas in Therapy
You’ll be happy to hear that there is a framework you can fall back on when you need to make these ethical decisions. Kitchener (1984) set out five principles to apply to ethical decision-making when you don’t have a specific rule to follow. These are:
- Autonomy – allowing clients freedom of choice to make their own decisions and to stay consistent with their own values.
Autonomy has to be balanced against the client’s ability to make sound decisions (for example, if they are a minor or a vulnerable adult). And on how their values are likely to be seen in the society in which they live. (For example, a nudist who prefers to be naked in settings where others would consider it inappropriate). - Nonmaleficence – the principle of ‘do no harm’. It’s important to balance the pros and cons of each possible course of action and take them into account in your decision-making.
It’s also similar to the philosophical principle used by many therapists of ‘the greater good”. For example, breaking confidentiality to report a risk of harm may prevent greater harm to the client or others. - Beneficence – acting in the client’s best interests. For example, referring them to a GP or more experienced therapist if you need to. Or offering a safe place to explore difficult situations and feelings. It would also include not unnecessarily prolonging therapy, offering reasonable adjustments for disabilities, and so on.
- Justice – treating all clients fairly, so being aware of transference and countertransference, following the law that protects certain groups from prejudice, and even having a clear and open pricing structure.
Justice is not about treating everyone the same, but about adapting to everyone’s needs equally where you can. Kitchener (1984, Page 49) called it ‘“treating equals equally and unequals unequally, but in proportion to their relevant differences’. For example, having a chaperone with a client who might be considered vulnerable. - Fidelity – being honest and trustworthy in your dealings with clients.
This isn’t just about building rapport, although that comes into it. It’s also ensuring your clients can trust you. That might be about keeping your word, maintaining professional boundaries, or demonstrating respect for their time and needs. (e.g., not constantly moving appointments about without giving good reasons).
Sometimes, the principles might conflict, for example, the recent debate over assisted dying. Is someone making that decision expressing autonomy, or do they need protection from themselves? I’m not going to provide an answer to that one, by the way, because I don’t want to go too far off-topic. But context is key, and you might come to different decisions in different situations.
Tips For Ethical Decision-Making
When faced with a real-time ethical dilemma, having a framework for clear thinking is essential. These questions (adapted from Forester-Miller & Davis,1996) can help guide you.
- What are the ethical dilemmas?
- What does your professional body’s Code of Ethics say about this?
- What guidance might you draw from previous experience or supervision?
- What are your choices?
- What are the likely consequences of each option, and how do they fit with Autonomy, Nonmaleficence, Beneficence, Justice and Fidelity? If you have problems remembering the five principles, this will help … Act Now, Be Just and Fair
Then choose and implement the one that you feel will lead to the least harm and/or the most good. I’d also recommend a consultation with your supervisor as soon as possible, to ensure there are no options that you’ve overlooked or actions which need to be taken later.
Balancing Professional Guidelines with Real-Life Practice
Ethical dilemmas are part of running a therapy practice. Even experienced practitioners are sometimes unsure about the best course of action. It’s why we have a support system of reflective practice, supervision, CPD training and even, now and then, supportive social media groups. (i.e., the ones that aren’t going to make you feel about an inch high for asking a question. See Footnote 1).
Reflective practice isn’t just about identifying things you could have done better. It’s also about understanding your decision-making process and learning to address future dilemmas with greater confidence.
Developing Confidence in Ethical Decision-Making
These situations rarely come with clear-cut answers, and your decision may vary depending on the context, your professional framework, and the individual client. It’s more about making the best decision you can with the information you have available at the time. One way I often describe it to students is that “ethics is what you do when you think no one else is watching”.
Ethical decisions made ‘in the moment’ are rarely perfect, and hindsight can signpost areas for professional development. Remind yourself that ethical decision-making improves with practice, reflection and support.
In the end, if you act with compassion and ask yourself what you would want if your role and the client’s were reversed, you’ll rarely go astray.
Footnotes:
[1] I recommend Meeting of Minds. Counselling and Hypnotherapy Tips and Resources on Facebook, https://www.facebook.com/groups/therapymeetingofminds
References:
Forester-Miller, H. and Davis, T. (1996). A Practitioner’s Guide to Ethical Decision Making. [online] Available at: https://www.counseling.org/docs/default-source/ethics/practitioners-guide.pdf?sfvrsn=df2de618_4. Pages 2.4.
Kitchener, K. S. (1984). Intuition, critical evaluation and ethical principles: The foundation for ethical decisions in counselling psychology. Counselling Psychologist, 12(3), 43-55.
About Debbie Waller
Blog Author Debbie Waller is a hypnotherapist, supervisor, and trainer with more than twenty years of experience. As well as having a busy client practice, she runs Yorkshire Hypnotherapy Training and writes books and articles for therapists who want to deepen their knowledge and develop effective practice.
Disclaimer
The information and ideas shared on this blog are based on the author’s professional experience, research, and training. They are intended for educational purposes and to support reflection and professional development. Therapists should always apply their own professional judgment and consider the needs of individual clients when using any techniques or suggestions discussed here.
While every effort is made to ensure the information is accurate and helpful, no responsibility can be accepted for any loss, damage, or difficulties arising from the use or misuse of material contained in these articles.
