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Journal of Marital and Family Therapy 1986, Vol. 12, No. 3,225-230 ETHICAL DILEMMAS IN FAMILY THERAPY Susan L. Green James C. Hansen State University of New York at Buffalo A review of the literature in the area of ethical dilemmas facing family therapists revealed that there were a number of issues facing family therapists which are not included in the Principles for Family Therapists (1984) of the American Association for Marriage and Family Therapy. Seventy-five family therapists from across the nation responded to a questionnaire which asked what ethical dilemmas they face and how helpful the ethical guidelines are with these dilem- mas. Results indicate that family therapists are encountering dilemmas which are not included in the Principles, significantly more often than those that are included. The ethical principles were found to be helpful for those ethical dilem- mas attended to by the Principles. Involving the entire family in therapy has become increasingly popular. Family therapy adds new dynamics to traditional individual and group therapy. Not only are there multiple members present, but they are all closely related to each other. For these reasons, ethical guidelines for individual and group psychotherapy may not always be directly applicable to the family in therapy (Margolin, 1982). The American Association for Marriage and Family Therapy (AAMFT) has pub- lished ethical guidelines for family therapists. The newly revised Ethical Principles for Family Tkrapists (1984) includes eight broad areas of ethics, expanded to include 31 specific principles which family therapists are expected to follow (AAMFT, 1984). The eight categories of principles are: Responsibility to Clients, Competence, Integrity, Confidentiality, Professional Responsibility, Professional Development, Research Responsibility and Social Responsibility. The ethical dilemmas which family therapists face have been the subject of concern in recent literature (Margolin, 1982;Hines & Hare-Mustin, 1978;Fieldsteel, 1982;Okun & Rappaport, 1980; Rinella & Goldstein, 1980; Jurick & Russell, 1985). These authors suggest numerous issues which are peculiar to the situations that family therapists might encounter in their practices and make suggestions as to how best to resolve these problems. The AAMFT Ethical Principles for Family Therapists (1984) does not address a number of the issues cited by the authors above. Among these are: treating a family if one member does not want to participate, the training and qualifications of family therapists, testifying in legal proceedings, dealing with requests for information, obtain- ing the informed consent of children (Margolin, 19821, sharing values implicit in the mode of therapy, manipulating a family for therapeutic benefit (Okun & Rappaport, 19801, and preserving the family (Group for the Advancement of Psychiatry, 1970). Susan L. Green, MA, is a Doctoral Candidate and James C. Hansen, PhD, is a Professor, Department of Counseling and Educational Psychology, State University of New York at Buffalo, 409 Christopher Baldy Hall, Amherst, NY 14260. July 1986 JOURNAL OF MARITAL AND FAMILY THERAPY 225

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Journal of Marital and Family Therapy 1986, Vol. 12, No. 3,225-230

ETHICAL DILEMMAS IN FAMILY THERAPY

Susan L. Green James C . Hansen State University of New York at Buffalo

A review of the literature in the area of ethical dilemmas facing family therapists revealed that there were a number of issues facing family therapists which are not included in the Principles for Family Therapists (1984) of the American Association for Marriage and Family Therapy. Seventy-five family therapists from across the nation responded to a questionnaire which asked what ethical dilemmas they face and how helpful the ethical guidelines are with these dilem- mas. Results indicate that family therapists are encountering dilemmas which are not included in the Principles, significantly more often than those that are included. The ethical principles were found to be helpful for those ethical dilem- mas attended to by the Principles.

Involving the entire family in therapy has become increasingly popular. Family therapy adds new dynamics to traditional individual and group therapy. Not only are there multiple members present, but they are all closely related to each other. For these reasons, ethical guidelines for individual and group psychotherapy may not always be directly applicable to the family in therapy (Margolin, 1982).

The American Association for Marriage and Family Therapy (AAMFT) has pub- lished ethical guidelines for family therapists. The newly revised Ethical Principles for Family Tkrapis ts (1984) includes eight broad areas of ethics, expanded to include 31 specific principles which family therapists are expected to follow (AAMFT, 1984). The eight categories of principles are: Responsibility to Clients, Competence, Integrity, Confidentiality, Professional Responsibility, Professional Development, Research Responsibility and Social Responsibility.

The ethical dilemmas which family therapists face have been the subject of concern in recent literature (Margolin, 1982; Hines & Hare-Mustin, 1978; Fieldsteel, 1982; Okun & Rappaport, 1980; Rinella & Goldstein, 1980; Jurick & Russell, 1985). These authors suggest numerous issues which are peculiar to the situations that family therapists might encounter in their practices and make suggestions as to how best to resolve these problems.

The AAMFT Ethical Principles for Family Therapists (1984) does not address a number of the issues cited by the authors above. Among these are: treating a family if one member does not want to participate, the training and qualifications of family therapists, testifying in legal proceedings, dealing with requests for information, obtain- ing the informed consent of children (Margolin, 19821, sharing values implicit in the mode of therapy, manipulating a family for therapeutic benefit (Okun & Rappaport, 19801, and preserving the family (Group for the Advancement of Psychiatry, 1970).

Susan L. Green, MA, is a Doctoral Candidate and James C. Hansen, PhD, is a Professor, Department of Counseling and Educational Psychology, State University of New York at Buffalo, 409 Christopher Baldy Hall, Amherst, NY 14260.

July 1986 JOURNAL OF MARITAL AND FAMILY THERAPY 225

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This study explores the ethical dilemmas family therapists are facing in their work and the helpfulness of ethical guidelines in the decision-making process. This. problem has not been previously studied empirically. The study focuses on dilemmas in the eight categories and also on several ethical dilemmas which the Ethical Principles for Family Therapists (1984) does not address. It is hoped that this research will shed light on the extent of the problems facing family therapists in their daily work, encourage forums to address the actual dilemmas family therapists encounter, and aid in the development of ideas for future study.

METHOD

Subjects The subjects used in this study were drawn from a list of family therapists, nation-

wide, who purchased Values, Ethics, Legalities and the Family Therapist (L‘Abate, 19821, the first volume of The Family Therapy Collections.

This population was chosen because it was thought that people who would buy this book would have an interest in values and ethics, and would be able to respond thought- fully to the issues in this area. This population also provided for a national sample.

Three-hundred names were selected at random and questionnaires were sent by mail, along with self-addressed return envelopes. A cover letter briefly described the general nature of the study, assured confidentiality and provided an opportunity for subjects to request results of the study.

Ninety-nine questionnaires were returned, a 33% response rate. Of these, 6 were not usable because they were completed incorrectly. As a result, a total of 75 question- naires from 29 states were used in the analysis.

Of the 75 respondents, 31 were female and 44 were male. Thirty-five were AAMFT members and 85% were familiar with the AAMFT Ethical Principles for Family Ther- apists (1984). The mean age of the respondents was 39.8 and the mean number of years these therapists have practiced family therapy was 7.1. Thirty-seven respondents had master’s degrees, while 38 had doctorates. Forty-nine respondents worked in private practice, while the remaining 26 were employed in hospitals, clinics, churches, univer- sities and public schools. Of the family therapists in this group, 34 got their training in ethics in graduate school, 8 were trained in workshops, 10 were trained both in school and at workshops, and 23 reported having no training in ethics.

Measures Data for this study was collected using a three-part questionnaire. The first section

asked for “General Information.” The purpose of this segment was to obtain demographic data on the subjects. This information was used in two ways: 1) to obtain a more detailed understanding of the sample being measured, and 2) to explore the relationship between the demographics and the other two sections of the questionnaire.

The second section was a scale which dealt with ethical dilemmas that the subjects might have faced. The scale asked “Have you faced a dilemma with. . .” and lists 41 items. Thirty-one items were derived from the 31 specific AAMFT Ethical Principles for Family Therapists (1984). An additional 10 items were added which address issues identified in the literature that were not in the AAMFT’s principles. Respondents were asked to circle the response which best answered each question on a 5-point scale, labeled from “frequently” to “never.”

The third part assessed the usefulness of ethical guidelines in decision-making. This 5-point scale (1 = “not helpful,” 5 = “very helpful”) asked “HOW helpful are ethical guidelines when you encounter decisions concerning. . .” It lists 41 items which are identical in content with the 41 items from the previous section.

226 JOURNAL. OF MARITAL A N D FAMILY THERAPY July 1986

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Jn order to compare the additional items with the items covered in the ethical guidelines, nine groups were formed. Eight of the groups represented the areas covered in the ethical guidelines, and a ninth group contained the 10 additional items referred to in the literature, but not covered in the guidelines.

RESULTS AND DISCUSSION

Means and standard deviations were calculated for each of the 41 items on both questionnaires. Ethical dilemmas were rank-ordered by mean from highest to lowest, reflecting which dilemmas are most frequently faced. The ethical guidelines measure was also ranked from least to most helpful so that a comparison could more easily be made between the dilemmas that were most frequently encountered and the helpfulness of the guidelines.

On the ethical dilemmas scale, there were 8 items with means ranging from 2.5- 3.0 reflecting eight dilemmas which were most often faced. Of these 8 items, 6 were from the group of 10 additional items that addressed issues raised in the literature, and that were not in the Ethical Principles for Family Therapists (1984). These 6 items are: treating a family if one member does not want to participate (#9), feeling confident of your training and or qualifications (#25), seeing one family member without the others present (#38), informing clients of values implicit in the mode of therapy (#19), dealing with parental requests for information differently from children’s requests for infor- mation (#33), and sharing your values and biases with families (#15).

Not only are these dilemmas present, but a 2-tail t-test showed that they occurred significantly (p<.OOl) more often than other dilemmas which are covered in the AAMFT guidelines. This is an important finding in this study because it supports empirically what the literature has suggested as being ethical dilemmas for family therapists.

Low means on the ethical dilemmas faced scale could possibly have indicated that, on the average, family therapists are only “occasionally” facing dilemmas in their practices. A closer look at the data showed that in all but 3 of the ethical dilemma items, subjects had responded with all five choices (1-5). This indicates that family therapists do not face all dilemmas all the time, but that a t least some of them face almost all of these dilemmas some of the time.

The mean helpfulness ratings of the ethical guidelines ranged from 2.21-3.84. From the group of eight scores which reflected eight dilemmas which are most frequently faced, 6 items were rated as having the guidelines be “not helpful” to “somewhat helpful.” Of these 6 items, 5 are in the group of additional items which are not included in the ethical guidelines. These are items numbered 9,38,19,33, and 15.

A 2-tail t-test showed a significant difference @<.001) between the helpfulness of the guidelines with the additional items and the eight other groups. The guidelines were found to be significantly less helpful with the additional items dilemmas. This is not surprising, because one would not expect guidelines to help resolve issues which are not included in those guidelines. Overall, as the frequency of dilemmas increased, so did the helpfulness of the guidelines ( r = .22 p<.05).

Family therapists who were trained at workshops reported facing significantly more dilemmas in the area of professional development than those trained through formal education, supervision, or any combination of the three. This finding, while being important in and of itself, also brings up another important issue. One wonders if therapists can get enough out of workshops to be able to competently do family therapy. Workshops would seem to be good places to supplement one’s experiences, rather than the basis of a therapist’s practice. Further research is needed in this area.

Despite the limitations, a number of important points emerged as a result of this study. Family therapists are, indeed, facing ethical dilemmas which are not included in

July 1986 JOURNAL OF MARITAL AND FAMILY THERAPY 227

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Table 1 Means, Standard Deviations and Rank Orders of the Items on

the Ethical Dilemmas and Ethical Guidelines Scales' N = 75

Ethical Dilemmas Ethical Guidelines Faced** Helpful***

Rank Rank Items* Order M SD Order M SD

+ 9. 6.

+ 25. + 38.

+ 19.

+ 33.

+ 15. 8.

30.

20. 13.

+22.

26. 14. 12.

+ 41. 4.

28.

18.

+ 40. 17.

16.

1. 34. 37.

2.

Treating the entire family Being current on new family therapy developments Training or qualifications Seeing one family member without the others present Informing clients of values implicit in the mode of therapy Requests for information from family members Sharing values with clients Development of laws and regulations pertaining to family therapy Sharing professional judgments and client decision-making When to end therapy Correcting inaccurate information about your services Manipulating a family for therapeutic reasons Financial arrangements Storing and disposing of client records Maintaining high standards of scholarship Informed consent of children Public use of clinical materials Communicating client information to others Qualifications and representation of employees Preservation of the family Professional development of those you supervise Properly citing persons to whom credit is due To whom you provide your services Following AAMFT standards Separating supervisory and therapeutic roles Personal problems that impair your work performance

1 3.0 1.13

2 2.97 1.27 3 2.96 1.12

4 2.73 1.19

5 2.72 1.30

6 2.61 1.20 7 2.60 1.16

8 2.55 1.19

9 2.49 1.30 10 2.47 2.00

11 2.40 1.14

12 2.39 1.09 13 2.35 1.36 14 2.35 1.37 15 2.32 1.35 16 2.31 1.22 17 2.29 1.16

18 2.12 .97

19 2.11 1.45 20 2.07 1.11

21 2.05 1.37

22 2.05 1.27 23 2.04 1.37 24 2.01 1.29

25 2.00 1.20

26 1.99 1.06

39 2.53 1.23

36 2.72 1.37 9 3.32 1.33

40 2.41 1.32

33 2.8 1.35

14 3.20 1.37 22 3.04 1.30

21 3.04 1.42

19 3.08 1.35 38 2.60 1.33

12 3.27 1.44

35 2.72 1.36 37 2.63 1.39 2 3.84 1.33

15 3.19 1.42 26 2.91 1.30 3 3.6 1.38

1 3.84 1.23

31 2.81 1.52 41 2.21 1.24

32 2.80 1.43

20 3.08 1.58 25 2.91 1.41 7 3.33 1.49

34 2.75 1.39

24 2.95 1.50 10. Advertising of services 27 1.93 1.16 8 3.32 1.50

228 JOURNAL. OF MARITAL AND FAMILY THERAPY July 1986

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Table 1, (continued) N = 75

Ethical Dilemmas Ethical Guidelines Faced** Helpful***

Rank Rank Items* Order M SD Order M SD

35. Working outside your area of competence 28 1.92 .96 11 3.28 1.37 5. Assignment of publication credit 29 1.89 1.35 6 3.45 1.55

21. Conducting research ethically 30 1.80 1.26 18 3.11 1.58 24. Design and delivery of services and

regulation of practitioners 31 1.79 1.22 16 3.17 1.43 11. Using professional relationships to

enhance other interests 32 1.72 .99 17 3.11 1.54 27. Corrective ethical efforts with colleagues 33 1.72 1.01 10 3.29 1.50

7. Research with human subjects 34 1.69 1.10 4 3.59 1.52 + 29. Taking sides in legal action 35 1.67 1.33 30 2.83 1.44

32. Advertisement of published works 36 1.63 1.08 27 2.88 1.50 31. Sexual harassment 37 1.43 .77 13 3.23 1.66 36. Use of relationship with students and

trainees 38 1.36 .67 29 2.87 1.42

qualifications 39 1.23 .58 5 3.52 1.50 23. Payment for referrals 40 1.13 .53 28 2.87 1.77 39. Using AAMFT membership in other than

professional activities 41 1.11 .51 23 2.96 1.64

3. Claiming inaccurate professional

‘ N = 75. * = These items have been shortened to general topic area. Contact author for more

information. ** = These items are rated from 1 = “never” to 5 = “frequently.”

+ = These items are in the group of 10 additional items. *** = These items are rated from 1 = “not helpful” to 5 = “very helpful.”

the AAMFTs Ethical Principles for Family Therapists (1984). These dilemmas are faced significantly more often than those covered in the guidelines. Although evidence sug- gests that the present ethical principles are helpful, work needs to be done to develop guidelines which cover more of the actual dilemmas that family therapists confront.

REFERENCES

American Association for Marriage and Family Therapists. (1984). Ethical principles for family

Fieldsteel, N. (1982). Ethical issues in family therapy. In M. Rosenbaum (Ed.), Ethics and uahes

Group for the Advancement of Psychiatry. (1970). The field offamily therapy, 78,594-603. Wash-

Hines, P. & Hare-Mustin, R. (1978). Ethical concerns in family therapy. Professional Psychology,

Jurich, A. & Russell, C. (1985). The conflict between the ethics of therapy and outcome research in family therapy. In L. Andreozzi (Ed.), Integrating research and clinical practice (pp. 90- 96). Rockville, MD: Aspen Systems Corporation.

therapists. (Pamphlet). Washington, DC: Author.

in psychotherapy (pp. 259-268). New York Free Press.

ington, DC: Author.

9,165-171.

July 1986 JOURNAL OF MARITAL AND FAMILY THERAPY 229

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L'Abate, L. (Ed.). (1982). Values, ethics, legalities and the family therapist. Rockville, MD: Aspen

Margolin, G. (1982). Ethical and legal considerations in marital and family therapy. American

Okun, B. & Rapapport, L. (1980). Working with families: A n introduction to family therapy. North

Rinella, U. & Goldstein, M. (1980). Family therapy with substance abusers: Legal considerations

Systems Corporation.

Psychologist, 37, 788-801.

Scituate, M A Duxbury Press.

regarding confidentiality. Journal of Marital and Family Therapy, 6,319-326.

AAMFT Information Service Pamphlets You Can Use

For Physicians Only 0 For Professionals Only

Here are two informative pamphlets on our profession. One is aimed at professionals and the other is aimed at physicians and dentists. These pamphlets are meant to alert your colleagues in other professions to the signs of marital distress and to assist them in making informed and effective referrals. Quantity prices are as follows:

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Send Your Prepaid Order To: American Association for Marriage and Family Therapy

1717 K St., N.W. #407 Washington, D.C. 20006

230 JOURNAL OF MARITAL AND FAMILY THERAPY July 1986