Annelise BillingsEast Carolina University |
Caroline Tumulty-OllemarEast Carolina University |
Jadalee EymaEast Carolina University |
Both the AAMFT Code of Ethics (2015) Standard 1.9: Relationship Beneficial to Client and the ethical principle of beneficence require therapists to continue to provide services only so long as clients are benefiting from the therapeutic relationship (Murphy & Hecker, 2017). When practitioners are emotionally depleted and under elevated levels of stress, there is an increased risk for ethical violations (Barton, 2020; Murphy & Hecker, 2017). Elizabeth appears to be suffering from burnout as evidenced by the symptoms of decreased job performance, irritability toward family and coworkers, aggression toward clients, increased substance use, and diminishing control of her emotions (Holden & Jeanfreau, 2023). It is possible that these symptoms of burnout are being experienced as a sense of powerlessness in her own life, which may inadvertently manifest as an unconscious pursuit of power in her professional life and specifically within therapeutic relationships (McCarthy, 1997).
In congruence with research that shows an association between years of work experience and burnout, Elizabeth’s 20 years of clinical activity may predispose her to overconfidence and burnout (Holden & Jeanfreau, 2023). Additionally, providers can become less empathetic, ineffective with clients, and experience countertransference which may result in them ignoring warning signs of burnout, neglecting themselves, rationalizing their behavior, or being reticent to get help (Barton, 2020; Murphy & Hecker, 2017). All this combined can place the therapist in the precarious position of no longer benefiting the client in treatment, but also risking professional and legal consequences due to ethical infraction. This appears to be the place Elizabeth has found herself.
Identified ethical dilemmas
Creating a safe space where clients can speak about their experiences and feelings openly without judgment or consequence fabricates the very means that makes therapy a unique place and profession. Therapists are obligated by Standard 2.1: Disclosing Limits of Confidentiality to discuss the rights and limits of confidentiality at the very beginning of the therapeutic relationship, and throughout the process {AAMFT, 2015; Myers & Blausey, 2020). When Elizabeth used a client’s case for workshop scenarios and client testimonials in her book, she violated Standard 2.4: Confidentiality in Non-Clinical Activities (AAMFT, 2015). With confidentiality being a critical ethical principle discussed with clients, it is highly probable that the breach of Chad and Stacey’s privacy is what led to the ethical complaint filed against her. Though Elizabeth attempted to follow Standard 1.11: Non-Abandonment and the Aspirational Core Value of innovation and the advancement of knowledge of systemic and relational therapies, upon investigation the ethics board is likely to find other violations under Standard I, Standard II, Standard Ill, Standard V, and Standard IX (AAMFT, 2015).
Elizabeth’s false presentation of her professional credentials and competencies places her in violation of several AAMFT ethical standards and brings into question potential abuse of the therapeutic relationship and power (AAMFT, 2015). In violating Standards 1.8: Client Autonomy in Decision-Making and 3.8: Exploitation, Elizabeth leverages her therapeutic power to push her own agenda on Stacey and Chad and exploits their distress to continue in therapy, buy her book, and attend her workshops (AAMFT, 2015). As experts in the mental health field, therapists hold power in the ability to guide conversations, decision-making processes, diagnoses, and agendas (Levitt et al., 2016; Murphy & Hecker, 2017). By explaining that divorcing would be harmful to Chad and Stacey’s children and stating that they need to stay together, Elizabeth infringes upon their autonomy to make decisions about their lives. She further removes their decision-making power by refusing to provide referrals despite the clients’ desire to terminate therapy, which breaches Standard 1.10: Referrals (AAMFT, 2015).
Additionally, Elizabeth’s presentation as a doctor, both on television and locally, violated multiple standards of Standard Ill, Standard V, and Standard XI (AAMFT, 2015}. As stated by Murphy & Hecker (2017), “Therapists have an ethical responsibility to educate others about their credentials, as well as not to mislead others about their credentials” (p. 313). Elizabeth’s use and publication of her self-declared title of the “marriage doctor” and a “100% success rate” with the intent that it will attractmore attention, violates ethical Standards 3.8, 5.6, 5.9, 9.1, 9.2, 9.4, 9.5 and 9.8 (AAMFT, 2015). By failing to correct the television host, Elizabeth violated Standard 9.8: Correction of Misinformation and aided in the spreading of misleading and false information about herself and the mental health community (AAMFT, 2015). The ethical implications of falsely stating one’s competencies and using therapeutic power to push personal agendas can result in poor clinical outcomes and misinformation due to inadequate or damaging services (Levitt et al., 2016; Waltman et al., 2016).
With the emphasis on collaboration outlined in the Preamble of the AAMFT Code of Ethics (2015), it is a marriage and family therapist’s (MFT) obligation to engage in their professional systems just as they encourage their clients to do personally. Standard Ill requires MFTs to demonstrate a high level of professional competence and integrity through collaboration and development (AAMFT, 2015). Due to the voluntary and involuntary isolation that Elizabeth is practicing in, she violates Standards 3.3, 3.4, 3.11, and 3.12 (AAMFT, 2015). By failing to utilize her social support networks, balance objectivity, and engage in sustainable self-care practices, Elizabeth neglects to uphold these standards (Murphy & Hecker, 2017; Patterson et al., 2018). This is demonstrated by her disregarding her colleagues’ suggestion to slow her pace, publicly stating that couples who divorce have not tried hard enough, and using alcohol as a primary means to unwind. Ultimately, Elizabeth’s inability to maintain the identified ethical and professional standards indicates the extensive damage that burnout has caused, namely how her professional integrity has been compromised.
Decision making
Though it is unclear which decision-making model Elizabeth applied throughout this vignette, it could be argued that a feminist ethical decision-making model could have guided her away from the ethical blunders identified thus far. An inherent piece of this model is the assumption that both cognitive and intuitive levels of reasoning are necessary for identifying dilemmas as they arise (Hill et al., 1998). Additionally, the feminist model encourages the use of client feedback to ensure that client autonomy is honored at every step of the decision-making process (Hill et al., 1998). Perhaps most importantly, the feminist lens accounts for the power differentials that exist within the client-therapist relationship (Hill et al., 1998).
There are multiple points at which Elizabeth could have used this model to identify and appropriately respond to ethical dilemmas. For instance, Hill et al. (1998) describe the therapist’s feelings of discomfort as an initial telltale sign that there is an ethical dilemma at play. This is most prevalent in Elizabeth’s sense of awkwardness when referred to as “Dr. Elizabeth” and her irritation with Chad and Stacey; here were opportunities for Elizabeth to reflect on questions such as “What is this feeling about?” and “What is this discomfort trying to tell me?”. It might have also been helpful at this point to consider where Elizabeth’s rigid stance on divorce arose from, as this self-exploration could have revealed a foundation in personal values rather than a commitment to client autonomy. By forgoing the inflated sense of confidence that is common amongst seasoned therapists and recognizing her susceptibility to unconscious bias, Elizabeth might have been inclined to turn toward legal, ethical, and peer-based sources of consultation in pursuit of the most ethically sound solution (Waltman et al., 2016).
Moreover, Elizabeth’s abuse of the client-therapist power differential occurs in direct opposition to feminist goals of creating more balanced therapeutic relationships (Hill et al., 1998). To be clear, it should not be assumed that Elizabeth’s actions had malicious intent, but rather that her oversight of the position she holds resulted in egregious and potentially harmful decisions. By using a feminist decision making model, which prioritizes client feedback, she might have been able to see Chad and Stacey’s resistance as evidence of an ill-fitted solution motivated by countertransference rather than a battle for power. If Elizabeth is truly dedicated to upholding beneficence within her practice – as all MFTs should – it follows naturally that the client’s perspective be taken as vital to finding the best solution.
Though Elizabeth is an experienced practitioner, as she navigates a new life stage and enters a new realm of practice, she may benefit from supervision or consultation. Glebova et al. (2022) state that among the primary goals of therapeutic supervision is the development of a therapist who is both competent and ethical. Just as supervision is necessary for training therapists to develop professional competence, consultation allows the seasoned therapist to maintain a high degree of competency (Murphy & Hecker, 2017). Additionally, self-care may benefit Elizabeth by helping to increase work-life balance, resilience, and stress management (Barton, 2020; Murphy & Hecker, 2017). For Elizabeth, exercising self-compassion and acknowledging the good she is doing (i.e., non-abandonment of clients and advancement of knowledge of relational therapies) may be conducive to avoiding compassion fatigue and contributing to more sustainable professional behaviors (Holden & Jeanfreau, 2023).
Conclusion
In every word, action, and decision, therapists are faced with the formidable challenge of upholding legal and ethical standards while simultaneously exercising compassion towards themselves and their clients. When the well-being of an entire community depends on a therapist’s ability to balance these responsibilities, it becomes easy to lose sight of that person’s fallibility and the larger forces at play. Elizabeth’s flagrant violation of multiple AAMFT ethical standards is apparent throughout this scenario, but what is perhaps less obvious is her desperate attempt to meet unattainable demands with little to no support. Both involuntary and self-imposed isolation are the true systemic arbiters of dysfunction within each of Elizabeth’s ethical dilemmas. Evidently, the ethical pitfalls of any MFT must be examined at this systemic level—which is so vital to the marriage and family therapy profession—to gain the most complete, humanistic understanding of each dilemma. It may be all that Elizabeth, or any MFT, can do to remain vigilant of these factors lest they jeopardize the ethical principles they have vowed to uphold.
