Family Therapy Ethics with Service Members, Veterans, and Their Families

There are over 2.8 million military personnel between active duty, National Guard or Reserve, or civilians who are permanently assigned for duty (Defense Manpower Data Center; DMDC, 2019) and over half of current U.S. military personnel have a family (i.e., married with or without children or are single with children; DoD, 2019). In addition to current service members and their families, there are 19 million veterans in the U.S. (Shaeffer, 2021), approximately 60% of whom are married, and 14% with children living in their homes (National Center for Veterans Analysis and Statistics; NCVAS, 2019).

Given the likelihood that civilian providers will encounter SMVF in the U.S., it is imperative that MFTs understand the ethical considerations present for this unique population and are prepared to competently assess, diagnose, and treat SMVF across a variety of healthcare settings (e.g., Military Health System, Veterans Health Administration [VA], community healthcare). Although MFTs are in a unique position to support SMVF due to their extensive training in general systems theory that allows them to simultaneously consider how a person’s biopsychosocial-spiritual health factors as well as their diverse military-related experiences (e.g., service branch, rank, and military occupational specialty [MOS]) influence wellbeing, not all traditionally-trained therapists are equipped to meet the complex needs of this population nor are aware of the nuances in ethical decision making compared to non-military populations. This article, in conjunction with the AAMFT Code of Ethics (AAMFT, 2015) and the Competencies for MFTs Working with Service Members, Veterans, and Their Families (AAMFT, 2020), will help MFTs navigate relevant ethical issues while considering clinical practice guidelines and federal military regulations.

Clinical practice with SMVF

Though MFTs are obligated to abide by the ethical standards set forth by The American Association for Marriage and Family Therapy, those working with military populations, particularly active-duty service members, must be aware of additional considerations in their clinical practice. For example, maintaining confidentiality is an essential component for all therapeutic relationships and although limits exist in any setting (e.g., child or elder abuse, duty to warn, harm to self, etc.), there are additional limits that exist for military clients or in military settings compared to non-military populations. It is essential to shed light on these unique considerations given that behavioral health providers who work with military populations have reported that limits to confidentiality are one of their biggest ethical concerns (Hoyt, 2013).

First, it is helpful to keep in mind that the overall mission of the military is combat readiness and optimization. In efforts to achieve this goal, there is a special exemption protected under the Health Insurance Portability and Accountability Act (HIPAA; Defense Health Agency, 2015) called the Military Command Exception that permits the disclosure of protected health information (PHI) from military clients without consent. This exception does not apply to all behavioral healthcare services, but the intention is that information that could impede mission readiness is to be shared with a military client’s command staff. There is a specific instruction, DoD Instruction 6490.08, that outlines the criteria that need to be met to disclose PHI without consent (DoD, 2011). These circumstances include serious risk of self-harm, harm to others, or harm to a specific military mission, members in the Personnel Reliability Program or those identified as having potentially sensitive or urgent mission responsibilities, admission to inpatient care, acute conditions that interfere with assigned duties, substance abuse treatment, command-directed mental health evaluation, and other special circumstances (DoD, 2011).

In addition to the limits of confidentiality for military personnel discussed, the Uniform Code of Military Justice outlines the rules and regulations that define criminal behavior for military members that may also indicate a duty to report to command staff (Myers, 2019). These behaviors include inappropriate sexual contact, extramarital sexual contact, computer crimes such as cyberstalking, intimate partner violence, and fraternization (Myers, 2019; Sheftick, 2019). It is important to keep in mind that although the release of certain PHI without client consent is unique to military clients, the DoD aims to foster a culture that promotes seeking mental health treatment and even when PHI is required to be disclosed, only the minimum amount of information needed should be shared (DoD, 2011). MFTs working with military populations must stay abreast of the special laws and regulations that exist for military personnel before engaging in treatment to appropriately inform clients about their limits of confidentiality and to know how to engage with a military client’s larger system, if warranted.

Engaging with SMVF larger systems

MFTs are equipped to work with SMVF because military personnel not only exist within their family systems, but the military as an entity is composed of complex larger systems and hierarchies; MFTs are able to use their systemic and relational lens to conceptualize how each of these systems may impact SMFV wellbeing. While MFTs are accustomed to engaging and collaborating with other providers in a client’s life, working with military personnel means that MFTs will be required to disclose certain behaviors to work supervisors which is not appropriate for non-military clients (AAMFT, 2020). However, similar to non-military clients, MFTs should engage military members in the process of disclosing PHI in an effort to preserve the therapeutic relationship. If MFTs believe their professional code of ethics conflict with military regulations, it is recommended that they are purposeful about developing a process for ethical decision making (i.e., define the problem, review statutes, professional consultation, consider alternative actions, document the process, and monitor outcomes; Johnson, Grasso, & Maslowski, 2010) and seek support and consultation when appropriate.

Ethics in record keeping with SMVF

MFTs’ documentation practices differ when working with SMVF versus civilians, and between SM (i.e., regulated by the DoD) and V (i.e., regulated by VA; Department of VA, 2017; National Archives Federal Records Management; NAFRM, 2019). For example, time requirements for record storage are two years from the date of service in the DoD (see National Archives and Records Administration Disposition Authority Number DAA 0428-2012-0004-0005) versus the standard seven years for civilians (Sturm, 2012), and in some cases much longer for the VA (e.g., five years onsite at Vet Centers and 45 years offsite; Department of VA, 2021).

Confidentiality and informed consent via record keeping

Compliance with relevant government policies, military regulations, and AAMFT Code of Ethics (2015) can be particularly challenging when working with military couples and families. For example, on a military installation, couples therapy will be documented under the “sponsor’s” (i.e., active duty personnel) file. If the “dependent” (i.e., non-personnel) member of the couple wants access to session documentation, they may request it under the Privacy Act (DoD, 1974), however they will only receive portions of the record pertaining to themselves, the “requestor,” while anything pertaining to the “sponsor” is redacted.

Maintaining confidentiality is an essential component for all therapeutic relationships and although limits exist in any setting, there are additional limits that exist for military clients or in military settings compared to non-military populations.

Conversations with service members about ethics and documentation are best interposed in three particular therapy circumstances: (1 start of treatment, (2 concern pertaining to safety of self, others, or risk to mission readiness, and (3 sessions including a service member’s partner or family. Obtaining a written verification that the service member understands fully the limits to confidentiality, how documentation is maintained, and how content from the session may be released is imperative. For example, discussion of record keeping on topics associated with safety and mission readiness is of utmost importance, and documentation pertaining to this specific topic varies by branch of service (e.g., DoN, 2018). In these instances, details from the session and/or documentation may warrant a Command Need to Know (CNK; DoD, 2011).

MFTs are equipped to work with SMVF because military personnel not only exist within their family systems, but the military as an entity is composed of complex larger systems and hierarchies; MFTs are able to use their systemic and relational lens to conceptualize how each of these systems may impact SMFV wellbeing.

Ethics for technology-assisted therapy services with SMVF

Teletherapy services provide strengths when working with SMVF, including easier access, particularly when the service member or veteran is not located in the same state or country as their family (e.g., due to deployment or permanent change of station [PCS]). However, MFTs must provide informed consent that meets the same standards as in-person care (AAMFT, 2015), including on the topics of safety and mission readiness, made available in writing.

MFTs need to ensure they are following protocol for written communication via email or in the electronic health records (AAMFT, 2015), as military systems of communication adhere to standard formats that all personnel (active duty and civilian, physician and behavioral health clinicians) must follow. MFTs who document clinical care for SMVF into an EHR that is housed on government networks will also provide informed consent so that clients understand that no system is impenetrable, and document accordingly (e.g., limited to the course of treatment, substantiate clinical decisions, service planning, safety assessment, and progress).

Ethics for SMVF research

Given the connection between awareness of the evidence-based practices indicated for a given population served within the therapy context and strong ethical practice, MFTs must be good consumers of the research and evaluation (AAMFT, 2020; see Competency 1.4a). Therapist-researchers should pay particular attention to the power dynamics in researcher-participant relationships (AAMFT, 2015), ensuring that clients realize their treatment will not be altered or diminished should they not participate in on-site research programs. Therapist-researchers must also make-known the institution and sponsor of the research, while enacting additional steps to protect confidentiality when sponsored by the former.

Data confidentiality
The DoD and Department of Veterans Affairs aim to protect human subjects via IRB-approved protocols, informed consent processes, and compliance in data collection, management, and dissemination. Family therapist-researchers conducting research and evaluation sponsored or funded by the DoD or Department of Veterans Affairs should prepare to receive clearance from at least two IRB boards if engaging in research on a military or Veteran installation. It is particularly important to attend to topics that may be sensitive in nature to the well-being of the SMVF (e.g., military sexual trauma, other service-related trauma, suicidal ideations, infidelity, substance abuse/dependence, mental health issues) and to the privacy and autonomy of military partners (i.e., “dependents”).

Ethical interpretation and dissemination of findings
Family therapist-researchers can maximize ethical behaviors by implementing a research protocol that has been vetted by experts in the field, individuals who represent the population, and the institutional review board for all institutions involved in the program of study. Furthermore, dissemination of findings is one of the most essential steps in ensuring that the participants’ time in the study was not all for not.

Conclusion

There is no shortage of need for SMVFs who deserve quality and ethical care from MFTs. This article is one way of conveying the importance of ethics, laws, and military regulations for MFTs who are interested in making a difference by serving those who serve or have served our country. Although there are added ethical and legal dilemmas when working with military populations, as systemic thinkers, MFTs must not shy away from advocating for SMVFs in making changes in the Military Health System when appropriate (AAMFT, 2020; see Competency 2.3a).

The topic of this article will be covered in a chapter by the authors in the upcoming AAMFT textbook on ethics.