The Solid Ground of Integrated Ethical Practice

The five grounding principles

In our view, there is an expectation, a written and unwritten rule, a personal and professional imperative, that in order for couple and family therapists to practice from an ethical foundation, we stand on the solid ground of the following five principles: 1) the AAMFT Code of Ethics (AAMFT, 2015), State Laws and Regulations, 2) AAMFT Core Competencies (Nelson et al., 2007), 3) current CFT literature, 4) practicing as a socially just therapist, and 5) relational ethics. These five foundational principles collectively all include significant attention and attunement to implicit bias, discrimination, and intersectionality in our personal and professional lives. When we step off this solid ground to shaky ground, we put our client’s wellbeing in harm’s way. The ground you are standing on is not simply something you refer to when an ethical dilemma comes up in your practice, rather it is the essential ingredient of what you follow and integrate in all that you do as a therapist, in and out of sessions, in order to have an ethical and competent professional practice.

Let’s consider an upcoming appointment a therapist has with an unmarried couple, where the caller indicated they were coming to therapy because of a recent disclosure of infidelity. The caller reported the affair was discovered when the partner Jeff noticed a text with sexual content on his partner Eric’s phone. In preparation for seeing this couple, we believe the therapist needs to consider all five grounding guidelines and reflect on many questions. For instance, does the therapist have appropriate written policies concerning informed consent that clearly address secrets and the limits of confidentiality in couple’s therapy? Does the therapist have clear policies related to not providing individual therapy to one or both clients, in addition to couple’s therapy? If one client comes to the session and the other doesn’t, what are the policies to ensure fair and balanced couples therapy? Is the therapist prepared to have a collaborative, transparent conversation about these policies with the couple during the intake? Is the therapist familiar with the current CFT literature on treating infidelity? Is the therapist familiar with specific infidelity literature related to unmarried clients and clients who are in same-sex relationships?

The ground you are standing on is not simply something you refer to when an ethical dilemma comes up in your practice, rather it is the essential ingredient of what you follow and integrate in all that you do as a therapist…

What assumptions does the therapist have about monogamous relationships, or assuming monogamy of these clients? Has the therapist examined any relevant biases they may hold such as viewing an unmarried client relationship differently or as less serious? Has the therapist examined biases that may be related to client identities such as race, religion, sexual orientation, ethnicity, age, ability, gender, socio-economic status, etc.? Is the therapist aware of the many ways in which various marginalized identities are discriminated against by major institutions including housing, economic, judicial, educational, healthcare, etc.? How might this impact the couple and therapy? How might the therapist’s own identities and self of the therapist influence their work with the couple?

In our experience, in order to do no harm and to provide best practice therapy with the highest ethical standards, a therapist must consider the ground they are standing on with all client interactions from the first contact and intake to termination. This type of integration instills in us a habit of thinking through the five foundational essentials and using them as guideposts in our everyday practice as well as when ethical dilemmas arise.

Standing on the ground of Principles 1 and 2: The AAMFT Code of Ethics, state laws and regulations, and AAMFT Core Competencies

While our AAMFT Code of Ethics is clear that we may not discriminate, state laws and regulations may not be so clear. For instance, in some states, there are new laws that are allowing therapists to reject a client based on the provider’s beliefs and values. This means that in our case example of Eric and John, a therapist could refuse to accept them as clients and not provide treatment based on one of their identities, such as their sexual orientation. This would be a clear violation of the AAMFT Code of Ethics 1.1 and many of the AAMFT Core Competencies that give the directive to provide therapy to persons without discrimination. Part of advocacy work for the profession may include therapists working to challenge laws that allow discrimination. Knowing what your governing laws are in your geographic area (state or country) is imperative. Laws and regulations change, and it is ultimately the therapist’s responsibility to review them on a regular basis to ensure you are standing on current regulations while considering the implications of the AAMFT Code of Ethics and Core Competencies.

Standing on the ground of Principles 3 and 4: Literature and social justice

As therapists, it is imperative that we are familiar with the current CFT literature related to best practice of our clients’ presenting problems and identities, including intersectionality. Therefore, with our case example of Eric and John, it isn’t enough to be familiar with the infidelity literature or even the literature on infidelity in same-sex relationships. The intersections that impact this couple may be complex and we could do harm by ignoring different identities. If Eric is a Christian, black man from the Caribbean and John is a white male who has been recently diagnosed with a chronic illness that is impacting his ability to work and his sexual performance, we will want to be informed by the literature on these various aspects of the situation. We owe it to our clients to never stop learning and growing as professionals. Providing therapy in a way that is attuned to diversity, equity, and inclusion requiring knowledge, self-awareness, and skills is essential. The presenting client problem cannot be considered in a vacuum but rather with social identities, so we are standing on ground that considers the treatment of oppressed social groups based on deep understanding.

Standing on the ground of Principle 4: Relational ethics

With the advances in neurosciences over that past decade, we are more aware of how our “automatic responses” are developed over a lifetime of influence and experiences that trigger our reaction to relational stimulus. This has influenced how we consider the relational ethics that involve the way we reflect on, think about, and decide on our obligations and responsibilities to self and the other; while considering our personal and community values, morals, and preferences. Relational ethics also involve our ability to be empathetic; to put aside our view and begin to see the world through another person’s view. When we are being relationally ethical, our moral identity is deepened, our moral sensitivity is sharpened, and our empathic alertness and responsiveness are enhanced.

We believe a more collaborative, transparent, and reflective process versus an automatic response in ethical decision making is needed. Since the relational self is continually under construction in all our relationships, we understand that our interactions with others are participating in our own constructing and in the constructing of others. Since not all people have equal access to power in society and in their relationships, and since certain people experience a greater level of privilege in their relationships, it is important to acknowledge that both partners may not have equal power in shaping the stories of their partners’ lives, such as in the couple case of Eric and John. When we begin to consider relational ethics in all our relationships, we are held to a higher standard of authenticity. It is this higher standard of authentic relationships that will move us toward social justice in our personal and professional lives.

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