Theory and Practice of Couples and Family Counseling. James Robert Bitter
the principle underlying the individual’s freedom of choice. There are many ways in which the principle of autonomy can play out in family practice. At the outset of family consultation, you will describe to your client your preferred approach or model as part of what is called informed consent. Families have the right to say “no” to the services you offer if those services do not fit them. The principle of autonomy also favors the individual over the family or the group. In many Asian and Hispanic cultures, however, what is best for the individual is never considered above what is best for the family. It is important to keep in mind that autonomy is a decidedly Western value. Even in Western cultures, the principle of autonomy forces relational practitioners to articulate who they see as their client: Is it each individual in the couple or family, or is it the relationship or system as a whole? Will the practitioner support the needs and development of individuals or of the couple or family or attempt to do both? And how will conflicts in these areas be resolved? The ACA Code of Ethics (ACA, 2014) states that in couples and family counseling
counselors clearly define who is considered “the client” and discuss expectations and limitations of confidentiality. Counselors seek agreement and document in writing such agreement among all involved parties regarding the confidentiality of information. In the absence of an agreement to the contrary, the couple or family is considered to be the client [emphasis added]. (Standard B.4.b.)
The default position is that the relational system is the client when counselors do not indicate otherwise.
Beneficence is the promotion of the client’s welfare and well-being. Family practitioners take steps to consciously and consistently work toward the betterment of the couples and families with whom they work. Sounds simple, does it not?
Let us imagine a family that has come to you for support and guidance. (We use this family throughout the rest of this chapter to consider other ethical questions and concerns.) The family has recently been charged with child neglect. The specific charge of neglect involves the family’s 14-year-old child, who is suffering from leukemia. The parents hold religious beliefs that do not allow medical intervention to be given for any illness, even cancer. The parents want to gain your support for their freedom to choose the health care interventions they deem appropriate within their religious system. Prayer is their preferred form of intervention.
Supporting their freedom sounds like the right thing to do, but there in front of you is their 14-year-old child, suffering—and most likely dying—from cancer. So what actions do you take that would be seen as promoting the client’s welfare? And who exactly is your client: the parents, the child, the family as a whole? The answer to this question will be central to every move you make.
If promoting the 14-year-old child’s welfare seems clear to you, then you are viewing the child’s problem from the perspective of what is possible using Western medical procedures, a perspective clearly outside of the religious values that are informing the parents’ actions. As it turns out, even the child espouses the same religious convictions. If you support the family’s perspective, are you prepared to watch this young person die when everything within your own value system tells you the child has a chance with what you might deem proper medical care?
Nonmaleficence is the classic credo of doctors: Do no harm. This directive seems so simple, but the meaning of “harm” can be individual, contextual, cultural, or even historical. What the family practitioner means by harm can be quite different from the family’s definition, and even within a family differences may exist as to what constitutes harm for each family member.
In the early days of family therapy, Jay Haley (1963) used paradoxical interventions when certain client symptoms were thought to be maintaining a family’s problems: Haley would sometimes prescribe and augment the symptom as opposed to working directly to relieve it. For example, a father might exhibit great anxiety and worry about his family’s welfare, checking on his kids at school three, four, or five times a day. Haley might tell the father that he is not worrying enough. What about all of the hours of the night when other family members are asleep? Haley might even instruct the father to set his alarm clock to wake him every hour, on the hour. Upon awakening, he is to get out of bed and wake each of his children and ask whether they are okay. The father is directed to carry out this task for five nights in a row.
We already have noted that the definition of “harm” can differ across different periods in history. During the 1960s and 1970s, paradoxical interventions might have caught the scorn of some, but they would have been allowed to continue. Such interventions certainly brought about sudden, beneficial changes at times, even though their use raised the issue of whether the end justified the means. Today standing up in your agency’s case meeting and describing this intervention might very well lead to charges of an ethical violation.
Fidelity refers to the responsibility to maintain trust in the therapeutic relationship. Family practitioners must remain faithful to the promises they make to clients, especially when maintaining clients’ right to privacy. What does this principle mean in relation to family secrets? Building and maintaining trust is the cornerstone of an effective therapeutic alliance with clients. The codes of ethics for all of the helping professions recognize the importance of keeping individual family members’ private conversations with their counselor or therapist confidential unless that individual has given consent to share the content of the conversation. This right to privacy also is codified in law through the current HIPAA regulations and requirements.
Let us say that the 16-year-old daughter of a family speaks to you one on one prior to a family session about her recent experimentation with marijuana and her fear of her parents’ potential response. You listen intently and affirm the confidentiality of the conversation. During the family session, the father and the mother both indicate that they are worried about their daughter. Her grades in school are getting worse (“She has always been a good student”); she is hanging out with a different set of friends, and she sneaks out to see them at night, but she will not introduce any of them to her parents; and she is dressing differently. The parents ask her, “Are you doing drugs?” The girl denies that she is. The parents look to you: “Do you think she is doing drugs?” How do you reconcile the principles of beneficence, nonmaleficence, and fidelity in this case? What effect would disclosing this family secret have on the 16-year-old daughter? How might she view the counseling process and you as a family counselor? If you think this dilemma is hard, what will you do when you know that one of the parents is having an extramarital affair that is directly harming other members of the family? With each additional ethical principle, the professional waters muddy even more.
Justice refers to fairness, including equitable service for all clients. In 2004–2005, Counselors for Social Justice, a division of ACA, developed a website that specifically targeted issues of equity, oppression, discrimination, and injustice (see https://www.counseling-csj.org). Such a development highlights how valued this principle is within the counseling profession:
Counselors for Social Justice works to promote social justice in our society through confronting oppressive systems of power and privilege that affect professional counselors and our clients and to assist in the positive change in our society through the professional development of counselors. (Counselors for Social Justice, 2020)
In the teaching of ethics, the principle of justice has been the most misunderstood and debated. For many, equality and fairness mean equal treatment or the same treatment. Relational counselors understand equality to mean that all people have an equal right to be valued and respected even when they are different from one another. Both philosophy (Aristotle, 350 B.C.E./1985) and systems theory (Bateson, 1979) have noted that differences cannot be ignored: Being just means treating similar people similarly and different people differently.
For example, is working with a family with an only child and an income of more than $100,000 the same as working with a family of eight whose income is less than $25,000? Is the difference in incomes different enough to warrant a different way of providing family counseling? Do you think poverty has real effects on family life? If you are in private practice, and you have set a rate for your services at $100 per hour, will you even see the poorer family? How will you bill them?