Theory and Practice of Couples and Family Counseling. James Robert Bitter
of confidentiality. The ability to speak openly and with emotional honesty is supported by a trusting relationship that ensures a respect for privacy. This right to privacy in psychotherapy is recognized in all 50 states and by the federal government in HIPAA standards and Supreme Court decisions. But what degree of privacy can a family counselor or therapist truly uphold? Maintaining confidentiality can be an enormous responsibility for a practitioner working with just one person. When a counselor is working with multiple people in one room, the challenges to maintaining confidentiality increase exponentially. It is in the subtexts of confidentiality and family practice that ethical issues become extremely difficult, especially those of conceptualizing the client served, providing informed consent, and handling relational matters in an individual context.
Conceptualizing the Client
If your practice consists solely of individual clients, the definition of client is clear: It is the person sitting across from you in a counseling or therapy session. The more systemically oriented counselors, however, embrace the family as a whole as the client—with many, like Whitaker, insisting that all members of the family be present before therapy begins. The first practitioners of Bowen family therapy, structural family therapy, and the various strategic therapies emphasized family dynamics in which individuals were little more than parts of an interaction or actors in a systemic drama. In the past decade, there has been a concerted effort to reinstate the individual into family systems theories, with postmodern models tending to conceptualize families and clients as those individuals who are in conversation about any given problem. In these later models, those in conversation about a problem determine who needs to be involved in family sessions.3 What happens to confidentiality in these shifting conceptualizations of family is at the heart of one whole set of ethical concerns. Even within systemic orientations, there are those who choose to approach families not as one client but as multiple clients, a perspective that is assumed in most state laws.
Remley and Herlihy (2020) indicated that laws hold individuals, not the collection of people called a family, accountable for actions that may violate the freedom of others. This should not be surprising in a society that values individualism over collectivism. But it also has a similar impact on the more practical standards of practice involved in professional codes.
A clear example relates to the use of case notes in family practice. If the client is the family, there is one client. It is logical then that the family practitioner would write one set of case notes for the one client. But this is not necessarily so: IAMFC (2017), for example, suggests that “in situations involving multiple clients, couple and family counselors provide only the records directly related to a particular individual, protecting confidential information related to any other client” (p. 4). In both the law and this professional code, one family of five equals five individuals. To meet HIPAA standards, each individual has to have their own records, notes, consent, and other individual data. Having multiple clients in counseling or therapy thus has a direct impact on informed consent.
Informed Consent
AAMFT (2015) notes that confidentiality and informed consent are interrelated. Specific applications of confidentiality and its limitations need to be discussed early and often in treatment. Furthermore, the family practitioner and the clients need to agree on not only those limitations mandated by law but also those that the therapist may set for effective treatment.
ACA (2014) echoes this position, calling on counselors to
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. (Standard B.4.b.)
Even if you are successful in negotiating a contract that identifies the client as the whole family, issues of confidentiality persist. The limits on confidentiality with a whole family are the same as those that exist in group counseling or therapy: The practitioner cannot guarantee that members of the family will not disclose essentially private information to others outside of the session. This potential dynamic also weakens, if not removes, the legal benefit of privileged communication (Remley & Herlihy, 2020). In short, communication between a client and you as the counselor is valued legally, in that a court of law may find that the benefits of protecting privacy outweigh the public’s need to know the content of therapeutic conversations. However, once another person is present in the room, as in couples and family work, legal protection of privileged communication no longer exists. If they viewed their individual rights and protections from a legal perspective, clients might find that agreeing to family counseling might not be in their individual best interest.
Handling Relational Matters in an Individual Context
Given the propensity of both the law and professional codes to designate as the client each individual, a host of relational concerns must be clarified and addressed before counseling or therapy can begin. Among these issues are “extramarital affairs, commitment to the relationship, sexual activities/preferences/orientations, criminal activities, substance use, and mental states suggesting the risk of violence and dangerousness to self or others” (Woody & Woody, 2001, p. 31). Similar issues for children and adolescents must be considered, as must “behaviors that pose potential risk to the child’s health and welfare, e.g., truancy, substance use, gang affiliations, etc.” (p. 31).
If both your professional approach and your personal values are grounded in the idea that joining with family secrets does not promote the welfare of the family, what do you do with this predicament? IAMFC (2017) states, “Couple and family counselors do not participate in keeping secrets for or from clients” (p. 1).
All of the family practice codes support individual confidentiality, but only if it does not contribute to maintaining unhealthy family dynamics. There is not a great deal of direction in these guidelines for handling ethical dilemmas related to the common issues we have discussed. In holding to individual confidentiality within the context of family counseling or therapy, obvious concerns surface with the principle of beneficence and your obligation to promote client welfare.
Gender and Cultural Issues
Feminists long have noted that the normal family, across cultures, has not always been so good for women. A gender perspective in ethics reminds us that patriarchy has real effects on all genders and has to be taken into account when people are engaged in ethical decision-making. Feminists also remind us that patriarchy is just one form of oppression and that discrimination on the basis of race, gender, disability, religion, age, sexual orientation, cultural background, national origin, marital status, and political affiliation still has to be factored deliberately into ethical stances.
Because discrimination, oppression, and marginalization have been such a big part of the social contexts in which we live, a consideration of gender and cultural perspectives in ethical decision-making is essential. In spite of what may be codified in law, there are indeed multiple perspectives on the family that emanate from various cultures. Western cultures tend to portray the nuclear family as normal, limiting it to parents and their children. If the law and Western culture want to recognize aunts, uncles, cousins, grandparents, and ancestors as part of a family system, these family members are called extended family. Such languaging, just as much as physical separation, distances individuals from their natural support systems. In cultures in Africa, Asia, the Middle East, and South America, as well as in some Native American societies, many different members—and sometimes multiple wives—and multiple generations are included in the conceptualization of family. Such a conceptualization of family can often bridge the physical distance between individuals and create a very different ethical stance in the world.
Even in Western cultures today, the forms that constitute family vary widely from the nuclear model that has been enshrined as normal. Functional families are led by single mothers, single fathers, grandparents, single gay fathers, single lesbian mothers, gay coparents, lesbian coparents, and cohabitating