The Canadian Counselling and Psychotherapy Association outlined the base principles of offering psychological therapy as the following:
Beneficence - being proactive in promoting the client’s best interests
Fidelity - honouring commitments to clients and maintaining integrity in counselling relationship
Nonmaleficence - not willfully harming clients and refraining from actions that risk harm
Autonomy - respecting the rights of clients to self-determination
Justice - respecting the dignity and just treatment of all persons
Societal Interest - respecting the need to be responsible to society
- CCPA Code of Ethics (1999)1
These ideals of how a counsellor should behave can be applied to many ethical quandaries of therapy to reach a moral conclusion. For example, the principle of fidelity states the necessity for 'integrity in [the] counselling relationship' and from that one can see that a client-psychologist romance would be inappropriate. Similarly, the need for patient confidentiality is covered by both fidelity and justice as part of the relationship's integrity is trust, and it would not be respectful of a client's dignity to share their potentially embarrassing troubles. Perhaps most significant of a therapist's responsibilities is his or her duty to warn - the responsibility to notify the proper authorities should they believe their client poses a threat to others or themselves - which can be inferred easily from the principle of societal interest.
Other issues in therapy may arise from the personality of a client. It could be as simple as a personality clash between psychologist and patient, or something less straightforward such as an obsessive client becoming overly attached to their therapist, or irrationally upset/angry with them. Clients can also be unhelpful in other ways, such as missing sessions or prioritizing advice from external, unqualified sources. Therapists are not perfect either; some may push too hard, or have an approach to counselling that irritates some clients, or perhaps meet a client whose particular case speaks to some event in their past that makes it hard to remain objective. The balance between approachability and professionalism is a delicate one and while therapists should strive to form a working relationship with any client, there are cases when a referral is the best solution.
In situations where a client is conflicted about treatment, having received contrary advice from well-meaning family members, religious leaders, etc., it may be best to simply lay out the facts and respect their autonomy.
Due to its prevalence, faith can also prove to be a stumbling block in a client's treatment. In David B. Presley's article Three Approaches to Religious Issues in Counseling, he names avoidance, integration and eradication as means of dealing with a client's faith2. He concludes that avoidance may lead to incomplete treatment, integration is challenging and eradication may well be met with resistance. Interestingly, the APA allows both conversion to and from atheism as part of psychiatric treatment, though fully-informed consent is vital in both instances.
Finally, culture and gender must also be taken into account, in much the same way as described by our page on difficulty in assessment. What we perceive as normal, healthy behaviour varies from culture to culture, and the current psychological practices are largely dominated by American-European ideals. Therapists should strive for as complete an understanding of a client's background as possible in order to ascertain the roots of their issues, and glossing over foreign elements of that background could impede the process. To a lesser extent, gender roles within a single culture may make it necessary to treat the same condition very differently for a man and a woman. Depression is a good example of this - an article entitled Gender Differences in Depression by Piccinelli and Wilkinson notes that it more likely to find "females suffering from pre-existing anxiety disorders and males experiencing more externalising disorders, such as alcoholism, antisocial personality and drug misuse"3.
Fortunately, none of these problems are insurmountable to a therapist with persistence, patience and an open-mind.
1. McMahon, S., Schulz, W. & Sheppard, G., (1999 (revised 2007)). Code of Ethics - Canadian Counselling and Psychotherapy Association. 2nd ed. Ottawa, ON: Canadian Counselling and Psychotherapy Association.
2. Presley, D.B., (1992). Three Approaches to Religious Issues in Counseling. Journal of Psychology and Theology. 20, pp.39-45
3. Piccinelli, M. & Wilkinson, G., (2000). Gender differences in depression. The British Journal of Psychiatry. 117 (), pp.486-492
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