What’s the difference between a trained therapist and a compassionate friend? Look at outcomes and you are likely to be disappointed. For example, meta-analyses of studies comparing professionals to paraprofessionals (or students) either find that the latter group achieve significantly better results or, at worst, the same!
A clearer difference can be found in area of ethics. Unlike one’s BFF, a therapist is bound by their commitment to a code of professional practice. Keeping confidences and doing no harm are two prime examples. Most clinicians spend a semester or two studying ethics during their training. Continuing education on the subject is mandated by most state licensing boards in order for therapists renew their license to practice.
Unfortunately, much of current ethics training is focused on staying up-to-date with laws governing the profession or minimizing the risk of malpractice suits. Even the occasional focus on ethical “dilemmas” misses the point, narrowing the focus to the unusual and acting as though once resolved, we can go back to doing what we do.
As my colleague and friend, Dr. Julie Tilsen, observed, “We have detached ethics from the whole of practice, made it an ‘add-on.’ But, whether we realize or not, everything we do—and don’t do—is a matter of ethics. There is always an ethical standard in place, and that ethic typically reflects taken-for-granted values and understandings.”
Julie, who also serves as the Director of Ethics and Practice for the International Center for Clinical Excellence, concludes, “Any approach to practice is incomplete if it fails to articulate a stance on the ethics of the work—and by this I’m referring to the effects of what we do, in every moment of every encounter, with every person—whether or not a “dilemma” presents itself.”
As readers of this blog know, becoming aware of the effects of our work is what Feedback-Informed Treatment (FIT) is all about. That’s why Julie and I will be co-teaching the first ICCE small group intensive on Ethics this summer. In it, we’ll answer the question, “How do we know when clinical practice is responsible and ethical?” holding the assumption that ethical practice requires that our work is engaging and effective—from our clients’ point of view. The course will venture far beyond the traditional focus on legal issues and policy matters, helping participants learn an ethical stance that is both consistent with and informed by FIT.
The workshop is appropriate for case managers, social workers, professional counselors, alcohol and drug treatment professionals, psychologists, psychiatrists, clinical supervisors and agency managers. It is open to all practitioners regardless of discipline or theoretical orientation but of special interest to FIT practitioners who are interested in highlighting their response to client feedback as central to ethical practice.
The course is limited to 35 participants so register today. If you need Ethics CE’s, this is the course to attend!
Until next time,
Scott
Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
Ethics, understood broadly as this post defines it, is the core of our work. This includes our duty to become and remain excellent in what we offer and in how we offer it. Many of our clients/patients’ problems arise from or are made more difficult by past lapses (or worse) in relationships at various times in their lives, in other words, lapses in ethics. So it is both logical and natural that their recovery and growth require ethical care.
Thanks for these thoughts Joseph. Ethics and excellence go hand in hand.
Hello Scott, you highlight a vital core aspect of the therapist/client relationship here. Do you offer your workshop online for International folk? I still have memories of an excellent keynote address at BACP conference in Edinburgh a few years ago.
Hi Elizabeth…I remember that conference! I was in the UK in January doing 2 days on feedback informed supervision. Had a wonderful stay and met some really fantastic practitioners. We are working on several online courses. The Ethics course is not in production right now. Perhaps in the future. In the meantime, almost half of participants at our Chicago events are coming from overseas. You can maximize your time on the ground by attending one of the other two events being offered the same week: https://www.eventbrite.ie/e/fit-implementation-intensive-training-2015-tickets-13008971183 and https://www.eventbrite.ie/e/fit-professional-development-intensive-tickets-14207409745
I would love to add my voice to the request for some sort of online version of this, particularly an on demand one – down here in Australia it is expensive and time consuming to get anywhere!! Plus a lot of the great scheduled online seminars/workshops are generally in the middle of the night for us. I’m dedicated to providing an excellent/ethical service for my clients but getting up at 2am is just a step too far…! Even for your very engaging workshops!!
I totally agree with the need for strong ethics in therapy. I know people who are in jail, putting up websites stating that they are therapists. The lack of regulation and ethics leaves the public vulnerable to anyone who calls themselves a consultant, life coach, therapist, or other label that they dream up.
Dear Scott!
Thank you so much for continuously updating us on exciting and deliciously thought provoking bits of information! We are not in the business of solutions. We are in the business of ideas. And there is no way of creating a recipe for ideas, you just gotta get right in there with them and be curious about every twist and turn. And at the very peak of the best conversation we`ve had in years with a client we may find ourself hitting pause and bursting out “this makes absolutely NO SENSE AT ALL”. And we`ll laugh, they will get back to their lives and never need advice again. But hey, now Im just rambling.
Looking forward to seeing you again in Stange =)
All the best,
Bjørnar
Thanks Bjørnar! See you in June.
Scott, PLEASE consider offering this course online and with a not to the professional boundaries needed in online communities. This is an ongoing source of concern for many of us who moderate and facilitate online communities of mental health professionals. The rapid decline of professional behavior online is abysmal and we are in need of more thoughtful and more effective ways of curbing these “slips” and intentional choices to disregard what has historically been deemed “professional standards of behavior.”
Hello Scott. I enjoyed reading your take on ethics. I appreciate Heinz von Foerster’s “ethical imperative” to always increase options, and also Humberto Maturana’s emphasis on his ethical concern “to learn to live together”.
I’ve wrttine some thought about this, and will add them here, if the site will accommodate them.
Thanks as always,
Rob.
Ethics – an Evolution
Ethics will be a central concern for any human endeavour, and perhaps particularly those dealing with people and their concerns, their problems, their lives. But when we look at ethics we find a number of different approaches and like in many distinctions, ethics, and ethical concerns are not isolated phenomena. They change in a flow that is timely and coherent with the general social drift.
Minimal standards to belong to a club.
In the Oxford Dictionary the first definition of ethics is concerned with the rules of belonging to a club. Here the concern is about is what are the minimal standards, the minimal requirements to belong to a club. Ethics committees concern themselves with someone doing something unethical, so in the maintenance of minimal standards they are not concerned so much about ethics as the lack of it. If someone does not abide by the rules they get thrown out of the club. If someone doesn’t meet the minimal standards they are expelled from that community.
This basic fundamental notion within this definition of ethics is concerned with belonging. If you want to be a member of the APS there are certain things that you have to do. If a Doctor does something they shouldn’t do, they can expect an ethical inquiry. I had a letter sent to me by the Medical Board ten years ago when someone wrote an article about what I was doing in the newspaper because the Board was very sensitive about advertising at that stage and they wanted to know if I approached the journalist or if they approached me. If I had approached them that would of been advertising and I could of been fined or rebuked – it would of been unethical.
Towards excellence.
Another definition in the Oxford Dictionary is not about minimal standards but is about human duty in its widest extent. This invites an ethical approach to working in a clinical circumstances to attend to what can we do to contribute maximally to a client, what can we do that is in their best interest. This shifts the focus from minimal standards to a concern about excellence, and it brings a very different mood. It’s not about doing the least to stay safe, but rather how to be most useful.
Increasing options.
Heinz von Foerster stated what he called the ethical imperative, he was talking not only about therapy but life in general as being to increase options. We have often said in our work that we want to try to increase the options for our clients and it makes sense because problems have fewer options, solutions are characterised by a range options, so it makes sense clinically to increase options but von Foester is saying that this is an ethical issue. Ethically we have a responsibility, he says an imperative to increase options for our clients and also in education for students and in our family for our family members.
Learning to live together.
Humberto Maturana claims as a biologist that love is the fundamental human social emotion and to have a biologist that thinks this way is interesting. By love he doesn’t mean sentimentality or been in love. He takes love as an extension of respect, and he says that love is an emotion in which we grant legitimacy to another person to live in the world beside us. This extends to another creature – a spider or a tree, so love for Maturana is a matter of the legitimacy of another so we can live with them.
He says that learning to live together is the prime human ethic, and I think this has become the most pressing contemporary issue that our ethics needs to address. The world that we are in, the world of the Internet, cyberspace, international travel is changing at an escalating rate. One Thursday I was in Melbourne and the next Thursday I was in Melbourne again having been in a different country where people had come from Venezuela, from Chile, from Mexico as well as Philadelphia and all over the US as well as from Australia. These people from different countries, with different languages, different backgrounds, different cultures, different histories and we were working together, and this kind of experience is increasingly common. It was superb.
Whenever we don’t learn to work together, to live peacefully together, we have conflict. We saw an example of that in the recent waterfront dispute. Whenever people dig in about standards there’s war. When a group of people who hold a fundamentalist belief that their standards are the right standards, “my way is the right way and your way is the wrong way”, and the other side said “no my way is the right way and your way is the wrong way” – there’s conflict and enmity.
I heard on radio this morning where there are some Second World War Veterans in Britain that are furious that the Queen is wanting to award the Japanese Emperor The Order of The Garter because they are saying the Japanese Emperor caused of a lot of suffering in the Second World War so how could he be given the Order of The Garter? He doesn’t belong to that club, he should be excluded. But if we see that we are wanting to live in a world which is shrinking we have to live with people who were enemies. We have to otherwise we will keep fighting.
The issue of living together is not just a matter of being nice to each other, but it’s an ethical issue. In Chile terrible things happened with torture, imprisonment, but I understand they are saying “that’s past”. They are actually saying that they have to learn to put all that enmity in the past so that the previous torturers and torturees are now talking to each other. They are not wanting reparations. They are not wanting anything. They are saying they have got to get on with the task of working together.
Our world is a shrinking, mobile, multicultural community with increasing complexity. We can’t avoid it. We can longer say that my way is right and your way is wrong. If we look at the controversy in Europe about the Euro, where some countries are saying this is going to be to their detriment. If they give up their currency it may hurt them financially, but Europe is moving towards a new kind of community which demands living together.
In our clinical work, the mood and the concerns that we are attending to invite us to give less attention to what is the right way to do things, what is the right way for client to respond, and more attention to what can do or that they can do to solve their problems. We want to increase there options but underpinning all of that is the concern, how can we work effectively with this client.
I think that living together is an issue that we need to put in an ethical domain – an ethical concern with practical repercussions. When I look and see this ethical shift from rules and towards living together I see it paralleling a social change. Previous eras were concerned with the minimal rules required to remain in a club, with worries about control, maintaining power in a hierarchy, giving authority to someone who could say your in or your out. Living together these days we don’t have the choice of “your in”, “your out”. We’re all in this soup together.
I haven’t previously spoken about ethics as a focus because it seemed to me to be better to show it rather than to speak about it. When we’re working together where actually in this, we’re doing this. One of my joys of this work is to see how a group of individuals come together at the beginning of a program and by the end of it we’re living together, sharing, learning things we didn’t know before.
For me this is ethics at its best.
“Every human act takes place in language. Every act in language brings forth a world created with others in the act of coexistence which gives rise to what is human. Thus every human act has an ethical meaning because it is an act of constitution of the human world. The linkage of human to human is, in the final analysis, the ground-work of all ethics as a reflection on the legitimacy of the presence of others.” Humberto Maturana in “Tree of Knowledge” p 247.
Scott, as usual, is correct. Most people we see are hurting emotionally and that requires an emotionally healing solution. That really can only start by building a relationship with that person. The need to feel cared about, listened to and not judged are important first steps in creating a relationship in which the person will be able to look at their thinking and make the necessary changes to create change in feeling and behaviour.
A huge ethical violation that I see routinely is when individual therapists treat a client who is married. Without engaging the spouse as well in a treatment for which the therapist has a systems perspective, the odds are significant that the patient will perhaps feel better from therapy but at the cost of the marriage.
Worse even than that is when there are two therapists, a his and a hers therapist. Then the odds zoom up that the marriage will end in divorce because of iatrogenic (doctor-induced) damage.
A divorce is in systems perspective a fatal outcome, just as suicide would be from an individual therapy perspective.
Hi Dr. Heiter:
Thanks for posting to the blog. Anything in particular from the post you were responding to?
Scott
I have continually questioned the differential impact of ‘certified professionals’ and those who strive to act therapeutically e.g. nurses, paramedics, occupational therapists- all of whom are bound by the ethics of a regulatory body, which includes the values you have articulated. I have witnessed and learned from all of these professionals. Furthermore, I have established groups with parents, who have then gone on to be volunteers and whilst they do not have a regulatory body, have shown the highest code of values and ethics.
I agree with the importance of ethics. I also agree with the need to critically reflect on different perspectives, personal, social and cultural values. and the boundary between self and another. After many years as a lecturer and practitioner/researcher, in child, adolescent and family mental health, I still question the role of ‘therapists’ compared to those who act therapeutically. As you indicate ‘compassion’ is a human quality – which some individuals (therapists and non therapists alike) can either abound in or be extremely lacking in. I cannot be convinced that ethics and values and the desire to do no harm is an exclusive preserve of ‘ therapists’. Therapy seems to have become an extremely lucrative business- both in terms of the training required and then fees for providing therapy. It concerns me that these conditions can lead to a hegemony – just as the medical model became a dominant ideology- with both therapeutic and iatrogenic consequences.
For all ‘helping professionals, an ethical code of practice is essential. However, both compasison and values are traits of many individuals. The duty to reflect on these and be prepared to learn and change enables therapeutic practice , but it seems to me that this includes a broad church.
After more than 30 years, I remain optimistic about humanity because of the capacity that certain individuals can offer at different stages and in different situations. I’ve witnessed the trauma that can lead to a failure to offer compassion and the family and systemic damage that can arise from this. I’ve also had the privilege to see the healing that can occur from a diverse range of sources , which can help the most vulnerable on the path to recovery.
Many years ago, I was trained in ‘Life space’ therapy and have experienced how critical moments can be used to develop iterative change. I’ve seen nurses, nursery nurses and auxiliaries use the techniques to astonishing effect and later have seen vulnerable parents build on their strengths , using these techniques. However, they needed support and help to improve their relationships to the whole set of systems with whom they interacted, in order to have the therapeutic space to be able to engage.
I attended workshops with you in Newcastle (UK) Scott ,and have huge respect for how you have shared and democratised therapeutic strategies.
I would really welcome your thoughts (and others) on the current power ascribed to certified ‘therapists’ and the contrast to those , who provide 24 hour therapeutic care on low or no wages.
Therapy is one human being helping another in a time of need. That’s exactly what a compassionate friend does. A human being in need doesn’t need something diagnosing them, or fearing they might get too upset.
If we attend the workshop do we have evidence it will improve our client outcomes?
Or, can I just enjoy myself?
Anyway, kidding aside, wasn’t it Jay Haley who said “I never let ethics get in the way of good treatment.” ?
And regarding the ‘minimal standards to belong to a club cite by Bob M. above, my experience has been that Groucho was right…I wouldn’t want to join a club that would have me for a member!
I do think compassion is far more profound than is ethics, as it requires breaking the rules. Some friends are better than some counselors because they have less to lose it they screw up.
Ignore averages.
-SL