To throw some light on ethical dilemmas and contextual decision-making, a few relevant couple/family therapy case scenarios are illustrated which concern therapist responsibility, confidentiality and informed consent.
Very few mental health institutes in India have full-fledged couple and family therapy units and centres that provide focused training and experience in this area leading to concerns about the adequacy of training and therapist competence.
A therapist trained in individual psychotherapy needs to shift from the individual focus to the systems focus while the definition of client has to shift from the individual to the couple or family.
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This shift necessitates addressing questions of‘who’the client is and where does the therapist’s responsibility lie? Typically, in a mental health setting, an individual with a psychiatric disorder is referred for couple/family therapy when the treating team observes that interpersonal relationships and conflicts are significantly affecting the treatment and recovery. At times, therapy is sought when one member feels the need for help and initiates therapy for the family. In either case, the therapist needs to guard against forging an alliance with one family member at the expense of the others. A case example of a couple referred for therapy would help to illustrate this dilemma (see Case6.1).
Case 6.1
Mr. AH, 35 years old, had sought treatment for anxiety and depression.
A marital therapy referral was made in the context of his preoccupation that, like hisfirst wife, his present spouse too would divorce him over the frequent conflicts they had. Prior to bringing his spouse into the therapy room, the evidently anxious client requested that the therapist avoid questioning her about their marital conflicts. He described her as very temperamental and was sure that this would result in anotherfight and the dissolution of their mar- riage. The therapist listened to what Mr. AH had to say, encouraged him to come in for a joint session with his wife and assured him that his concerns would be addressed during the sessions.
In the scenario described in Case 6.1, the spouse who initiated therapy was trying to forge an alliance with the therapist, by approaching the therapist separately and trying to“warn her”of what was inadmissible content in therapy. A beginning therapist, uncertain about his/her competence could easily be swayed by this and skirt the problem area for fear of adversely impacting the alliance with the client.
However, this does not mean that the concerns of the spouse, who approached the therapistfirst, should be disregarded. Typically, couples who seek marital therapy have experienced a lot of distress and carry their own anxieties about the relationship. They also have their own notions about the therapeutic process, often expecting quick changes, provided the therapist‘explains’to the other spouse, or
“makes the other spouse understand”. Therapist neutrality is an ethical imperative in such situations.
The question as to which member the therapist is responsible to is a constant challenge throughout therapy. A couple/family therapist oftenfinds that one of the members tries to tilt theflow of therapy in his/her favour, by asking questions such as,“Am I not right in expecting this much?”Such questions reflect their implicit assumptions and hope that the therapist shares a similar world view. It is important to communicate to the members that the focus of therapy and the primary target of improvement is the relationship, and not individual demands or expectations of the family members. The fulfilment of individual needs/expectations is in the service of
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improving the marital/family relationship. The couple/family therapist is a rela- tionship advocate (Margolin1982), and not a champion for individual needs.
Another common ethical quandary for couple/family therapists relates to whe- ther therapy should be continued when a key family member clearly shows dissent over the continuation of therapy. In situations such as these, the therapist has to decide where his or her responsibility now lies. Does the therapist have to continue therapy with one spouse or insist on the presence of the other spouse also? These issues are discussed in Case6.2.
Case 6.2
Mrs. JZ was a 39-year-old, high school educated woman from a traditional background. Her 19-year-old son, the eldest of three children, was brought to the hospital for treatment of behaviour problems, exhibited after contracting encephalitis a year earlier. In the course of treatment, the treating team sus- pected problems in the family and made a family therapy referral. The hus- band refused to come for therapy, but upon the insistence of the treating team, he reluctantly attended one session of assessment. Throughout the session, he refused to speak or cooperate. The therapist noticed that the wife was reluctant to speak in the husband’s presence and wondered if her hesitation was due to her cultural background and upbringing. Sensing this, the therapist had individual sessions as well as sessions with her other children to help them express their concerns as a family. Revelations in the sessions indicated that the husband did not provide adequatefinancial support, had extramarital involvements and Mrs. JZ could be at risk for sexually transmitted diseases.
There were also some instances of the husband’s sexually inappropriate behaviour with their girl child.
Case 6.2brings out several ethical issues for the therapist to consider. When one family member has clearly indicated displeasure and dissent over continuing therapy, is it ethical to repeatedly request him to reconsider? Since it was clear that he would not participate in the therapy, then does the therapist assume the responsibility for the welfare of other family members? Since it was evident that there were several grave issues that had to be addressed, the family therapy unit decided to go ahead with individual therapy to address couple-related problems and empower the wife to deal with the problems on her own. Family therapy with the children and mother focused on strengthening their relationship, redefining their roles and the husband’s inappropriate behaviour towards the daughter. The underlying objective of therapy was to empower the mother– children subsystem.
Individual marital therapy (IMT) has received mixed reviews from family and couple therapists (Gurman and Kniskern 1978; Wells and Giannetti 1986).
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Recently, Shah and Satyanarayana (2011) demonstrated that systemic individual marital therapy (SIMT) may be suitable in contexts where only one partner is available.
Case 6.3
Mr. K was referred for family assessment and intervention for marital con- flict. Assessment indicated that Mr. K had remarried with consent from the first wife, with the aim of having a progeny. The couple agreed that the child would be looked after by both the wives. The second wife had been diag- nosed with a mental illness prior to the marriage and it was with the consent of “all members” that the marriage took place. Soon after the husband’s second marriage, thefirst wife expressed strong disapproval of her husband’s sexual involvement with the second wife.
Thefirst challenge in working with Case6.3was in the definition of the‘cou- ple’. The American Psychological Association (2010) ethics code states that,
“When psychologists agree to provide services to several persons who have a relationship (such as spouses, significant others, or parents and children), they take reasonable steps to clarify at the outset (1) which of the individuals are clients/patients and (2) the relationship the psychologist will have with each per- son”. In this complex situation, thefirst wife and the husband had come together for therapy and there was a strong bond between them. It was important to understand the concerns of the first wife, given the entry of the second wife. It was acknowledged that the decision to remarry was solely for the purpose of procre- ation. It was equally important to help the couple comprehend the ramifications of their decision of this remarriage. The needs and rights of the second wife also had to be considered here. It was an ethical challenge for the therapist to have the second wife present in the conjoint sessions, especially because the latter was not able to participate fully owing to her psychiatric condition.
In this context, the therapist’s responsibility was not only towards the couple who sought therapy but also towards the second wife who was a significant member in this relationship. She was vulnerable because of her mental illness and appro- priate treatment was initiated for her. The therapist took an ethical decision to become the voice of the weaker member of the family, in order to equalize the power differences. Through the sessions, the first wife was helped to empathize with the position of the second wife. It was important to help the husband develop commitment towards taking care of the second wife, and provide for herfinancially in the future also.
Mental health professionals working in the rural or semi-rural settings in the Indian may encounter such marital alliances and the attendant disequilibrium. The ethical challenges cannot easily be answered by professional codes of ethics and therapists need to balance the needs of all family members in the family unit.
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