Ethical Issues in Group Counseling

Ethical Issues in Group Counseling

Any counseling scenario introduces a variety of ethical issues because counseling involves human beings who are frequently at their most vulnerable, seeking help and advice from human beings who are fallible. What complicates the ethical rules and norms that surrounding counseling scenarios is that the relationship between the counselor and the client is central to the efficacy of the counseling. Rules that stifle the development of an organic, helpful relationship can stifle the goal of counseling. However, there are clearly rules that must be followed to ensure that the client is protected from counselors who may act in an unethical manner. The very fact that counselors and clients enter into unique, personal relationships as part of the therapeutic process can make it difficult for even the most professional of counselors to determine, in the moment, whether a particular behavior is ethical or unethical. The result is that there are a number of ethical bright-line rules and guidelines determining behavior that is ethical and unethical in the counseling process.

The ethical considerations grow more complicated when one considers a group therapy scenario. Some of these complications are due simply to the fact that group therapy introduces more people into the relationship, and, therefore, introduces more opportunities for conflicts and misunderstandings. Group therapy can take a variety of different formats, but is essentially therapy where there are multiple client participants with one or more healthcare facilitators. The goal of group therapy is for the group members to help one another achieve therapeutic goals. However, the group environment introduces some ethical issues that do not exist in one-on-one therapy, as well as exacerbates some of the ethical problems that already plague traditional one-on-one counseling scenarios. "Ethical issues in group psychotherapy are complex and differ from individual psychotherapy with regard to the types of ethical dilemmas that are encountered. Keith Spiegel and Koocher (1985) highlighted some of these differences and concluded that in group therapy there is (a) less control over the content and direction of the therapy session, (b) greater potential for adverse experiences, (c) greater potential for stress that might result from confrontation and criticism from other group members, and (d) the possibility of a client growing dependent on the group" (Klontz 2004). These special considerations mean that a therapist has to weight the potential benefits of a the group process against the potential downfalls, including possible ethical problems, of having the client in a group therapy scenario.

Discussion

Generally, this paper will approach group work as a single process and largely from an experiential approach. However, this approach is somewhat disingenuous. "There are many types of therapy combinations that fall within what is commonly referred to as experiential therapy" (Klontz, 2004). These various types of therapies can include, but are not limited to: expressive therapy, gestalt therapy, intense feeling therapy, encounter therapy, cathartic therapy, emotional-flooding therapy, psycho-imagination therapy, symbolic-experiential family therapy, Mahrer's experiential therapy, psychodrama, process group therapy, aromatherapy, and metaphoric therapy"(Klontz, 2004). There is some overlap between all of these different group processes, and they are not exhaustive of all possible approaches to group therapy. Therefore, it is critical to keep in mind that, "although all of these psychotherapies are related in regard to their primary vehicle of change, in many cases, they differ significantly in terms of how they conceptualize therapy and how they utilize experiential techniques. As such, there may be unique ethical issues of concern that are specific to each approach" (Klontz, 2004). Therefore, general concerns about the ethical issues inherent in group therapy may be more or less applicable to each approach; some therapeutic approaches will be more vulnerable to some ethical issues, while other approaches may introduce an entirely different range of ethical considerations and concerns.

Generally, any type of social work or therapeutic approach requires the practitioner to look at any relevant guidelines or rules in order to determine ethical behavior in the therapeutic scenario. The problem is that professional ethical codes are not very informative for group practice (Gumpert & Black, 2006). Social workers are aware of this problem, and believe that the codes need to address areas of group practice that are likely to result in ethical issues (Gumpert & Black, 2006). In particular, they believe that the most frequently encountered ethical dilemmas are ones that should be addressed by the ethical codes (Gumpert & Black, 2006). Despite the fact that the current ethical codes do not adequately address potential ethical conflicts, there is some disagreement about how to change the codes in a meaningful and relevant way. The central dilemma appears to be whether to have standards that are process or outcome focused (Cohen & Olshever, 2013). Some codes may attempt to bridge those differences, but, if they do so they need to acknowledge the differential emphasis that they place on process and outcome (Cohen & Olshever, 2013). Moreover, it is crucial to keep in mind that ethical codes, guidelines, and standards will never provide a completely comprehensive outline of all of the ethical issues that can arise with group practice. Instead, they should be seen as a starting point for the resolution of ethical dilemmas, rather than the maximum that a practitioner needs to do (Cohen & Olshever, 2013).

One of the ways to help resolve potential ethical conflicts in a group work setting is to identify potential ethical conflicts. This seems like a simple process, but is actually far more difficult than one might imagine because personal bias is a huge component in creating conflict. Groups are composed of individuals, with each individual bringing his or her own individual values into the group environment. Sometimes group norms and values can come into conflict with the norms and values of individual group members or of the surrounding society (Gumpert & Black, 2006). As a result, identifying cultural differences is one way to help avoid potential ethical conflicts in a group setting. Much of the research on cultural difference has focused on the intercultural context of patients and healthcare providers. This research has uncovered four significant culture-based communication barriers: language barriers, different values regarding health and illness, differing role expectations, and potential prejudice (Suurmond & Seeleman, 2006). These same barriers can exist between group members. Therefore, looking at the individual members of the group, and the expectations that each member may bring to the group setting is critical in identifying ethical dilemmas.

One way to help counter the potential negative impact of cultural barriers is for the group facilitator to be aware of potential culture conflict and trained with how to deal with those conflicts. Group workers who are not aware that cultural differences can cause conflicts and who do not know how to mitigate the potentially negative consequences of these cultural conflicts may find themselves in a completely dysfunctional group if there is an underlying cultural conflict in the group. One of the more interesting concepts to occur in recent time is the use of simulated patients when training health care professionals. "Using simulated patients enables a health care professional to practice skills in the development of diagnostic capabilities, different communication skills, gathering and giving information, identifying the needs of different client groups and working as part of multi-professional/interagency team. Through simulation learning can be achieved in a real life setting, with none of the risks associated to the real life situation" (Holland & Ousey, 2011). In other words, the simulated scenarios allow the healthcare workers to gain experience without risking the harm that could result to group members who are placed in a group that becomes dysfunctional.

When healthcare professionals were permitted to use inclusive simulated patients, it became apparent that there were five themes where minority status had an impact on healthcare interactions. These five broad emergent themes were: "language; knowledge; power;

inequalities and inclusion" (Holland & Ousey, 2011). While working with minority communities did not resolve healthcare worker's potential cultural problems with members of that minority group, it did increase awareness in a way that seemed beneficial to those who were able to practice with minority patients in a simulated setting. "The inclusion of members of black and minority ethnic communities (BME) as simulated patients was discussed by participants and viewed to be a positive step in the facilitation of increasing social networks; reducing cultural barriers and offering an outlet by which these communities could integrate into society. The sharing of their own experiences developed a feeling of personal achievement through an understanding in others of their own community and values" (Holland & Ousey, 2011). This should be encouraged in real group therapy settings, so that all of the members of the group feel as if they are included in the group process, and that none of their experiences are being marginalized because of a minority status.

Therefore, it seems important for group facilitators to have had some experience, even if it is simulated practice experience, in dealing with members of any minority community that they are likely to encounter in group practice. The more experience a facilitator has with a minority group, the greater the likelihood the facilitator will be able to help those members feel included, rather than excluded from the group process. This is critical, because inclusion is an important social phenomenon. "Communities who are strong and inclusive lead to better quality of life, stronger sense of identity and belonging, sharing mutual respect and equality. It is further recognised that a cohesive and inclusive community is one where there is a common vision and sense of belonging for all communities; the diversity of people's different backgrounds and circumstances are appreciated and positively valued; those from different backgrounds have similar life opportunities and strong and positive relationships are being developed between people from different backgrounds in the workplace, in schools and within neighbourhoods" (Holland & Ousey, 2011). Inclusiveness would seem particularly critical in a therapeutic environment, because group members who feel excluded would seem unlikely to participate in the therapeutic process, which would, in turn, impact the effectiveness of the entire group. Inclusiveness is strongly related to the concept of social justice.

Although there has not been an emphasis on social justice in group work literature, there is a suggestion that social-justice based approaches should be incorporated into group therapy environments (Macnair-Semands, 2007). What this suggests is that cultural issues, which can include race, religion, social class, and gender issues, are probably going to play an important role in group dynamics, even in a therapeutic setting that ostensibly has nothing to do with those social classifications. Moreover, the group facilitator has to be consciously aware of the bias that exists in society, as a whole, and make efforts not to allow that bias to repeat as part of the group process.

One particular type of group that is likely to contain members from a wide variety of cultural backgrounds is an addiction/recovery group. Interestingly enough, addiction counselors frequently have to deal with ethical issues that go beyond what other group facilitators face. This is because addiction is a unique disease and is diagnosed by some of the problems that face counselors in the area, such as relapse and deceit. Both of these factors have the potential of being very detrimental in a group environment, but can also be instructive if managed appropriately. Moreover, some of the more successful addiction group models do not rely upon professional facilitators, which can create an ethical issue for counselors working in the field, who may see a conflict between these traditional approaches and what the counselor understands to be best practices in the field. As a result, addiction counselors must be cognizant of several ethical issues, including, but not limited to: the lack of agreement over credentials for group leadership; differences in what research has revealed and what is being done in the field; questions regarding the efficacy of group work to treat addictions; confidentiality; informed consent; and any reporting requirements (Scott, 2000). The last requirement is particularly important; many people are referred to addiction groups as part of court-ordered programs, so that the counselor takes on a dual function as a member of the court and as a mental-health professional. While this can occur in other group settings, it is a frequent occurrence in addiction treatment groups.

After cultural considerations, the most pressing ethical dilemma for group therapy may be the issue of confidentiality. In a one-on-one therapeutic setting, therapists are generally going to have clearly outlined professional guidelines regarding patient confidentiality, as well as specific consequences for violating patient privacy. In a group environment, these safeguards of patient privacy evaporate; the group members have no professional obligations to one another. Therefore, any member of a therapy group faces the risk that confidential information will be shared inappropriately with people outside of the group. Furthermore, it is critical to keep in mind that group members do not have to have malicious intent to violate one another's confidentiality:

Groups are social by nature, and there is often incentive for group members to gossip about what they have heard or witnessed in a group-therapy session (Lakin, 1986). To help protect clients' rights to privacy, the APA's Ethical Standard 10.03 advises clinicians to "describe at the onset the roles and responsibilities of all parties and the limitations of confidentiality" when providing services in a group setting (p. 1072). In particular, it is important for group therapists to warn members about the importance of keeping confidences, inform group members about the dilemma of confidentiality in a group therapy setting, inform clients of the possible risks associated with breaches in confidentiality, and take steps to set forth rules of confidentiality to be adhered to by the group (Lakin, 1986; J.D. Moreno, 1991). In addition, ASGW Best Practices Guideline a.7.d. advises group workers to explain to members that unless a specific state statute indicates otherwise, legal privilege does not apply to group discussions (Rapin & Keel, 1998) (Klontz, 2004).

The reality is that confidentiality is an ethical risk that cannot completely be controlled in a group setting. Even if a group member could be penalized for discussing what other group members have said in therapy, the damage to the person whose confidentiality had been violated would already have been done. Therefore, it is imperative that group facilitators make it clear to all participants that, while confidentiality is expected, they need to be aware that confidentiality laws do not protect them in the same way as they would in a one-on-one group counseling scenario with a mental health professional. Moreover, if a group member appears to be talking about information that could be harmful to that person, for example, discussing participation in a crime for which that person has not previously been charged, the facilitator may have an ethical responsibility to speak to the person about the potential consequences of revealing that information in a group therapy setting.

Another ethical risk associated with groups is the lack of control that the facilitator has over the entire group process. Groups are social micro societies, and group interacts are going to impact the therapeutic process in ways that the facilitator may not have realized at the commencement of the group. "Just as the social power of the group can be an important driving therapeutic force, it can also harm group members if not closely monitored. According to Lakin (1986), social pressure to conform to norms in the group could interfere with an individual's ability to make rational and informed decisions, and the group could create a reality that might never have been accepted by the individual were he or she not a member of the group. As such, the group leader must be aware of how to moderate the influence of group pressure in ways that maximize therapeutic effectiveness" (Klontz, 2004). One way that therapists could do this is to take steps to minimize the potential negative impact of disruptive group members, perhaps through implementing strategies similar to "time-outs," which are proven beneficial disciplinary strategies that do not harm existing relationships when used correctly and effectively (Morawska & Sanders, 2011).

In addition to those overarching ethical concerns, facilitators face ethical concerns that can be specific to the subject matter that is the focus on the group. Therefore, a group focused on prenatal genetic counseling would have different ethical concerns than a sexual assault survivor support group. Therefore, an important ethical issue involves the group facilitator's familiarity with the subject matter of the group discussion. It is an impediment to the group process of the facilitator has "less than optimal training and experience" in the subject matter of the group (Hodgson & Weil, 2012). Therefore, subject-specific training and ethical concerns need to be a focus in group scenarios.

An ethical issue related to group therapy, but not part of the therapy itself involves when a healthcare professional should refer a person to therapy. In other words, is it unethical for a practitioner in an unrelated area to fail to recommend counseling or group therapy to a client who is need of some type of help? At this point in time, there is not really an ethical duty to refer a stable client to counseling. However, that premise may be unethical. It is clear that psycho-social interventions are known to positively impact people, and that these positive impacts go beyond mental health benefits. "Humans are more susceptible to a variety of illnesses when they suffer from feelings of meaninglessness or existential frustration" (Mosalanejad & Koolee, 2012). Moreover, clients believe that spirituality and mental health have a positive impact on other health outcomes and want their physicians to address those areas (Mosalanejad & Koolee, 2012).

Even when a group is coming to an end, a therapist has to be aware of potential conflicts. Ending a group can have different emotional consequences for different group members. Magione et al. identify several areas of potential conflict in group scenarios, particularly the ending of group sessions. These include: "informed consent, time and role boundaries, privacy and confidentiality, unplanned endings, therapist-initiated termination, finances, and competence" (Magione et al., 2007). It is important for the facilitator to understand that ending a group is a complex process, particularly because patient confidentiality and privacy concerns continue even after the group has concluded (Magione et al., 2007). Furthermore, the facilitator has to be aware that the ending of a group can bring with it feelings of loss, which may impact some group members in an negative way, necessitating further interventions with those group members (Magione et al., 2007).