Conversations About Ethics
Mark Sorensen, PhD, CGP, and Henry Spitz, MD, CGP, FAGPA

Each profession has a code of ethics that defines the moral standards for that specific discipline. Establishing ethical codes is a valuation process. It requires examining the scope of the profession and determining the moral issues that relate to behavior, ultimately determining what is good and what is bad behavior. 

According to AGPA’s Guidelines for Ethics, membership presumes strict adherence to standards of ethical practice. As a specialty organization, AGPA supports the ethical codes of the primary professional organizations to which members belong. Providing guidelines for the ethical behavior of group psychotherapists serves to inform both the group psychotherapist and public of the AGPA's expectations in the practice of group psychotherapy.

Recent conversations with five members of the Board of Directors of The National Registry of Certified Group Psychotherapists revealed conformity of opinion. There was a strong consensus that group psychotherapists should understand and adhere to the prescribed standards of behavior as defined by AGPA’s Guidelines for Ethics. The ultimate goal of AGPA’s ethical standards is to provide the highest quality care to clients. Not surprisingly, however, there was a diversity of opinion about the critical elements of those standards and which ethical issues are more important to each of the five individuals.

Aspiring to Excellence
“Every profession takes on an obligation to aspire to excellence,” said Hillel Swiller, MD, CGP, FAGPA. “Indeed, that is what sets the professions apart. To me—as a physician, as a psychiatrist, as a group psychotherapist—that translates into a dedication to ongoing training,” he said. While Swiller believes that the AGPA has an obligation to provide as broad a range of educational and training opportunities as possible to the membership, he also believes it is responsibility of each group psychotherapist to involve him or herself in the training process.

“As much as I think AGPA’s Annual Meeting, Journal, and newsletters are excellent sources of information, I do not think they are sufficient,” said Swiller. “Group psychotherapists must involve themselves in ongoing education programs that they create for themselves, based on the opportunities available in their communities and their own needs, as indicated in AGPA’s Guidelines for Ethics.”

Section 1 of the Guideline’s Professional Standards states: “It is the personal responsibility of the group psychotherapist to maintain competence in the practice of group psychotherapy through formal educational activities and informal learning experiences.”

Swiller also acknowledged the crucial role that the National Registry of Certified Group Psychotherapists plays in enhancing and communicating professional excellence. “The Registry helps establish and promote the criteria for excellence. The CGP credential demonstrates an awareness of professional continuing education and training requirements and this dedication to excellence.”

Eleanor Komet, PhD, CGP, FAGPA, agrees that training is essential. “One must be adequately trained as a group psychotherapist,” she said. That means being aware of the group process and how to address issues in group, because group therapy is not the same as individual therapy.”

Client Screening
One of the critical elements that group psychotherapists deal with is screening and preparing clients for group. Section 1.1 of AGPA’s Guidelines for Ethics states that: The group psychotherapist shall provide the potential group patient/client with information about the nature of group psychotherapy and apprise them of their risks, rights and obligations as members of a therapy group. 

“More than good judgment is needed for the selection process,” said Komet. “Group psychotherapists need to be able to determine if a group is good for the client, and vice versa. Patients must also be adequately prepared to participate in group so they’ll understand what will happen.”

Creg Crosby, MA, LPC, CGP, concurs that training is essential, particularly as it relates to patient screening and education. In his travels around the country conducting training programs, Crosby has observed that it is not uncommon for many managed care, social service, and other community service agencies to overlook the patient education and screening process, ignoring patient education and what it means to be in group.

“In private practice, group psychotherapists do the screenings. They focus on the therapeutic issues that should be reviewed and understood by the client,” said Mr. Crosby. “Because of the volume of clients these agencies deal with, my feeling is that these other types of service delivery systems don’t tend to take the time for group preparation.” This is one area that Mr. Crosby believes is most likely to be ignored and where changes in other organization’s ethical guidelines could help.

He notes that the Registry has been working with other accrediting organizations to not only recognize the value of the CGP credential but also to accept and endorse the group screening process.

Boundary and Confidentiality Issues
Part of that education process includes communicating clearly with the client about confidentiality and boundary issues. “Group is rife with possible problems that relate to communications,” said Barry Helfmann, PsyD, CGP, FAGPA, Immediate Past Chair of the Registry. “In individual treatment, a patient can say what he wants to anybody. A patient can quote anybody to the therapist, and the therapist must uphold that confidentiality. In group, it’s different. By it’s very nature, participation in group has the potential of abridging another’s right to privacy.”

“Most group therapists ask patients not to have any contact outside of group,” said Komet. “But when you live in a small city or an urban area, that may be impossible; group members are bound to run into each other, as well as the therapist, at the movie theatre or even the grocery store. What is important is making sure that clients are informed about confidentiality, and that they do not handle things outside the group setting that need to be addressed within the group.” 

Helfmann agrees that there are all kinds of opportunities for outside communication to occur between group members, even in metropolitan areas. “What about the parking lot? The elevator? The reception room? Group psychotherapists have an obligation to inform patients that they may bump into people they know in your office.”

“Managing boundaries within group therapy is magnified with children. You have to keep in mind that you are not just dealing with children, but multiple systems—the parents, the schools, the community,” said Connie Concannon, MSW, CGP, FAGPA. “You want children to feel safe and know that you will honor confidentiality. Particularly in light of last year’s shootings at Columbine and other high schools, Concannon finds herself constantly put in a position to determine when a child’s behavior constitutes a danger to someone else. “When working with children’s groups, you have to think about the community at large and examine if a child’s behavior presents a risk to that community. You need to determine when children are acting act and when life-endangering behavior may be setting in.”

“If teens are sleeping around, having multiple sexual partners, for example, they may be placing themselves or others in danger. The group therapist must determine at what point that danger sets in and parents or others in authority should be informed.”

AGPA’s Guidelines for Ethics provide clear guidance in this area. Section 2.1 states: The group shall agree that the patient/client as well as the psychotherapist shall protect the identity of its members. Section 2.2 notes: The group psychotherapist shall not use identifiable information about the group or its members for teaching purposes, publication or professional presentations unless permission has been obtained and all measures have been taken to preserve patient/client anonymity. Section 2.3 states: Except where required by law, the group psychotherapist shall share information about the group members with others only after obtaining appropriate patient/client consent. Specific permission must be requested to permit conferring with the referring therapist or with the individual therapist where the patient/client is in co-joint therapy. 2.4 notes that: When clinical examination suggests that a patient/client may be dangerous to himself/herself or others, it is the group psychotherapist's ethical and legal obligation to take appropriate steps in order to be responsible to society in general, as well as the patient/client.

While informed consent is critical to this process, it is impossible to cover all contingencies in a code of ethics. “Outside communication is under addressed in our field,” said Helfmann. “Even how the group therapist handles note-taking can be viewed as a possible violation of confidentiality. Do you write about a particular patient, but leave out what is happening in the group? Do you use last names? Do you keep your notes on a computer?” 

While group psychotherapists are bound by confidentiality, it becomes a clinical issue when a client violates that trust “Even in a patient signs a confidentiality form, it is not legally binding,” said Crosby. “If you have a client who will not honor confidentiality, the therapist has an obligation to make this issue a high priority for the group and to consider both individual and group ramifications to breaches of confidentiality before making decisions such as removing a member from the group,” said Helfmann.

Ethics and the Law
All those interviewed felt there is a fine line between what is ethical and what is legal. “For me, state law, licensing agencies, and the AGPA provide guidelines for what is ethical,” said Concannon. “As a therapist, I must know what I am required to report to the state.”

“While it is the individual’s responsibility to stay abreast of legal and ethical issues, AGPA can help.” said Helfmann. “Attend the Annual Meeting, which offers excellent educational programs. Read our newsletters and journal to keep informed about national issues affecting ethics and group psychotherapy. Take advantage of peer supervision by more senior practitioners. Sign up for the Registry’s new ethics course.”

Changing Values
There is no doubt that as society changes, ethics change. “Ethics are partially a product of the society and culture in which we live and the theoretical foundations of the nature of psychotherapeutic practice,” said Swiller. “Ethics and history go together,” said Crosby. That being the case, there is no doubt that technology is now resulting in new ethical conundrums.

“Technology has raised new issues. New means of communications offer opportunities. But with that comes potential danger for every professional,” said Swiller.
“Conducting therapy on the web or even communicating through e-mail presents new legal and ethical dilemmas,” said Helfmann. 

“Technology certain complicates issues for us,” agreed Komet. “While I think technology has certain advantages (patients will send an e-mail and say things they will not say in person, for example), it also presents problems. Words can take on 47 different meanings depending on how they are uttered. I’m also watching body language in group. If something is written, I have less understanding and less control of how it is interpreted,” she said.

Concluded Swiller, “Despite changes in society and culture, some things always remain the same. From the beginning of Hippocrates, our ethical codes have first required that we do no harm.” 

This article was published in the February/March 2001 issue of The Group Solution.