Professional Ethics and the Group Psychotherapist
K. Roy MacKenzie, MD, CGP
Group psychotherapists are bound to the professional ethical standards of their primary discipline. Two sets of issues present themselves to today’s clinician: 1) How are the well-established ethical guidelines for individual clinical work adapted to the group environment? and 2) What are the ethical implications that arise when working in a managed care environment?
The following ethical concerns apply to all psychotherapy and all psychotherapists, but take on added features in the group context.
- Patients have the right to receive information about the nature of the group treatment and the possible risks. These should be augmented with a discussion of the theoretical orientation of the specific group to which the patient is being referred. This discussion can be combined with some comments about the relationship between the patient’s presenting complaints and the type of treatment chosen. It is also useful to review alternative approaches that are in common use and to explain why the treatment in question has been chosen. The therapist must be clear that he or she has a responsibility to intervene to prevent anyone from having a negative experience and that the patient has a right to terminate the group at any time, though the patient is requested to discuss such thoughts with the group before actually terminating.
- The patient should be maintained in therapy only as long as clinically indicated. Although this guideline is applicable to all types of therapy, it must be continually kept in mind in group therapy, where issues specific to the group context can make judgments about termination more complex. There may be strong attachment bonds to the group that make leaving difficult and make talking about leaving just as difficult. The therapist may be reluctant to bring the topic up lest another member or two seize on the idea and consider leaving as well, even if they are less ready to do so. In closed groups, the original contract will have spelled out when the group is to end, but individual circumstances may make it relevant to question that time limit for a given member. For example, an error in assessment may have occurred and the approach being used may prove not suitable for the patient. Presenting this situation to the individual and to the group may be difficult.
- Discrimination on the basis of race, color, gender, sexual orientation, age, religion, national origin, or physical handicap is addressed in most professional ethical guidelines and is strictly prohibited. This guideline must be reconciled with the development of groups for specific target populations. Groups are frequently composed according to these very criteria. Reconciling these two aspects is perhaps less of a problem in a private office but can become a sensitive issue in a larger service system where there are finite resources.
- The therapist is covered by the usual guidelines regarding confidentiality, but these do not apply in the same way to the group members. The expectation of confidentiality should be spelled out in writing and repeated verbally both to the individual and to the group in the course of the first session so that it is clearly understood and the reasons appreciated. Any hint that this guideline has been broken should be discussed directly and immediately in the group and with the offending member. This area becomes less clear in inpatient units, where patients are expected to attend group but often are provided with limited opportunity for orientation. The therapist may need to intervene in inpatient or crisis intervention groups to caution a member about excessive personal disclosures, especially those of a factual nature about the member’s life outside.
- Sensitive situations can arise regarding information the therapist receives from or about an individual member in the group. For example, phone calls between sessions may be shared with the group at the therapist’s discretion—they form part of the larger frame of the therapeutic situation. A first step would be to check with the patient at the time of the call about how the information is to be shared with the group. The patient should be encouraged to bring the matter before the group himself. If the patient does not do so, the therapist may make an oblique reference later in the next session to something that might be discussed, and if the hint is not taken, the therapist might then identify the event and encourage the member to elaborate on it.
Another sensitive situation arises if the therapist obtains information about extragroup socializing. If there is a clear negative response from the member to the idea of sharing the contact with the group, then there needs to be a serious discussion with the member concerning the original condition. It should be clearly spelled out how a repeat of the extragroup contact will be handled, and a clinical note should be made summarizing the discussion. Repeated problems of this nature might be grounds for discontinuing a member.
This discussion is based on contacts that have significant treatment implications in relationship to the type of group being conducted. The more the focus of the group is on learning from the interactional group process itself, the more care must be taken. Remember that actions may speak louder than words and that all extragroup contacts need to be carefully considered by the therapist even if no immediate action is contemplated.
- The clinician must be aware when the needs of the patient are beyond her clinical competence to effectively manage. Consultation must be sought at such times and appropriate referrals made. Group psychotherapy embraces a wide range of diagnoses and techniques, and a few clinicians will be skilled in every one. Hiding behind a general competence in running groups may mask areas of deficiency in special areas. The interpersonal support or stress of sitting in a group may create a situation in which a member begins to reveal important information that was not discussed at assessment and that alters the implications of the original treatment plan. In such situations, if the subject cannot be pursued adequately in the group, it is best to take the patient aside after the session and review the matter in more depth.
- Sexual intimacy is prohibited between professional and patient. Popular fantasies to the contrary, it is much less likely to happen in the context of group therapy than in individual treatment. However, the therapist has a responsibility to pursue the implications of sexual behavior between group members if it occurs. The therapist’s role is not to condemn or support it, but to understand the situation and be sure that one or other of the participants is not being taken advantage of or acting out issues arising from the group.
Ethics and the managed care environment
The clinician working in the managed care environment is participating in a complex ethical arena. Clinicians see their primary responsibility as being to their own patients, and this historical tradition of the healer is fundamental to a trusting and collaborative therapeutic alliance. However, the other side of this situation also needs to be considered. Historically, many people have not had access to adequate health care and may receive access to a much broader range of services because the managed care organization has a responsibility to provide the care to the population it serves. Indeed, it may have the resources to do so better and in a more timely and equitable manner than an individual practitioner could hope to do so. These two forces may at times seem in competition, and balancing them can be difficult.
A few general principles about how a managed care system operates might be helpful. Ideally, these principles can be incorporated into accreditation guidelines. They will not prevent disagreements but may help a collaborative resolution process evolve. Issues related to the following situations are being challenged through the legal process, and one can anticipate the emergence of more universal guidelines over time.
- The role of the clinician as a patient advocate should not be altered by the system of health care in which the clinician practices. This does not mean that the patient necessarily should have access to every possible treatment option, but that clinicians not be prohibited from presenting their assessment of the treatment options most indicated.
- Healthcare system allocation guidelines that restrict choices beyond normal cost-benefit judgments should be established at a policy-making level. The clinician can then be clear about the nature of rationing guidelines and can explain these to the patient.
- The input of clinicians should be incorporated into the process of developing service guidelines. The sign of a more mature organizational structure is when clinical viewpoints are sought and considered. There can then be a minimum of middlemen between patient and clinician.
- A formal, timely and accessible appeals mechanism should be in place for situations in which the clinician believes a serious clinical error is possible.
- The focus should be on cost-effective delivery of health care, not on arbitrary withholding of care. In terms of group psychotherapy, a reasonable guidelines is to provide a trade-off (a “flex” in today’s parlance) of three group sessions for every one allowable individual session.
- Patients should be fully informed about benefit limitations.
It might be helpful to recall that Hammurabi, King of Babylon (1750 B.C.), introduced laws that limited doctors’ fees and punished those who injured their patients. Similarly, the Hippocratic oath, taken by all physicians, requires that at the very least, doctors “do no harm” to their patients. Group therapists on the brink of the 21st century are in a unique position to carry on these historical sentiments by paying careful attention to the pressures brought to bear by a changing health care service delivery system and the vicissitudes of reduced funding for mental health services.
The challenge of providing the highest quality clinical care and educating the public and third party payers about the appropriate use of group psychotherapists during difficult times remains one of the primary tasks facing group therapists. Rethinking many ethical issues in light of the shifting environment in which we practice today will go a long way toward realizing this goal.