Ethical Question & Answer 

This is the first of a regular feature in The Group Solution that will focus on ethical issues confronting group leaders. Readers are strongly encouraged to share their views on any of these topics through Letters to the Editors and also to write to us about any ethical dilemmas that you would like to see addressed in this new column.

Q: The terrorist attacks of September 11 have created an urgent need for mental health assistance. Groups will play a major role in the relief effort. What issues arise when considering the question of payment for services during these unusual circumstances?

A: The current crisis triggered by the incidents in New York, Pennsylvania, and Washington, DC, and the ongoing threats of bioterrorism has mobilized a wide array of issues for the members of the group therapy community. Virtually everyone across the nation has been affected by this disaster and is eager to be helpful and participate in meaningful ways.

In the days immediately following the incidents, many of us were active as volunteers, leading groups attempting to address the consequences of these physical and emotional assaults. For the most part, these interventions were done on an emergency basis and were led by volunteers who sought no compensation for their work.

Several businesses and charitable organizations, however, requested help from group-knowledgeable clinicians and offered to pay for these services. Opinion was divided among practitioners; some feeling strongly that they wanted to make a contribution to the process and in so doing felt they did not need to be compensated monetarily, and others, perhaps equally generous, sensing that the reality of the time taken away from their practices and jobs was too great a financial sacrifice and were interested in being paid for their time.

Now that some time has passed, it seems that ethical and moral considerations have arisen out of these experiences. In my view, most of these issues appear to cluster around the therapist’s dilemma between altruism and self-care. On the one hand is the genuine desire to bring to bear our specialized skills via the use of groups to reach large numbers of people struggling with the sequellae of the terrorism experience. A central part of what motivates people to choose a career as a therapist is based on the desire to relieve human suffering and to ease the emotional burden in the lives of others.

At the same time, doing trauma work is complex, emotionally intense, and not without risk to the therapist. Indirect or vicarious traumatization that comes from being saturated with repetitive input that is strongly affect laden and resonates with many of the therapist’s own personal concerns is common to trauma and disaster work. The possibility of emotional contagion, group irrationality, scapegoating, boundary blurring, and other problematic group phenomena are increased at times like these and can easily lead to therapist burnout.

I believe that therapists need to practice what they preach. We encourage our patients/clients to take care of themselves at times of crisis and much has been written about the need for caregivers to do the same. Accepting payment is one part of the self-care process for the therapist. If one has strong mixed feelings about this subject, then perhaps accepting money at a slightly reduced fee might be an acceptable alternative.

The adage about money and therapy that says when therapy works it is priceless and when it does not, anything you pay is too much applies here. In order to provide first-rate therapy, we have to be in first-rate shape emotionally. Being clear and unambivalent about your position vis a vis being paid for one’s efforts helps offset some of the avoidable conflicts and resentments that can accompany pro bono disaster and trauma work.

Henry Spitz, MD, CGP, FAGPA
New York, New York

This article was published in the June/July 2002 issue of The Group Solution.