What are ethical standards?
Psychotherapy is governed by professional and ethical standards designed to protect patients and support safe, competent, and responsible care. These standards address matters such as confidentiality, informed consent, professional boundaries, conflicts of interest, competence, record keeping, and the circumstances in which therapy may need to end or be transferred to another professional.
The specific rules that apply depend on the therapist’s profession, regulatory body, and province or territory. Psychologists, psychiatrists, social workers, counsellors, and psychotherapists may therefore be governed by somewhat different standards. Nevertheless, many of the underlying ethical principles are shared across the psychotherapy professions.
Confidentiality
Confidentiality is one of the foundations of psychotherapy. In general, what a patient discusses with a therapist, as well as the fact that the person is receiving therapy, is treated as private information.
Confidentiality is not absolute. There are limited circumstances in which a therapist may be legally or ethically required or permitted to disclose information, such as certain situations involving serious safety concerns, child protection, a court or other legal requirement, or when the patient has consented to information being shared. The precise limits depend on the therapist’s profession and the laws of the jurisdiction in which treatment is provided.
Therapists should explain the important limits of confidentiality as part of the informed-consent process.
Informed consent
Patients have a right to understand the service they are agreeing to receive. This generally means that therapists should provide enough information for patients to make an informed decision about participating in psychotherapy.
Depending on the circumstances, this may include information about the nature and purpose of therapy, the therapist’s qualifications and approach, fees and cancellation policies, confidentiality and its limits, record keeping, communication outside sessions, possible involvement of supervisors or consultants, and significant risks or alternatives associated with treatment.
Consent is not simply something obtained at the beginning of therapy. Important changes in treatment may require further discussion and renewed consent.
Conflicts of interest and overlapping relationships
Therapists are expected to identify and appropriately manage situations in which another relationship, obligation, or interest could interfere with their professional judgment or with their ability to place a patient’s interests first.
For example, difficulties can arise when a therapist has a significant social, family, financial, supervisory, or professional relationship with a patient outside therapy. These are sometimes called dual or multiple relationships.
A somewhat different conflict can arise when a therapist separately treats two people who are closely connected to one another, such as close friends, family members, colleagues, or people who are in significant conflict.
Example: Suppose a therapist is already providing individual psychotherapy to one person and is then contacted by that person’s close friend for individual therapy. The therapist might eventually receive confidential information from each person concerning the other. This could make it difficult to protect both patients’ confidentiality, remain therapeutically neutral, and act in each person’s interests independently.
For this reason, a therapist may sometimes decline a referral or determine that another therapist would be more appropriate.
There is an additional complication that can understandably be confusing to patients: the therapist may not be able to explain fully why a conflict exists. Saying, for example, “I cannot see you because your friend is already my patient” would itself disclose confidential information about the other person. A therapist may therefore need to say simply that they are unable to provide the service because of a professional conflict or another ethical consideration.
Not every overlapping relationship creates an ethical problem. This is particularly important in smaller communities or specialized professional communities, where some degree of social or professional overlap may be unavoidable. The relevant question is usually whether the overlap creates a meaningful risk to confidentiality, professional judgment, boundaries, or the patient’s care.
Seeing more than one therapist at the same time
Receiving services from more than one mental health professional is not necessarily a problem. In some circumstances it can be appropriate and clinically useful. For example, someone might see an individual psychotherapist while also participating in group therapy, receiving specialized trauma treatment, attending couples therapy, or seeing a psychiatrist for medication management.
Concerns are more likely to arise when two therapists are simultaneously providing substantially overlapping individual psychotherapy, particularly when they are addressing the same problems without knowing about or coordinating with one another.
This is sometimes referred to as concurrent treatment, multiple providers, or duplication of service.
Potential problems can include:
- different therapists working toward incompatible treatment goals
- contradictory recommendations or therapeutic approaches
- difficulty determining who is responsible for particular aspects of care or safety planning
- important clinical information being divided between two providers
- one treatment inadvertently interfering with the other
- duplication of work, appointments, or expense without a clear clinical benefit
- confidentiality complications when communication between therapists would be useful but has not been authorized
For these reasons, therapists will commonly want to understand what another therapist is providing and why both treatments are needed. With the patient’s consent, the therapists may also communicate with one another so that their respective roles and treatment goals are clear.
There are many situations in which concurrent treatments can work well. The ethical concern is therefore not simply that “two therapists are involved,” but whether the arrangement makes clinical sense and whether the treatments are sufficiently coordinated to protect the patient’s interests.
Professional competence and scope of practice
Therapists are expected to practise within the limits of their education, training, experience, and professional scope.
A therapist may therefore recommend consultation with or referral to another professional when a patient’s needs fall outside the therapist’s competence or when another type of assessment or treatment would be more appropriate. Referring a patient elsewhere is not necessarily an indication that something has gone wrong in therapy. Sometimes it is precisely what responsible professional practice requires.
Professional boundaries
The psychotherapy relationship involves an inherent difference in roles and responsibilities. Ethical standards therefore place particular importance on maintaining professional boundaries and preventing exploitation.
Therapists must not use the therapeutic relationship to meet their own emotional, financial, sexual, social, or other personal needs at the patient’s expense. Boundaries surrounding physical contact, gifts, social relationships, business arrangements, self-disclosure, electronic communication, and contact outside therapy may consequently be handled differently from relationships outside psychotherapy.
Some boundary decisions depend heavily on context rather than on rigid rules. The guiding consideration should be the patient’s welfare and the integrity of the therapeutic relationship.
Records and information sharing
Therapists generally have professional and legal responsibilities concerning the creation, security, retention, and disclosure of clinical records.
Patients may have rights to obtain access to information in their records, although there can be legal or professional exceptions. Information ordinarily should not be released to another healthcare provider, family member, insurer, employer, or other third party without appropriate consent unless disclosure is otherwise authorized or required by law.
When several professionals are involved in a patient’s care, therapists should also consider what information needs to be shared, with appropriate consent, to support safe and coordinated treatment.
Ending or transferring therapy
Therapists are not required to continue providing treatment indefinitely, and there are circumstances in which therapy may appropriately end at the initiative of either the patient or the therapist.
When a therapist needs to end an ongoing treatment for clinical, ethical, safety, competence, or other professional reasons, ethical practice generally requires attention to continuity of care. Depending on the circumstances, this may involve discussing the reason for ending, providing reasonable notice, helping identify alternative services, transferring relevant information with consent, or making arrangements for urgent care.
The objective is to avoid unnecessary disruption or abandonment of a patient who continues to require care.
Respect, discrimination, and cultural safety
Ethical psychotherapy also requires respect for patients’ dignity, autonomy, identity, culture, values, and circumstances. Therapists should not discriminate against patients and should be attentive to the ways that culture, social position, discrimination, power, and systemic factors may affect both psychological difficulties and the therapeutic relationship.
Ethical practice does not require therapists and patients to share the same beliefs or perspectives. It does require therapists to avoid imposing their personal values in ways that interfere with appropriate care.
What happens when an ethical issue arises?
Ethical standards cannot anticipate every situation. Psychotherapy often involves complex circumstances in which several legitimate responsibilities need to be considered at the same time.
When an ethical conflict arises, a therapist may need to clarify professional roles, discuss the issue with the patient when possible, seek confidential professional consultation, obtain additional consent, coordinate with another provider, modify the treatment arrangement, make a referral, or occasionally decline or discontinue a service.
Some of these decisions can understandably seem unusual or frustrating to a patient. In certain situations, particularly those involving another person’s confidentiality, the therapist may also be unable to provide a complete explanation for the decision.
Patients are always entitled to ask questions about the ethical or professional considerations affecting their care. A therapist should ordinarily be able to explain the relevant principles and their implications as fully as confidentiality and other professional obligations permit.