If you use the phrase “ethical issues in therapy,” every therapist on the planet will assume you mean the ethics of the therapist—confidentiality, client autonomy, duty to warn. Licensure renewal typically requires ongoing continuing education in ethics. Ethical questions show up in our clinical consultation groups in the form of our obligations to our clients and how we make sure we don’t inadvertently harm them. Ethics and our ethical obligations to both clients and the profession are ubiquitous in the fields of psychotherapy and counseling.

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Here’s a new thought: clients have ethical concerns, too. And a related thought: we therapists have approximately zero training in how to help clients address these ethical concerns. A partial list of ethical dilemmas that clients bring to therapy includes whether to: stay in a difficult marriage or divorce, maintain a secret affair or end it, cut off or stay connected to a difficult parent, tell a non-vaccinated loved one to skip a family gathering or let them come, keep a family secret or reveal it. And then there are ethical issues that the therapist sees but the client may not, such as when a divorced parent is undermining a child’s relationship with a despised and destructive ex-spouse.

As someone trained in the 1970s, I can tell you how I was taught to deal with these ethical dilemmas. Keep the focus on the client’s personal needs and desires (“What do you need to do for you?”) and steer the client away from the other side of their ethical dilemmas—their sense of responsibility to others. In the language of the day, we learned to discourage clients from “shoulding” themselves.

This “do what works for you” paradigm came crashing down for me in the 1990s, when I worked with a distressed, newly-divorced father I’ll call Bruce, who was about to abandon his children by moving away and starting a new life. He had already done the same thing after his first divorce in another part of the country. He came to a session to wrap up our work and say goodbye. I knew I had to try to influence him to do the right thing by his children, but nothing in my training had prepared me for that conversation. What skills could I call on to navigate between the Scylla rock of silent neutrality (“What do you need to do for you now?”) and the Charybdis whirlpool of prescriptive moralizing (“Just do the right thing for your children”)?

That case, along with readings about the cultural impact of “value-free” individualistic psychotherapy, helped me to realize that the therapy field has a blind spot when it comes to ethical issues in the lives of clients. In this context, “ethical issues” refers to client behavior that has consequences for the welfare of others. We either see clients’ ethical struggles in strictly psychological terms, like the punitive superego, or as something we ought to steer clear of lest we impose our values on clients.

A problem with either of these default positions is that they do carry an implicit ethical message: that the only moral stakeholder is the client. An exclusive focus on asking, “What do you need to do for you?” carries the message that complex ethical dilemmas involving tension between self-needs and obligations to others really come down to one dimension: the needs and desires of the self. For years I told clients agonizing over whether to divorce that “your kids will be fine if you do what makes you happy.” My point is that when clients bring us their ethical dilemmas, we are ethical consultants, like it or not. So I decided it was time to get good at it.

In my recent APA-published book, The Ethical Lives of Clients, I articulate five skills in ethical consultation, using the acronym L.E.A.P.-C: Listen, Explore, Affirm, offer Perspective, and (sometimes) Challenge. Therapists use these skills all the time in our work. Now I am applying them to the client’s ethical issues: listening for the client’s sense of how their actions are or potentially are affecting others, exploring their ethical concerns and the roots of those concerns, affirming their willingness to confront an ethical dilemma, offering perspective on the tension between the client’s needs and responsibilities to others, and, in some cases when there is imminent, foreseeable harm, challenging the client to consider the impact of their actions on others.

After decades of doing this work and teaching it to therapists, I am convinced that skillful ethical consultation not only does not drive clients away—a common therapist worry—it empowers them. With Bruce, I listened to and explored his pain and worries, I affirmed him as a father, I offered a perspective on his importance to his children and the likely consequences if he abandoned them, and finally, when he minimized the impact of his exiting their lives, I challenged him by saying that I was worried that he was treating a short term problem (his distress over the divorce and his desire not to have to deal with his ex-wife anymore) by risking long term damage to his children. I offered to be there for him to deal with his current personal crisis, which I was confident he could get through.

Bruce made a decision that had integrity for himself and his children—he stayed with them and later reconnected with his older children from his previous marriage. In the years since that case, I’ve learned that while there is tension in the short run between needs of self and ethical responsibilities to others, in the long run, human flourishing comes from facing the tension and finding authentic ethical integrity. Helping people in this crucible is part of our job as therapists, so let’s get good at it.

File under: Law & Ethics, The Art of Psychotherapy