Ethical Issues Unique to Group Therapy
Group therapy is the form of counseling offered to many people with similar problems at the same time. It is a fast growing practice especially in North America. In its practice, a person professionally trained in the psychiatric field handles the patients and ensures they are all comfortable in each other’s company. It consists of six to eight members per group who convene face-to-face and share their predicaments while the others listen and retort to them. They are always in the company of one or two therapists during the process. The therapy is usually aimed at giving assurance to the patients that they are not unique and that others too face similar problems. They also get encouraged when they get the chance to interact with people who have recovered from the same problem. It is preferred in most cases because of the support it offers to members from their interaction (Northern, 2009).
Group therapy has been known to take many forms all aimed at reaching out to the patients (Schulherr, 2008). The most common practice is where patients meet with each other to discuss the problems they are facing. The psychiatrists do not do much since the interaction between the patients is more important. Schulherr, (2008) argued “… group discussions are leader-suggested topics and group members’ own issues. Often a particular group session will include time for both” (Pg 182). This shows that the members of a certain group focus more on having the discussion of what might have led to the problems that they are facing. It also gives the members ideas of how they can avoid a relapse after the therapy. The importance of the therapist is to ensure the discussions are maintained within the main issue and are helpful to all the patients, thus the topics to be discussed are strictly suggested by the therapist. Members also get the chance to talk in turns to state their problems and responses from the others are allowed. They get encouragement from the already recovered members and gain confidence to go on with the counseling program. The members of the group and the therapist are also required to uphold ethical standards unique to the profession.
Key words: group therapy, ethical standards, psychiatrist, relapse
Group therapy differs from individual therapy to some extent. This is because in a group therapy, the patients will be many with similar problems unlike the individual therapy where all patients are attended to separately even in situations where the problem is similar. Group therapy is also diverse and more involving to the patients than the individual therapy. Research has proved that the use of group therapy has shown faster results due to the diversity of the issues addressed, which are rarely tackled in the individual therapy. This is because the issues faced by the patients may be the same but with different circumstances. The participation allows the other patients to learn more from the experiences of the other patients. They are also able to accept the problem and have courage to change on the realization that they are not in solitude in their situation. However, in both cases, the patients must have the will power to get help. They must not be pushed by anyone to get the help (Fonagy and Bateman, 2005).
Consideration is always given to the gender, age group and preference of the members when forming the groups. Many circumstances and problems may lead to individuals suffering psychologically, thus needing psychological therapy. For instance, apprehension can lead to victims needing professional help (Forti, et.al, 2007). Patients may also suffer from alcohol addiction or very high temper, which may need to be evaluated from the root cause. Obesity has also been known to be a cause of depression in America due to criticism of the victims by others (Schulherr, 2008). To avoid the tendencies by the victims to harm themselves, therapy has been used widely to console and give a new meaning to life for the patients. Sexual abuse to children and adults has also been known to cause depression among adults and violent behaviors in children. These require professional counseling that will encourage the victims. Group counseling in this case assures the victims that they are not at fault for whatever has happened and that others too have gone through the same.
Stages of Group Therapy
Group therapy is done in various stages that will guarantee the recovery and development of the patients. These stages consider the adaptation of the members to the group and average duration it takes for the patients to take the problem positively and work on it. The stages include:
Before the sessions can begin, the therapist is required to evaluate the members of the group and the nature of the problems they are facing. He/she should also ensure that they are all similar in nature to avoid having a person in the group who will not relate to the therapy. For instance, a group dealing with family issues will have only members with similar family issues. The therapist assesses the members to ensure they are legible for the group sessions (Wrate and Will, 1985).
Before the sessions can begin, the therapist needs to ensure that the patients are in agreement with the form of treatment. For those incapable of deciding on their own, their families or people responsible for them will be consulted to ensure nothing is done against their will. This will also enhance cooperation.
With the permission and the consent of all the group members and those responsible for them, the therapist can begin the sessions. The members of the group should be aware of the meetings and the agenda for each meeting so that they can prepare. These sessions will include the sharing of the problems where they help each other in finding the basis of the problem. The therapist then uses his or her professional skills to offer possible solutions to the victims.
When the therapist is satisfied that the therapy session has been fruitful, he/she suggest to the group members that they end the session. This should also be when the group members are confident that they are no longer troubled and can handle the situation on their own. The therapist discusses with the families of the group members to bring formally the session to an end (Wrate and Will, 1985).
Legal Requirements in Group Therapy
The law does not provide comprehensive laws to govern the practice of group therapy that will protect each group member and the therapist. Both parties need to be adequately protected from each other since the issues discussed are vital and could get negative reception from either side. According to Alonso and Swiller, (1993), “Situations could arise when a group member can become violent and present a clear threat towards another specific group member or members” (Pg 352). The same form of aggression can happen towards the therapist. Although this should be acceptable because it is an issue being addressed by the therapists, controls should be taken to avoid the harm of both parties. Due to the lack of clarity in the legal requirements, the rules applied are the same that apply to the psychiatric treatment in general. Aside from the protection of the interacting parties, the legal requirements also state the standards that the group therapists should meet and the qualifications of the therapists. This is to ensure that they are professional in the execution of their duties and relationship with the group members.
Benefits of Group Therapy
In most cases, people going to therapy have the feeling of isolation and loneliness. They have the feeling that they are different from anyone since they are undergoing problems, which are not faced by other people. Group counseling helps change this feeling to that of acceptance. During the sessions, the patients can relate to other people in the same situation including those who have recovered from the state. According to Williams, (2010), “What can feel like being excluded, can, in time, come to be felt as a valuable opportunity to take stock of the action” (Pg 87). This is because the victims meet people like them face-to-face, discuss the problems, find solutions with the help of the therapist and get the morale to move on with life. Their esteem is also boosted and they can lead a normal life if they find a proper solution to the problem or simply seek help.
It reduces reliance on the group therapist for emotional support. Williams, (2010), stated that, “Dependence upon the therapist alone is diminished because of the existence not only of fellow patients, but of the group itself” (Pg 87). The group members often come to the realization that they are capable of solving their own problems. They also come to terms with the fact that they are responsible for their lives and anything that happens. Instead of blaming others for their misfortunes, they learn to take charge and change for the better. This begins when they confront each other over not accepting their problem. For instance, it would be easier for one of the members in the group to tell the other bluntly to accept their problem, than would be for the therapist. This is because the therapist only helps those who are in acceptance. It would also appear judgmental for a person without the same issue to condemn the other. The free interaction is important to the members who learn to depend less on the therapist and likewise other people, and take responsibility.
The group therapy offers support to the members after the therapy. The relationship between the group and the therapy is strictly professional. This is unlike that of the group members among themselves, which is personal. The members form close ties, which last for longer periods. The fact that they are brought together by the same problems gives them the obligation to watch over each other. They ensure none of them in the group suffers a relapse thus guarantees recovery. This is as opposed to the individual therapy where the patients have no one to relate to except the therapist, who cannot extend the care after the designed period.
Ethical Issues in Group Therapy
Therapists deal with a variety of people with different characters, backgrounds and attitudes. The reactions of the people to the counseling services also vary. Some are well receptive and co-operative to the counselors. Usually this group seeks the help out of free will. On the other hand, the counselor/therapist can come across violent patients who are unwilling to go through the process peacefully. This could be the actual nature of their problem or due to pressure to seek help. Society has also been harsh on people with various psychological problems such as a high temper. The effectiveness of a therapist in delivery of services therefore, depends on their expertise. Handling the underlying issues with utmost due care and skill is therefore a requirement for the profession. Understanding of the patients is also required since the intention for the therapy is to provide solutions and support for the psychologically disturbed and to boost their self-esteem. Therefore, the set ethics and standards set to govern the psychiatric treatment in the medical field are important. A therapist is required to exhibit moral standards in the execution of his/her duties whether dealing with groups or individuals. Efficiency and positive outcome is also required.
However, there are unique ethics that are required of the group therapy that ensure the comfort of both the therapists and the members of a specific group. Due to the openness in this kind of therapy, where the individuals talk about their personal experiences among many others, sufficient measures have to be put in place to avoid controversial results and complaints from either side. The ethical issues include:
The entire group members have the right to have the information shared kept away from the public. This is by both the therapist and the other members in the group. This is an ethical issue in the psychiatric treatment, specifically the group therapy. A well-qualified therapist should not at any point let out the information shared by the group members to a third party. This protects the privacy of each of the members’ information, which is also a constitutional right. Evidence of leakage of the information to third parties by the therapist could lead to serious outcome such as loss of the job. It could also go as far as a lawsuit by the patient, which is punishable by the court of law, according to the specifications in the psychiatric treatment laws. According to Heimberg, and Becker, (2002), “The instrument is a contract for confidentiality among the members of his group whose purpose is the reduction of social anxiety among its members” (Pg 153). With the guarantee that their information will be safe, the patients will be more likely to speak openly to the therapist and share the problems they are facing with the therapist. Resistance will be minimal and positive results will be realized.
Heimberg, and Becker, (2002) stated that, “Each member acknowledges the need to keep the personal information shared in the group private.” (Pg 153). This is very important in any group setting. Just as the therapist needs to guarantee the privacy of the information by the group members, the members should also guarantee the confidentiality of information relating to them. This is a required ethical standard required of the patients in the therapy. The therapist must sensitize them on the importance of the privacy and the ramifications if they do not comply. To assure the members of this, the agreement to the confidentiality should be put in writing where all the members sign their agreement for evidence in cases of breaches. The contract is known as the ‘Confidentiality Contract for Social Phobia Groups’ (Heimberg and Becker, 2002). The information shared in the session is supposed to remain between the members and under no circumstances should it be shared with a third party without the consent of the person whom it concerns.
There are situations that arise in the process of a group therapy that will require the therapist to make urgent decisions on, using their due care and skill. Christner, Stewart, and Freeman, (2007), stated that, “Ethical dilemmas usually arise in an interpersonal context. This makes ethical decision making much more difficult than on an exam” (Pg 65). The therapists are not required to violate any of the ethics governing. In such a situation, the therapist is required to make a decision concerning a rising issue without violating the rules that govern them such as confidentiality. Ability to make effective decisions regarding the matters of the patients is an ethical requirement of the profession. Failure to provide solutions for the patients will exhibit lack of proper leadership, which will lead to the member of the group losing confidence in the group leader. Leadership is also required for the decision-making ability of the therapist to be significant.
There are steps that the group therapist can apply to reach a fair decision, which will not favor some members and leave others dissatisfied. The process also ensures the conclusion reached will not compromise the other ethics of the profession. In children and adolescents, problems of misunderstanding are likely to arise that will need immediate attention. In this case, the therapist needs to identify the problem from the concerned parties who are his group subjects. He/she can further come-up with alternatives that may solve the problem without conflicting any of the members or creating anxiety. The therapist can further analyze the options he/she has at hand and the possible effects they are likely to have on the patients. After the analysis, the therapist can use the influence he has to the subjects to implement the option he deems best. He can then assess the outcome to confirm that the results are not below the expectations or the required standards (Christener, et al, 2007). This becomes more successful if the patients trust the leadership of the therapist.
According to Christer, Stewart, and Freeman, (2007), “Competence may refer to the technique, skills in working with particular problem areas (group therapy), a particular population, or emotional stability” (Pg 65). For a person to be competent as a group therapist, they need to exhibit the capability of handling the situations brought to them. The ethical requirements of the group therapy require the group therapist to be competent in the area of practice. This is achieved by accuracy and consistent practice in the same field. Having a degree or academic education does not guarantee the acquisition of knowledge in the field. Therefore, for a person to be considered as proficient in the field, their skills have to be evaluated by the relevant authorities. Competence to provide group therapy effectively entails the ability to be competent as a therapist in general and the ability to be competent as a group therapist. This is because the therapist whether working with groups or individuals, must possess the skills of a therapist in general. Diversity in the service provision is also required.
A therapist is required to offer therapy to people from diverse backgrounds. This is because issues affecting people differ in many ways. This could be drug addiction, rejection, depression, sexual abuse and low self-esteem. The age groups and gender also varies; they could be children, adults, male or female. The ability to handle any case and have positive results incase of an emergency qualifies a therapist as competent. According to, Christener, Stewart, and Freeman, (2007), “Most agencies and organizations do not provide training opportunities to in this valuable skill to make up for weaknesses in graduate training… spend their time and money to ensure competence.” This shows that the competence can only be achieved through efficient training and practice.
Protection of Members
When dealing with people suffering from different issues, it is the responsibility of the organization through the therapist to protect them (DeLucia-Waack, 2004). The members of the group should not be at any risk of harm when undergoing therapy. This is because the circumstances of the problems faced are different. For instance, a person escaping from a sexual abuser may live in fear of the person coming after them. It may also be real that they are targeted by the abuser to keep them from leaking the information to the authorities. The ethics of group therapy require that the group member be protected from further attacks by both the members and the therapist. There should be no instances where the group members or the therapist scheme with the external parties to betray one of their own; this is punishable by the court of law where there is sufficient evidence. The members should also choose whom they want to see and whom not hence, maximum protection to them. The therapist using due care can also determine what the members can be exposed to for protection purposes. For instance, a suicidal patient should not be offended and exposed to sharp objects of high buildings where they can commit suicide.
In any profession, the separation of personal life, feelings and emotions from ones work is necessary. The profession should be considered a very separate entity from the individual’s personal life. Therapy is a profession like any other where the person in practice has to be professional when dealing with the patients just as they need to be competent. This is challenging since the issues the therapists deal with may be emotional. For instance, a therapist dealing with a group whose members have undergone sexual abuse in the hands of trusted people in their lives? It is a pitiful state and the victims may need emotional support from the therapist. The therapist should be in a position to do this without sending mixed signals to the patient. The profession dictates that the therapist should be empathetic and show understanding. However, they should not sympathize to an extent of showing their emotions. This is the advantage of the group therapy since the group members will offer consolation to each other as the therapist gives them solutions on how to move on. The relationship between the group therapist and the members should therefore be maintained strictly at a professional level.
Punctuality is also an element of professionalism. There are rules and regulations that are similar to all professions. The ethical issue of the group therapy regarding the punctuality as a form of professionalism is however very demanding. This is because the therapists deal with very vital matters that require the trust of the patients. The therapy can only be effective to the group members if he/she is able to gain their trust. Failure to which, they will not freely open-up for the sessions. The professional character of the therapist should not be questionable. Ability to make it to the sessions in due time is an indication of dedication and professionalism, the ethics Therefore of the professional demand professional interaction and observation of regulations for efficiency.
Screening and Orientation of Members
Screening is when the members of a group are assessed to establish whether they have the same issues and whether they can relate to each other’s problems. This is to ensure no group member will be uncomfortable and unable to get the help he or she requires. Orientation on the other hand requires introducing the members to the surrounding and familiarizing them to the contents of the therapy for the purposes of preparation. Screening and orientation is an ethical issue in the practice of group therapy (DeLucia-Waack, 2004). They are important since the performance of the group therapist will be efficient. The members of the group will also be able to open up to each other since they are already aware of the similarity in their problems. Time is also saved since the sessions start immediately.
Consent to Treatment
A patient cannot be treated or subjected to therapy without their approval. A therapist can only attend to a patient who willingly seeks the treatment or through the next of kin in an event where they are not in a position to make the decision individually. Christener, Stewart, and Freeman, (2007) stated that, “the law and society presume that children are not able to make major life decisions on their own, and the rule that exists to deny children the right to make decisions independently, generally serve to protect them” (Pg 730). The only circumstance where a patient may be treated against their will is when they are not in a position to give consent and the treatment is for their own good. The ethics of group therapy require a patient to be in the group out of free will. They are also allowed to accommodate the people incapable of seeking the help willingly and are legible for the therapy. During the session, the therapist or the other group members should not have any person giving information against their will. The information released by one member to the others in the group should also be out of free will and not through intimidation or the use of force.
However, the ethics allow the group therapist to choose the people to belong in a particular group. As discussed earlier, ethical decision-making is necessary. This is applicable in as much cases such that the patient or group member cannot choose the group to belong to. It is assumed that the competence of the therapist and the ethical decision-making capability will enhance the use of skill, due care and expertise to group the patients where they deem right. In the case of children, there consent will not be required but the permission from the parents to advance the treatment (Christener, et al, 2007). In cases where the treatment has been suggested by the parent or child’s guardian, the intention of the parent should not be given much consideration. This is because of the many misunderstandings of children behavior due to limited training on child development. Claims that the child is violent and disobedient should not be given much care. The therapist should instead use their professionally acquired skills to get to the root of the problem to help the child. The parent/guardian should also be sensitized on the basics of taking care of a troubled child.
Keeping of Group Records
Group therapies are required to continue regularly over a specified period. This should be specified by the group therapist to the members and the themes for every session clarified. This avoids confusion and ensures that the members and the therapist are prepared in advance for the anticipated session and its discussions. The therapist may also be handling different groups during different sessions. To avoid confusion, the ethics of group therapy require the therapist to maintain records of the different groups. According to Christener, Stewart, and Freeman, (2007), “The central dilemma with regard to record keeping in group psychotherapy is whether to keep the records separately for each individual group member or to keep one record for the group as a whole” (Pg 81). Although important and an ethical requirement, it is controversial since the preferred method may compromise the other ethics of group therapy. For instance, choice of group record keeping will interfere with the confidentiality of the information. This occurs where the group members have access to the records. A court proceeding of one of the members requiring the details of one member may have access of the other members as well. It however reduces the bulk of the records (Christener, et al, 2007).
On the other hand, the individual record keeping will be bulky and time consuming when access is needed either by the court, the therapist or the group member it concerns. It however guarantees the confidentiality of the patients since the access of a member’s file/records will only be by the therapist and the member. Since it is a required ethic, the standards should be met and the records maintained. Although bulky and limiting fast and easy retrieval, the individual records should be maintained to avoid compromise on the other ethical issues.
The members of a group therapy and the therapist are required to maintain confidentiality in the course of their therapy and even after. Information should only be released with the consent of the victim. However, this is not applicable in the case of sexual abuse of a minor by a close relation or a guardian. For instance, a child abused by an uncle or a guardian. The ethics of group therapy require that the matter be reported to the authorities. This is mainly because the abuse is likely to continue after the therapy if not reported or the perpetrator dealt with. Therefore, to ensure the safety of the patients during and after the therapy, matters pertaining to sexual abuse especially to minors must be reported (Christener, et al, 2007). Concealing the matter is considered a breach to the ethical concern.
Challenges of Group Therapy
Research has proved that group therapy in some situations can have negative effects on the group members especially the youth. According to, Kaminer, (2005), “… it has been argued however, that aggregation of youths who display problem behavior into group interventions may, under some conditions, produce iatrogenic effects on all participants.” Iatrogenic effects are the result of advice from the therapists that worsen the problem or the behavior of the patient or the member of the group. It can also result from treatment. This is a rare reaction among the youth following the therapy. It is however not clear what leads to these reactions since the therapy or medication is always intended to making the victims get better and feel good about themselves. This has hindered desired progress for victims seeking group therapy. This is because of the uncertainty of the impact of the therapy on the individuals.
Therapy is important for people suffering psychologically. Causes of psychological sufferings vary; therefore, the therapist has to ensure he/she detects what the cause is. Group therapy will require the victims to undergo the counseling procedure together, thus the members of one group have to be comfortable with each other and with similar predicaments. As a therapist, one is entrusted with very vital information concerning the members of the therapy group. The members trust each other with their information, which is very risky. Therefore, the ethics of the group therapy are put in place to ensure no one is hurt by another. Professional relationship with the patients ensures there is no over reliance on the therapist. The group members and the therapist are sensitized on the importance of keeping information relating to others confidential. Despite some of the challenges, group therapy is encouraged since it is more accommodating to the patients.
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