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53
C h a p t e r 4
ETHICAL AND LEGAL ISSUES
IN FAMILY AND COUPLE THERAPY
Jeffrey E. Barnett and Cara H. Jacobson
Family and couple therapy is a branch of psycho
therapy that works with multiple clients’ relation
ships with one another in order to nurture growth
and change. This type of psychotherapy conceptu
alizes the origin of conflict as being dysfunctional
interactions within the family or couple system.
This approach to psychotherapy also emphasizes
relationships as important factors in attaining and
maintaining mental health. At any given time, over
1.8 million people participate in marriage and family
therapy (American Association for Marriage and
Family Therapy, 2018). Family and couple therapy
is a growing field, and this treatment is helpful
and necessary for numerous families and couples
experiencing conflict and distress related to relation
ship difficulties. Although this treatment is highly
sought out and very needed, not all clinicians are
trained to provide effective family and couple therapy.
In addition to possessing the necessary clinical
expertise to effectively offer these treatment services,
it is crucial that family and couple therapists are
knowledgeable about ethics and legal issues relevant
to their work. This chapter addresses the ethics and
legal issues for family and couple therapists to take
into consideration, including competence; multi
cultural awareness; informed consent; boundaries
and multiple relationships; and legal issues related to
confidentiality and its exceptions, the duty to warn,
and child custody issues.
CLINICAL COMPETENCE
Before providing couple and family therapy services,
it is essential that mental health clinicians first
develop the clinical competence needed to provide
these services effectively (see Chapter 26, this
volume). Competence is defined by Epstein and
Hundert (2002) as “the habitual and judicious use
of communication, knowledge, technical skills,
clinical reasoning, emotions, values, and reflection
in daily practice for the benefit of the individual
and the community served” (p. 226). Similarly,
Haas and Malouf (2005) described competence
as possession of the requisite knowledge, skills,
attitudes, and values, as well as the ability to imple
ment them effectively for the benefit of the client.
More specifically, Rodolfa et al. (2013) presented a
model of competence for the practice of psychology
that includes the following six domains: scientific
knowledge, evidencebased decision making/
critical reasoning, interpersonal and cultural
competence, professionalism/ethics, assessment,
and intervention/supervision/consultation.
Understanding Competence
The development of each clinician’s clinical com
petence begins in graduate school with academic
course work and supervised clinical experience
(see Chapter 26, this volume). It does not stop there,
http://dx.doi.org/10.1037/0000101004
APA Handbook of Contemporary Family Psychology: Vol. 3. Family Therapy and Training, B. H. Fiese (EditorinChief)
Copyright © 2019 by the American Psychological Association. All rights reserved.
APA Handbook of Contemporary Family Psychology: Family Therapy and Training,
edited by B. H. Fiese, M. Celano, K. Deater-Deckard, E. N. Jouriles, and M. A.
Whisman
Copyright © 2019 American Psychological Association. All rights reserved.
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Barnett and Jacobson
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however, because attaining and maintaining com-
petence is an ongoing endeavor that each clinician
must work at on an ongoing basis throughout the
course of his or her career. Competence should not
be seen in all or nothing terms; one is not either
fully competent or completely incompetent. Com-
petence falls along a continuum and has many
elements to it, with each one potentially falling
at a different place along that continuum. One
may possess a certain degree of competence in
some aspects of practice and different levels of
competence in others. Additionally, one may be
considered competent at one point in time and not
at others; without adequate ongoing efforts, com-
petence can deteriorate and knowledge and skills
can become obsolete over time (Neimeyer, Taylor,
Rozensky, & Cox, 2014).
Rather than asking if one is competent, it is more
appropriate to ask if one is sufficiently competent
in the use of the specific treatment techniques and
modalities relevant to the client’s treatment needs
and if one is sufficiently competent in the treatment
of the client’s particular presenting problems. Thus,
clinical competence should not be considered from
a global or holistic level but more specifically as it is
relevant to treating a particular client.
Although many of the competencies (i.e., areas of
knowledge, skills, and abilities) that are associated
with being an effective individual therapist are
relevant to clinical work with families and couples,
they are not sufficient for practice as a family or
couple therapist. Mental health clinicians seeking to
treat families and couples will need to significantly
add to their general competence in order to provide
effective treatment in the specialty area of family
and couple treatment.
As addressed in Standard 2.01, Boundaries
of Competence, of the American Psychological
Association’s Ethical Principles of Psychologists and
Code of Conduct (APA Ethics Code; APA, 2017a),
psychologists should provide services to populations
and in areas only within the limits of their compe-
tence. Competence can be understood in terms of
three distinct obligations that clinicians accept in
treating clients. These three obligations include
becoming familiar with professional and scientific
knowledge, acquiring professional skills, and finally,
knowing when it is appropriate to make referrals to
other professionals when one does not have the skills
or ability to perform work in a competent manner
(Dean, 2010). When treating families and couples in
psychotherapy, it is important that clinicians possess
the specialized knowledge, skills, training, and expe-
rience needed to provide effective treatment.
Clinicians who treat families and couples need
to have adequate education, training, demonstration
of skills, and licensure as a minimum level of
competence in treating these populations. Training
programs currently determine methods of assessing
students in different competency areas, including
family and couple therapy. Additionally, most
programs offer academic courses in the treatment of
families and couples, and many graduate students
are given the opportunity to work clinically with
these populations during their training. Ideally,
therapists can gain this real world experience
prior to treating families or couples independently
once they are licensed. Yet, licensure should not
be misconstrued as implying clinical competence,
as it only implies that the clinician possesses the
necessary general competence to practice psychology
independently. Family and couple therapists should
work to continually enhance the knowledge relevant
to competence as a family and couple therapist
through ongoing professional education, staying
current with the professional literature, and by
contributing to the field by engaging in research and
scholarship that enhances our knowledge base.
Acquiring professional skills. Initially, these
skills may be developed through supervised
clinical experience during a therapist’s training.
For practicing family and couple therapists, the
development and enhancement of these skills may
be achieved through participation in advanced
specialty training and certification programs in
family and couple therapy that include supervision
and evaluation of relevant clinical skills.
The American Board of Professional Psychology
(ABPP) recognizes 14 specialties in the practice of
psychology. ABPP defines a specialty as an “area
in the practice of psychology that connotes special
competency acquired through an organized sequence
of formal education, training, and experience”
(ABPP, 2015, paragraph 5). Furthermore, in addition
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Ethical and Legal Issues in Family and Couple Therapy
55
to having a recognized set of competencies, each
specialty has its own identified “requirements for
education, training, experience, research bases of
the specialty, practice guidelines. . . .” (paragraph 5).
Couple and family therapy is one of the 14 special
ties in psychology that are recognized by the ABPP.
Although board certification is not required to
practice couple and family psychology, with licen
sure being the only requirement to practice inde
pendently, board certification sets the standard for
recognition of advanced competence in specialty
areas. Thus, board certification provides a recog
nized standard for demonstrating advanced compe
tence in couple and family therapy.
While psychologists may demonstrate their
specialized competence in couple and family therapy
through board certification by ABPP, several training
and certification programs exist that provide mental
health clinicians the opportunity to develop special
ized knowledge and skills relevant to family and
couple therapy. For example, clinicians can become
trained and then certified or credentialed in emotion
ally focused therapy (see Chapter 18, this volume)
or the Prevention and Relationship Enhancement
Program (see Chapter 19, this volume) in treating
couples; or the Incredible Years series programs
(see Chapter 21, this volume), parent–child inter
action therapy (see Chapter 23, this volume), Family
CheckUp and Everyday Parenting (see Chapter 24,
this volume), or Triple P Positive Parenting Program
(see Chapter 25, this volume) in treating families.
These are just a few of the many types of available
empirically supported couple and family therapy
approaches in which one may become certificated or
credentialed. Additionally, clinicians should engage
in ongoing efforts to maintain and build upon their
competence and to stay current with the latest devel
opments in the field, including seeking consultation
with experts in various aspects of practice, partici
pating in continuing education courses, and
immersing themselves in the current research litera
ture relevant to family and couple therapy.
Self-assessment of competence. When a mental
health clinician does not possess the needed
competence to provide the treatment services
necessary to meet clients’ treatment needs, it is
often in the clients’ best interest to refer them to a
professional who possesses that needed competence.
Often, however, whether a clinician should treat
a particular family or couple or refer them to a
colleague for treatment is not clear. Careful and
honest reflection on one’s ability to effectively treat
the family or couple is of great importance for
meeting one’s ethical obligations and for ensuring
that clients’ treatment needs are appropriately
met. Yet, mental health clinicians, like all health
professionals, demonstrate great difficulties
with accurate selfassessment. Clinicians tend to
overestimate their abilities and to be unaware of
difficulties or deficits in their competence (Dunning,
Heath, & Suls, 2004; Kruger & Dunning, 1999).
Thus, selfassessment alone is insufficient and
clinicians must actively utilize consultation with
colleagues to help determine the appropriateness of
treating certain clients.
Although it is important for clinicians to
engage in selfassessment and utilize consultation
regarding all populations treated, family and
couple therapy involves specific concerns that
become very relevant to assessing competence in
a continuous and conscious way. APA Ethics Code
Standard 2.04, Bases for Scientific and Professional
Judgments, requires psychologists’ work to be
based upon established scientific and professional
knowledge. In addition to the need to remain
current on empirically based treatments related to
family and couple therapy, multicultural biases;
prejudices; implicit and explicit beliefs; and personal
values, morals, and life experiences come into play
strongly when working with families and couples.
Standard 2.06 of the APA Ethics Code, Personal
Problems and Conflicts, states that psychologists
must be “aware of personal problems that may
interfere with their performing workrelated duties
adequately” (APA, 2017a, p. 5) and in a competent
manner. For psychologists to remain competent, it
is recommended that they address these different
areas by using supervision and consultation and by
being open to colleagues’ feedback and guidance. In
Standard 2.03 of the APA Ethics Code, Maintaining
Competence, it is stated that psychologists should
make ongoing efforts throughout their careers to
develop and maintain their clinical competence
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Barnett and Jacobson
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and effectiveness. This continuous process of self
assessment, consultation, and the development
of ongoing competence is critical for the effective
treatment of couples and families in therapy.
Couple and Family Therapy Competencies
Competencies related to family and couple therapy
are unique and different from the competencies
required to conduct effective individual psycho
therapy. As discussed previously, competence in
individual therapy is necessary but not sufficient
for the practice of family and couple therapy, due to
the unique nature of family and couple work. The
field of family and couple therapy is highly special
ized; thus, clinicians should be knowledgeable about
family and couple systems theories as well as specific
family systems therapy concepts and treatment
implications such as triangulation, boundary perme
ability, alignments and coalitions, and paradoxical
tasks in the therapy (Bowen, 1978; Haley, 1976;
Minuchin, 1974; see Chapter 7, this volume).
Families and couples often seek treatment
when their family or dyadic system becomes
dysfunctional, and cases should be conceptualized
using a systems perspective throughout the entire
course of treatment. In this type of specialized
treatment, the family or the couple—rather than a
specified individual—is the client, and clarifying
the clinician’s obligations to each party from the
outset is vital for treatment to be effective (Fisher,
2009). A systems perspective should permeate
case conceptualization, assessment and diagnostic
issues, treatment planning, interventions, and
even considerations regarding termination of
treatment when working with families and couples.
Additionally, family and couple therapists should be
knowledgeable of and competent in the use of the
treatment skills demonstrated to be relevant to the
effective treatment of these clients (see Chapter 26,
this volume, for detailed information on these
competencies).
MULTICULTURAL COMPETENCE
In all psychological treatments, multicultural
considerations should be used as a lens through
which to view every clinical case (see Volume 2,
Chapter 26, this handbook). Its implications are so
important in work with clients that multiculturalism
is considered to be the fourth force in psychology,
with psychoanalysis, behaviorism, and humanism
being the first three forces (Pedersen, 2001).
Multicultural considerations should be integrated
into all clinical work in order to strengthen clinical
conceptualizations and treatments, regardless of
the clinician’s theoretical orientation. Principle E
of the APA Ethics Code, Respect for People’s
Rights and Dignity, directs clinicians toward being
aware of and respecting cultural, individual, and
role differences and considering these factors
when working with clients to avoid participating
in activities or treatments based on prejudices,
biases, or stereotypes. Additionally, in 2003 the
APA published the Guidelines on Multicultural
Education, Training, Research, Practice and
Organizational Change for Psychologists, further
reinforcing the importance and value of including
multiculturalism in all clinical interactions. In
2017, APA updated these Guidelines in order to
reconsider diversity and multicultural practice,
with intersectionality as its primary purview
(APA, 2017b) The APA Multicultural Guidelines
recommend that all psychologists (whether they are
involved in education, training, research, practice,
or organizational change) work toward knowledge
of themselves and their own cultural identities, as
well as knowledge of other cultures, in order to
provide clients with the most appropriate, relevant,
and effective services possible (APA, 2003, 2017b).
The development of multicultural competence
is built upon selfawareness of biases, and this
examination is a dynamic rather than a static
process. Sue et al. (1998) defined multicultural
competence as the development of cultural
knowledge, cultural skills, and cultural awareness
so as to intervene effectively. Cultural knowledge is
understood to be the ability to gather meaningful
facts to increase comprehension about one’s own
and others’ cultures, cultural skills consist of the
abilities to intervene in effective and competent
ways regarding culture, and cultural awareness is
defined as the ability to accurately understand a
cultural situation from the client’s perspective as
well as an awareness of the clinician’s implicit biases
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Ethical and Legal Issues in Family and Couple Therapy
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and privileges present in that cultural situation
(Pedersen, 2001).
Multicultural Knowledge
With Families and Couples
To develop multicultural competence with families
and couples, clinicians must understand families
through the lens of their selfviews, beliefs, cultural
backgrounds, and family interactions and practices
(McGoldrick, Giordano, & GarciaPreto, 2005).
Gathering this knowledge does not stop with being
aware of clients’ cultures; clinicians must be aware
of the role of their own identities and beliefs and
how they intersect in complex ways with how
clinicians view and interact with families and
couples in treatment. It is important to understand
cultural attitudes toward families and couples
as well as differing definitions of normality and
dysfunction (McGoldrick et al., 2005).
Developing specific cultural knowledge is
essential when working with families and couples.
Therapists in the United States are frequently
taught treatments that are rooted in Eurocentric
frameworks and thus prioritize Western values,
often failing to address important differences
among cultures (Kelly, Maynigo, Wesley, &
Durham, 2013). For example, when working with
Asian Indian American families in therapy, one
should inquire about gender roles and the role
of the extended family in the treatment process.
Additionally, an intergenerational or structural
theory or framework may be particularly helpful
for many Asian Indian Americans, considering
the influence of the extended family and concerns
related to family rules, boundaries, and roles
(DuPree, Bhakta, Patel, & DuPree, 2013). Similarly,
when treating African American families or couples,
it is essential that the clinician be aware of how
larger systems affect the family structure and may
lead to mistrust within the family or couple system,
in the relationship with the therapist, and in the
larger societal system (Kelly et al., 2013).
Clinicians also need to be aware of empirically
based knowledge when working with lesbian, gay,
bisexual, transgender+ (LGBT+) couples and fami
lies. There is a perception that the norm is White,
Westernized, heterosexual, and cisgender (i.e., being
assigned at birth to the gender one later identifies
with); therefore, it is crucial for clinicians to seek
out literature on the treatment of people who iden
tify as LGBT+ in terms of development and identity
(Martell, 2015). It is also necessary for clinicians to
possess knowledge of the larger societal forces that
these families and couples are dealing with, so as
to provide competent treatment by taking broader
systemic influences into consideration. Additionally,
when providing family or couple therapy to LGBT+
populations, clinicians need to selfreflect upon
biases, stereotypes, and privileges they may hold and
consider how these may impact their perceptions of
and interactions with these clients.
These examples highlight the importance
of developing culturally sensitive practices that
incorporate knowledge about cultures. It is also
valuable to note that although gaining specific
knowledge about each client’s reference group is
helpful, it is important not to make assumptions
based solely on research and to always check in
with the particular family or couple in treatment to
understand their specific cultural experiences.
Multicultural Skills With
Families and Couples
Hays (2001) provided a framework for therapists
to better recognize and understand individual and
cultural influences as a dimension of psychotherapy
work. This model is referred to as the ADDRESSING
framework and it recommends that clinicians take
into consideration a combination of information
about age, developmental and acquired disabilities,
religion, ethnicity, socioeconomic status, sexual
orientation, indigenous heritage, national origin,
and gender with all clients (Hays, 2001). Using this
framework promotes culturally sensitive practices
that should enhance psychotherapy skills with
families and couples, as it will likely result in an
increased awareness of who one’s clients are; the
forces or stressors they are dealing with; and their
worldview, perceptions, and experiences.
The use of culturally sensitive skills should
begin with the initial assessment of each family
and couple. It is recommended that clinicians
approach this work in interactive and supportive
ways, assessing clients’ worldviews rather than
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making judgments about clients’ beliefs, values, and
practices based on their identified or observable
individual factors as well as cultural differences
(Ibrahim & Schroeder, 1990). Upon initial
assessment, clinicians may use scales such as the
Scale to Assess World View (SAWV) to help clients
to clarify their own cultural worldviews and to help
the family or couple therapist to understand them
(Ibrahim & Schroeder, 1990).
Multicultural Awareness
With Families and Couples
When treating families and couples, it is important
to continuously check in with one’s self and with
clients to confirm that conceptualizations and
interventions are culturally sensitive, relevant, and
appropriate. It is also important that family and
couple therapists understand their personal values,
biases, and privileges and how they may impact
their view of and interactions with clients, their
judgments about treatment goals, and their choice
of interventions.
To achieve and maintain cultural competence,
it is crucial that clinicians continuously explore
their own individual and relational assumptions
in terms of questions related to cultural values,
gender role biases, traditional versus egalitarian
family roles, infidelity, divorce, and other mores and
cultural customs. These ideas are likely to change
throughout one’s lifetime, and thus the examination
of personal values is a dynamic and ongoing process
that requires honest reflection and can be aided by
consultation with colleagues.
INFORMED CONSENT TO COUPLE
AND FAMILY THERAPY
The doctrine of informed consent is based on the
premise that each client has the right to receive
and understand information about the professional
services being offered that is sufficient to enable
the client to make an informed decision about
participation. Historically, physicians provided
treatment without first seeking patients’ consent.
Physicians possessed knowledge and expertise,
evaluated their patients, and determined the
treatments and interventions that they deemed to
be in their patients’ best interests. Over time, as
some patients perceived themselves to have been
harmed by their physicians’ actions, they filed
malpractice suits against their physicians. When the
courts ruled in the patients’ favor, awarding damages
to them, these legal rulings created precedent and
altered professional practice standards. The rulings
of these lawsuits have created the doctrine of
informed consent as it is known today, and many
of the standards from these legal rulings have
been incorporated into the requirements found
in licensing laws and ethics codes (Barnett, Wise,
Johnson-Greene, & Bucky, 2007).
Ethics Standards and Requirements
The APA Ethics Code (APA, 2017a) addresses
informed consent requirements for psycholo-
gists in several relevant enforceable standards.
Standard 3.10, Informed Consent, requires that
psychologists first obtain the informed consent
of participants before providing them with any
psychological services, “except when conducting
such activities without consent is mandated
by law or governmental regulation . . .” (p. 6).
Standard 10.01, Informed Consent to Therapy,
clari fies the need for informed consent by stating
that the establishment of this consent should occur
as early as is feasible in the treatment process and
that the clinician should inform clients about
(a) the nature and anticipated course of therapy;
(b) fees and financial arrangements; (c) any
involvement of third parties; (d) confidentiality
and its limits; (e) the nature of any experimental
or unproven treatments or techniques, potential
risks, and treatment alternatives that are reasonably
available; (f) the right to refuse participation; and
(g) the licensure status of the clinician, including
whether he or she is a trainee and practicing under
another individual’s license, in which case the
clinician should also share the name of his or her
supervisor with the client. Additional informa-
tion to be shared in the informed consent process
includes (a) the clinician’s credentials, training,
and experience relevant to the professional services
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Ethical and Legal Issues in Family and Couple Therapy
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being offered; (b) scheduling and cancellation poli
cies; (c) emergency contact information; (d) any
recording (audio or video) of treatment sessions;
and (e) termination or transfer of clients.
Further, for the informed consent process to be
considered valid, four criteria must be met. First,
the informed consent must not be coerced; it must be
provided voluntarily. Second, the individuals involved
must be competent (emotionally, intellectually,
and legally) to provide consent. Third, therapists
must actively ensure clients’ understand ing of that
to which they are agreeing. Finally, the informed
consent must be documented. Merely having a
verbal agreement about the parameters of the
treatment to be provided is insufficient (Snyder &
Barnett, 2006).
Snyder and Barnett (2006) reported that informed
consent is an ongoing process that has the benefit of
“promoting client autonomy and selfdetermination,
minimizing the risk of exploitation and harm, foster
ing rational decision making, and enhancing the
therapeutic alliance” (p. 37). Furthermore, the
information sharing component of the informed
consent process helps in demystifying psychotherapy,
reducing apprehension and anxiety clients may have,
and increasing their investment in the treatment
(Beahrs & Gutheil, 2001).
It is also important that cultural and other
diversity issues be integrated into the ongoing
informed consent process, with the process being
modified to meet each participant’s needs. As Pope
(1991) explained, the informed consent process
must be customized to meet each individual person’s
needs. For example, how one typically conducts the
informed consent process may need to be modified
with people for whom English is not their first
language, for those who are visually or hearing
impaired, and for those whose cultural norms may
require the inclusion of others in the informed
consent process (e.g., community elders, extended
family members, religious leaders).
Informed Consent and Assent
When someone is not able or authorized to give
her or his own informed consent, assent is sought.
Individuals who are not legally authorized to
provide their own informed consent include minors
(although the age of majority varies by jurisdiction
and there are exceptions in some jurisdictions; e.g.,
for minors who are married, have a child of their
own, or are in military service) and individuals who
do not have the intellectual capacity needed to fully
participate in the informed consent process, such as
people who are intellectually disabled or suffering
from cognitive impairment due to mental illness,
head trauma, or dementia.
Assent is a process of sharing information with
an individual and providing information about the
treatment to follow so that the individual is as well
informed about it as is possible (Kuther, 2003).
Even if someone does not have the right or ability
to give their own consent, receiving this informa
tion at the outset of the professional relationship
is important for the reasons mentioned above
regarding informed consent.
With minors, even when not legally authorized
to provide their own informed consent, the assent
process needs to be tailored to each person’s
developmental level and level of understanding
(Koocher & Daniel, 2012). As minors’ age and
developmental level increases, their ability to
participate more actively in this information sharing,
discussion, and decisionmaking process increases.
Minors as young as 12 years of age often possess
the ability to understand the consequences of their
decisions, including health care decisions (Redding,
1993). At increased developmental levels, minors
develop the capacity to understand the information
presented, to express preferences, and to comprehend
the likely outcomes of their decisions (McCabe,
2006). Thus, even when minors are not afforded the
legal right to give their own informed consent, the
assent process should be modified to include seeking
and considering minors’ preferences regarding
treatment plans and related issues. Important reasons
for including minors in the informed consent and
assent processes include (a) demonstrating respect
for minors and their autonomy, (b) helping to
promote the therapeutic relationship and alliance,
(c) helping to empower minors on their own behalf,
and (d) promoting minors’ active participation in the
treatment process (Lind, Anderson, & Oberle, 2003).
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TREATING MULTIPLE INDIVIDUALS
IN FAMILY AND COUPLE THERAPY
In contrast to individual psychotherapy, in family
and couple therapy there is not a single individual
who is identified as the client. Thus, as Fisher (2009)
stated, clinicians should not ask the question “Who
is my client?” Because couple and family therapists
are treating multiple individuals, the issue of who
the client is becomes rather complex. Answers may
vary depending on therapists’ theoretical orientation,
their manner of conceptualizing family and couple
therapy, and the wishes and preferences of those
seeking and participating in the treatment. Some may
view the family or the marriage or the couple itself
as the client. Thus, the client may be a relationship
or a family unit.
Clinicians should not rush to view the individual
who contacts them to initiate treatment as the client.
Often, one member of a family or one partner in a
couple will contact a clinician to seek out family
or couple therapy. Although seeking treatment
and initiating contact are important, they do not
by themselves create a therapeutic relationship or
contract. The interests, goals, objectives, and welfare
of all individuals involved in the treatment should
be considered by the clinician. Consistent with the
goals of the informed consent process, a treatment
agreement should be developed with the active
participation of all individuals involved. If one or
more members of the treatment constellation are
not in agreement with the proposed treatment plan
or the parameters of the treatment relationships and
process, these disagreements must be discussed fully
and work must be done to reach consensus before
proceeding with initiating treatment.
These recommendations are consistent with
Knapp and VandeCreek’s (2003) guidance stating
that before initiating treatment, therapists should
first “clarify their roles and relationships with all
parties” (p. 148). It is important not to assume
that one family member holds decisionmaking
authority or to collude with existing patterns of
family functioning that may be part of the issues
that brought them to treatment. When sharing
the ground rules of couple or family therapy with
clients, a widely accepted technique is to avoid
keeping secrets belonging to one family member
from the others and to state that all individual
communications in between treatment sessions will
be shared with the other family members at the next
treatment session (e.g., Kuo, 2009; Margolin, 1982).
The therapist will inform all individuals involved in
the treatment of this rule and obtain their acceptance
of it during the informed consent process.
Rather than asking “Who is the client?”, “What
are the client’s expectations and needs?”, and “What
are the therapist’s obligations to the client?”, Fisher
(2009) recommended modifying these questions
and instead asking “Exactly what are my ethical
responsibilities to each of the parties in this case?”
(p. 1). Considering this question will help ensure
that each person’s needs and interests are given
attention during the informed consent process.
Additionally, children’s and adolescents’ desires may
often be overlooked in family therapy, with parents
taking the lead in expressing treatment goals as well
as in providing consent to treatment. It is the family
therapist’s responsibility to ensure that each person
is given a voice and that each person’s needs and
best interests are considered. This may prove to be
challenging, especially when there are competing
needs and interests expressed, or in situations
wherein one or more family members are not willing
participants in therapy. Special care should be taken
to address each person’s needs and to obtain their
informed consent or assent to the treatment.
Consistent with the above principles, the APA
Ethics Code (APA, 2017a) in Standard 10.02, Therapy
Involving Couples and Families, requires that
When psychologists agree to provide
services to several persons who have
a relationship (such as spouses,
significant others, or parents and
children), they take reasonable steps
to clarify at the outset (1) which of
the individuals are clients/patients and
(2) the relationship the psychologist
will have with each person. This
clarification includes the psychologist’s
role and the probable uses of the
services provided or the information
obtained. (pp. 13–14)
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Ethical and Legal Issues in Family and Couple Therapy
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Boundaries
Boundaries are described as the ground rules of the
professional relationship. As Smith and Fitzpatrick
(1995) explained, boundaries provide “a therapeutic
frame which defines a set of roles for the participants
in the therapeutic process” (p. 499) and they “provide
a foundation for this relationship by fostering a sense
of safety and the belief that the clinician will always
act in the client’s best interest” (p. 500).
In couple and family therapy, relevant bound
aries may involve touch, time, space, location, self
disclosure, and gifts, among other issues. As Gutheil
and Gabbard (1993) first articulated, boundaries
may be avoided, crossed, or violated. To avoid a
boundary is to never engage in behaviors associated
with it. For example, for a family therapist to never
share any personal information about herself or
himself in any way would be to avoid the boundary
of selfdisclosure.
To cross a boundary is to traverse the boundary
but to do so in a clinically relevant, meaningful,
and appropriate manner. Thus, if a family member
asks if the therapist has worked with families
before, it would be relevant and likely helpful for
the therapist to share some information about his
or her professional education, clinical training,
and relevant experience. In fact, this form of self
disclosure could appropriately be included in the
informed consent process. Crossing the boundary
of selfdisclosure could also involve the therapist
sharing something about herself or himself
personally that is relevant to the client’s treatment
issues, with the goal of sharing this information
to assist the client toward her or his treatment
goals. Sharing generally about the challenges a
clinician had with his or her adolescent child in
the past and how working on respectful, open, and
honest communication on a regular basis proved
to be helpful for them could be a powerful and
meaningful intervention for the client.
In contrast, boundary violations involve
traversing a boundary but doing so in a manner
that is not motivated by the client’s needs or best
interests, is not clinically relevant to the client’s
treatment goals or plan, is likely to be exploitative
or harmful to the client, violates cultural or other
norms for the client, or is unwelcomed by the client
(Barnett, Lazarus, Vasquez, MooreheadSlaughter,
& Johnson, 2007; Zur, 2007). A therapist extending
the time of a treatment session to discuss his or her
own personal life or issues with a client that the
therapist finds interesting and relates to would likely
be a boundary violation in that this action appears
motivated by the therapist’s needs and interests, is
not directly related to the client’s treatment needs or
treatment plan, and is not likely to benefit the client.
Thus, boundary crossings may be quite appro
priate and even necessary for the effective conduct of
couple and family therapy. To avoid all boundaries
in an effort to prevent any possible ethical trans
gressions is not only impractical, it likely would
result in a rather sterile therapeutic environment and
an ineffective treatment alliance (Zur & Lazarus,
2002). Boundaries are a normal part of all relation
ships, but they must be managed effectively and
with thoughtful intent. When applied in this manner,
they are an essential part of treatment. Touching a
grieving client on the arm or shoulder, extending
the time of a session when a family member is
in crisis, and scheduling a family therapy session
in the clients’ home when one family member is
bedridden are examples of appropriate and clinically
relevant boundary crossings.
Multiple Relationships
Multiple relationships are formed when a mental
health clinician enters into a second relationship
with a client in addition to the treatment relation
ship. Examples can include business, personal,
social, romantic, and other relationships. A thera
pist also engages in a multiple relationship when
accepting into treatment an individual with
whom she or he has previously been in another
such (business, personal, social, romantic, etc.)
relationship. The APA Ethics Code (APA, 2017a),
in Standard 3.05, Multiple Relationships, makes it
clear that not all multiple relationships need to be
avoided, only those that hold significant potential
for exploitation of, or harm to, clients. However,
Standard 3.05 also explains that
A psychologist refrains from entering
into a multiple relationship if the
multiple relationship could reasonably
be expected to impair the psychologist’s
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objectivity, competence or effectiveness
in performing his or her functions
as a psychologist, or otherwise risks
exploitation or harm to the person with
whom the professional relationship
exists. (APA, 2017a, p. 6)
The APA Ethics Code (APA, 2017a) also makes
clear that psychologists may never engage in sexual
intimacies with current clients (Standard 10.05)
or with relatives or significant others of current
clients (Standard 10.06), may not provide therapy to
former sexual partners (Standard 10.07), and may
only enter a sexual relationship with a former client
under the most rare and unusual circumstances
as articulated in Standard 10.08. The goal of each
of these standards is to ensure that psychologists’
objectivity and judgment do not become impaired
and that clients are not exploited or harmed. It is
essential that clients and prospective clients trust
that psychologists will prioritize clients’ welfare and
that all decisions and actions by the psychologist
will be motivated by clients’ treatment needs and
best interests.
Conflict of Interest
To help family and couple therapists make decisions
about which multiple relationships are likely to be
helpful and appropriate and which ones should be
avoided, the APA Ethics Code states in Standard
3.06, Conflict of Interest:
Psychologists refrain from taking on a
professional role when personal, sci
entific, professional, legal, financial, or
other interests or relationships could
reasonably be expected to (1) impair
their objectivity, competence, or effec
tiveness in performing their functions
as psychologists or (2) expose the per
son or organization with whom the pro
fessional relationship exists to harm or
exploitation. (APA, 2017a, p. 6)
This guidance is consistent with the recom
mendations made above and can form the basis of
an ethical decisionmaking process when making
decisions about whether to engage in certain
boundary incursions or multiple relationships.
Family and couple therapists should also consider
Standard 3.04, Avoiding Harm, and Standard 3.08,
Exploitative Relationships, when making these
decisions.
LEGAL ISSUES IN FAMILY
AND COUPLE THERAPY
There are several issues relevant to the practice
of family and couple therapy that are regulated
by state laws. These include the licensure law
(and related regulations) in the clinician’s state of
licensure as well as additional laws passed by the
state’s legislature that are relevant to all licensed
health professionals in that state. Examples of
these laws include legally mandated exceptions to
confidentiality such as the requirement to report
suspected abuse or neglect of a minor client; the
duty to report suspected abuse or neglect of older
adults or other vulnerable adults; and laws relevant
to the duty to warn and protect when threats
of harm are made regarding other individuals to
the family or couple therapist. Other laws pertain
to clients’ involvement in legal proceedings and
the ability to share treatment information with
other health providers. Each of these should be
reviewed with clients as part of the informed
consent process. Because the exact wording and
requirements of these laws may vary by jurisdiction,
it is recommended that family and couple therapists
educate themselves about such laws in their state
of licensure. These typically can be found on each
licensure board’s website.
Exceptions to Confidentiality
Confidentiality is defined as “the secretkeeping duty
that arises from the establishment of the professional
relationship psychologists develop with their clients”
(Younggren & Harris, 2008, p. 589). Without an
assurance of confidentiality, clients may not feel safe
enough to open up and do meaningful therapeutic
work. Yet, confidentiality is not absolute and excep
tions to confidentiality exist. These exceptions attempt
to strike a balance between the need for privacy—to
encourage potential clients to feel safe enough to
seek needed treatment—and the need to protect
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Ethical and Legal Issues in Family and Couple Therapy
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vulnerable individuals from harm. Individuals are
typically considered vulnerable when they rely
on others for their daytoday care or protection.
Examples include minors as well as adults who do
not live independently and rely on others for their
ongoing care. Family and couple therapists are
required to inform clients of all required exceptions
to confidentiality at the outset of the professional
relationship. Informing clients of the confidential
nature of treatment as well as the limits to this
confidentiality is a crucial part of the informed
consent process.
Child abuse and neglect. The Federal Child Abuse
Prevention and Treatment Act (U.S. Department
of Health and Human Services, 2010) defines child
abuse as “any recent act or failure to act on part of a
parent or caretaker which results in death, serious
physical or emotional harm, sexual abuse or exploi
tation” or “an act or failure to act which presents an
imminent risk of serious harm” (para. 2). Neglect is
defined as “a failure to meet the child’s basic needs,
e.g., not providing enough food, shelter or basic
supervision, necessary medical or mental health
treatment, adequate education or emotional comfort”
(APA, 2015, para. 3).
In 2012, U.S. state and local Child Protective
Services (CPS) received an estimated 3.4 million
referrals of children being abused or neglected.
Of the child victims, 78% were victims of neglect;
18% of physical abuse; 9% of sexual abuse; and
11% were victims of other types of maltreatment,
including emotional and threatened abuse, parents’
drug or alcohol abuse, or lack of appropriate super
vision (U.S. Department of Health and Human
Services, 2012).
It has been found that mandated reporting
issues negatively affect family therapists’ abilities
to maintain a systemic focus (Strozier et al., 2005).
Thus, it is important for family and couple therapists
to remain aware not only of the mandated reporting
laws in their practice jurisdiction but also the impact
of reporting on the therapy relationship in order to
competently protect and treat their clients.
Elder adult abuse and neglect. Elder abuse and
elder neglect are defined respectively as intentional
or unintentional actions that cause harm or create
a serious risk of harm to a vulnerable elder by a
caregiver (Bonnie & Wallace, 2003). State laws on
this issue vary, with some referring only to older
adults and others addressing vulnerable adults in
general. Additionally, some state laws mandate the
reporting of suspected abuse and neglect, whereas
others also include selfneglect and exploitation of
these individuals.
Between 7.6% and 10% of vulnerable adults are
subject to abuse, neglect, selfneglect, and/or exploi
tation each year (Acierno et al., 2010). Due to the
high prevalence of these experiences, in working
with families or couples it is likely that therapists
will come into contact with these difficult situa
tions at some point in their careers. It is important
for family and couple therapists to be aware of the
statistics as well as the warning signs of elder abuse.
As in other legal scenarios, it is crucial for therapists
to competently assess all relevant clients for signs
of abuse and neglect, have knowledge of mandated
reporting laws, and be sensitive to the impact that
reporting suspicions of abuse and neglect may have
clinically on families and couples.
Duty to warn and protect. The duty to warn and
protect applies to situations wherein a client makes a
threat to do harm to an identifiable victim or group
of victims. Warning involves making a good faith
effort to contact the intended victim and protect
ing involves contacting the police. However, each
state has its own laws on these matters, with some
having a duty to warn law, some having a duty to
protect law, some requiring both, and some states
not allowing clinicians to breach confidentiality
in these situations (Werth, Welfel, & Benjamin,
2009). In many jurisdictions, the duty to protect
allows clinicians to address dangerousness in
treatment (e.g., intensifying outpatient treatment,
seeking hospitalization, modifying medication
treatment). If such actions remove the chance of
the threat being acted upon, the clinician does
not need to breach confidentiality by warning the
potential victim (Werth et al., 2009).
Unfortunately, as Kämpf, McSherry, Thomas,
and Abrahams (2008) reported, these laws are often
highly complex, leading to frequent misunderstand
ings among mental health clinicians about their
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responsibilities in these situations. Additionally,
Pabian, Welfel, and Beebe (2009) found that 76.4%
of psychologists they surveyed “were misinformed
about their state laws, believing that they had a
legal duty to warn when they did not, or assuming
that warning was their only legal option when other
protective actions less harmful to client privacy
were allowed” (p. 8). Because these decisions are
often complex and can have significant implica
tions for the parties involved, it is recommended
that family and couple therapists familiarize them
selves with relevant state laws and utilize consul
tation and ethical decisionmaking models when
responding to these situations.
Additional Legal Issues in Family
and Couple Therapy
Additional legal issues that are likely to arise in
the practice of family and couple therapy involve
providing treatment when child custody issues are
present and responding to subpoenas and court
orders. These are such common occurrences that
each family and couple therapist is advised to be
prepared for these eventualities.
Child custody. In treating families with minors,
therapists must be cognizant of custodial issues. It is
important to clarify custodial rights from the outset,
obtain documentation of these rights (e.g., a copy
of a court order), and to only provide treatment to
minor clients with appropriate legal authorization.
Additionally, doing this work requires the therapist
to ask important legal questions such as “Who will
participate in treatment?”, “Who has the right to
consent to treatment?”, “Who will pay for treat
ment?”, “Who has the right to release records?”, and
“Who has access to the information about therapy?”
(Lebow & Rekart, 2007). When treating families
who are going through or considering divorce, a
treatment contract that clarifies the nature of the
professional services being provided is essential to
include in the informed consent process.
Family or couple therapists should make it
clear at the outset of treatment that psychotherapy
is being provided, that this therapy does not
consist of a child custody evaluation, and that
no recommendations for custody will be made in
court. This is essential because the roles of treating
therapist and forensic evaluator are very different
roles that are inconsistent with each other. Family
and couple therapists are their clients’ advocates;
they accept clients’ statements at face value and
work with the goal of assisting clients to achieve
their stated goals. Forensic evaluators, in contrast,
should be objective third parties with the goal
of evaluating everyone in the family unit so that
recommendations regarding the child’s best interests
may be made to the court. Serving in both capacities
for a family or couple creates an inappropriate
conflict of interest that jeopardizes the caring
relationship and trust needed to be an effective
therapist as well as the objectivity and neutrality
needed to be an effective forensic evaluator.
Subpoenas and court orders. Other scenarios
that may potentially arise when providing family
or couple therapy involve responding to subpoenas
and court orders. Without a court order, therapists
do not release confidential information about clients
unless there are specific releases of information that
the clients have approved in writing. When court
orders are mandated, therapists should inform the
family or couple of the nature of the order as well
as the limits of confidentiality before proceeding.
Furthermore, family therapists may only provide
testimony on the treatment they have provided,
what has been reported to them and by whom, and
what they have observed. They should not make
child custody recommendations or give opinions
on legal matters, since they have not conducted
an objective evaluation of each of the parties
involved.
Court orders are issued by judges and must
be complied with or the therapist may risk the
consequences of being held in contempt of court.
Subpoenas, however, are issued by attorneys.
Although they cannot be ignored, therapists
should not immediately comply with them by
releasing ordered treatment records. Subpoenas
do not carry the weight of court orders, and there
are several possible ways of responding to them
without releasing confidential client information
without the client’s permission. An important first
step when receiving a subpoena is to contact one’s
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Ethical and Legal Issues in Family and Couple Therapy
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own attorney for guidance on how to respond to
it. Additional guidance is provided in the APA
Committee on Legal Issues’ publication on strate
gies for dealing with subpoenas (APA Committee
on Legal Issues, 2006).
RECOMMENDATIONS FOR THE ETHICAL
AND LEGAL PRACTICE OF FAMILY
AND COUPLE THERAPY
As has been highlighted previously, multiple ethical,
legal, and clinical challenges are associated with
the practice of family and couple therapy. However,
with forethought and ongoing attention to the
issues addressed in this chapter, family and couple
therapists may competently assist their clients in
a manner consistent with the highest standards
of their profession. Specific recommendations to
consider include the following:
■■ Be sure to possess needed competence before
providing clinical services to families and
couples. Obtain the necessary scientific
knowledge and develop the required clinical
skills to effectively provide clinical family
and couple therapy services. If unsure of the
competencies needed to work with these
populations, review relevant practice guidelines
and consult with colleagues who possess
recognized expertise in family or couple therapy.
■■ Attend to multicultural competence as an
essential element of one’s professional competence
overall. Obtain the needed education, training,
and supervised experience to effectively work
with clients from a wide range of backgrounds.
Be aware of one’s own biases, prejudices, and
privileges, along with stereotypes one may hold,
and how they may impact one’s interactions
with clients. Remain open to alternative family
and couple constellations and multiple ways to
engage in healthy relationships. Be sure to address
diversity, in all its forms, as it may be relevant in
work with clients.
■■ Provide every client with the opportunity to give
her or his fully informed consent to all treatment
services before treatment is initiated. Help clients
understand treatment options and alternatives
available to them and their relative risks and
benefits. Ensure that clients understand what
they are agreeing to and that their consent is
provided voluntarily. With families and couples,
it is important to address in advance how
individual communications with the therapist
between sessions will be handled, including
whether they will be kept secret or shared at the
next treatment session.
■■ With clients who do not have the legal right to
provide their own consent to treatment, including
minors, obtain their assent by explaining the
parameters of the proposed treatment and
including these clients in informed consent
discussions and decision making to the extent
that their developmental level and level of
understanding allow.
■■ With families and couples, conceptualize informed
consent and assent as ongoing processes that assist
the therapist in clarifying clients’ expectations and
needs and the therapist’s obligations to each of the
individuals involved.
■■ Be cautious about multiple relationships with
families and couples. It may be common to treat
an individual who seeks family or couple therapy
as the client. Clarify all roles and relationships
from the outset and be sure to remain objective
and impartial in this new role, clarifying the
identity of one’s client (e.g., the family, the
couple). Make the treating therapist’s role clear
and state that a forensic evaluation is not being
conducted.
■■ Become familiar with all the laws and regulations
in one’s practice jurisdiction that are applicable
to family and couple therapy. Give particular
attention to mandatory reporting requirements
regarding the suspicion of abuse and neglect
of minors and other vulnerable individuals,
including elderly and/or developmentally delayed
adults who rely on others for their daytoday
care and wellbeing, and duty to warn and protect
laws that are relevant to client threats to harm
identifiable individuals. Be mindful of legal
definitions and thresholds for taking action. The
requirements of these laws, definitions of key
terms, and thresholds for taking required action
vary by jurisdiction. Whenever faced with these
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Barnett and Jacobson
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situations, consult with experienced colleagues
and utilize an ethical decision-making model for
assistance in determining the most appropriate
course of action.
■■ When minor children are to be involved in treat-
ment, clarify custodial arrangements by obtain-
ing official documentation that specifies each
parent’s rights regarding health care decision
making before treatment begins. Never treat
minor clients without the appropriate legal
authorization to do so.
■■ Be cautious about releasing confidential informa-
tion and taking all reasonably available steps to
protect client confidentiality. When requests for
treatment information are received, confer with
clients to determine their preferences. Do not
release confidential information unless ordered
by a court to do so or if the client provides written
authorization to do so.
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