Ethics and Values in Psychotherapy
Clinical Impact Statement: This manuscript informs psychotherapists about the nature, role, and potential impact of one’s personal beliefs and values in psychotherapy. Challenges psychotherapists may face regarding values conflicts, suggestions for how to navigate them, and recommendations for training programs, trainers, and trainees are made.
Ethical practice is essential for all psychotherapists. As licensed professionals, we are obligated to ensure that we meet the minimal expectations set in our state’s licensing law, the regulations that accompany it, other laws relevant to the practice of our profession, and our profession’s code of ethics. Yet, our goal should be to go far beyond codified minimal expectations. Licensure creates a fiduciary responsibility that requires that our clients’ best interests are our primary concern and motivation (Jorgenson et al., 1997). While this responsibility makes clear that psychotherapists should not engage in behaviors that are exploitative of or harmful to clients it does not provide clear guidance on how to best meet each client’s treatment needs.
As an alternative to a focus on avoiding harm, Handelsman et al. (2002) recommend positive (or aspirational) ethics. This approach views meeting minimal expectations and avoiding unethical behaviors as necessary but not sufficient for meeting our ethical obligations. Rather, this approach encourages each of us to actively work to do the best we can for each client in our professional roles. This requires us to be cognizant of and motivated by the underlying values of our profession and to aspire to achieve their fullest possible intent in all decisions we make and in each action we take in our professional roles.
The Values of the Profession
Codes of ethics are based on a widely accepted set of underlying values. As described by Beauchamp and Childress (2012), these include:
Beneficence – the obligation to provide benefit to those we serve in our professional roles.
Nonmaleficence – the obligation to avoid exploitation of and harm to those we serve.
Fidelity – Fulfilling our obligations and acting with integrity.
Autonomy – Working to promote each client’s independent functioning of us over time and not acting in ways that promote their dependence on us.
Justice – Treating clients fairly and equitably in the services we provide and in access to care.
To these, Barnett (2008) adds self-care as one of the values that guides ethical practice since a failure to adequately attend to one’s self-care can result in a decreased ability to effectively implement the other five values.
Each of these values is foundational to the practice of psychology, as articulated in the Ethical Principles of Psychologists and Code of Conduct (Ethics Code, APA, 2017). This should be evident from even a cursory reading of the Ethics Code’s General Principles: Principle A: Beneficence and Nonmaleficence, Principle B: Fidelity and Responsibility, Principle C: Integrity, Principle D: Justice, and Principle E: Respect for People’s Rights and Dignity. Further, the final sentence of Principle A states, “Psychologists strive to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work,” highlighting the inclusion of self-care in the profession’s underlying values.
These values-based General Principles of the APA Ethics Code are not enforceable and do not set minimum standards that must be met (Knapp et al., 2017). Instead, they are aspirational in nature; intended to guide us in our decision-making so we may do the best we can in our professional roles. It is also hoped that these General Principles will provide the foundation for each psychologist’s professional identity.
Professional Identity and Personal Values
While it is hoped that psychotherapists will embrace the values of the profession, we each bring to our professional roles our own personal values as well. These personal values may be strongly held beliefs and convictions that are essential aspects of one’s identity. Of course, personal values influence decisions and actions in our personal and professional lives. Although the Ethics Code makes clear that actions in one’s personal life are “not within the purview of the Ethics Code” (Introduction and Applicability), the role of one’s personal values in the context of professional work is less clear. The Ethics Code does state that when “making decisions regarding their professional behavior…”, in addition to considering the Ethics Code, laws, and regulations, psychologists “may consider…the dictates of their own conscience”.
Some psychotherapists may have strongly held personal values and convictions that are not in alignment with the values of the profession. Reconciling these differences may prove difficult for those attempting to be true to each of these. Knapp et al. (2017) propose an integration of personal and professional values (and ethics) as being optimal. This alignment is recommended over a focus on either alone. Being guided only by one’s personal values may result in actions that violate the intent of the Ethics Code, while attempts to focus solely on the values of the profession will likely not be fruitful as our personal values are always present and influencing us to some extent.
The Psychotherapist’s Personal Values in Psychotherapy
Psychotherapy cannot be free of the influence of the psychotherapist’s (or client’s) personal values. They are integrated into who we are as individuals, and they influence every decision we make and every action we take. Kelly and Strupp (1992) found that psychotherapists’ personal values influence the treatment decisions they make as well as their perceptions of clients and treatment outcomes. They also found that over the course of treatment, some clients may adopt personal values similar to those of their psychotherapist, a phenomenon termed ‘values conversion.’ Interestingly, this occurs even when psychotherapists are not intentionally attempting to alter a client’s values.
Alternatively, psychotherapists may have very strongly held personal values that may actively influence decision-making in their professional roles. The right to act on one’s personal values in one’s professional role is, for some, a highly controversial issue with significant emotional valence. This may include a desire to offer treatments that are consistent with one’s personal values but that are not supported by the profession’s values (or even state law), such as conversion therapy or refusing to treat certain individuals whose values conflict with one’s own such as refusing to treat LBGTQ clients.
There is no requirement that psychotherapists have the same values as their clients and no requirement that psychotherapists exclude all influence of personal values from their professional work. A psychotherapist’s personal values and aspects of their identity may inadvertently be disclosed to clients when they wear a wedding band, crucifix, Star of David, or religious attire, for example, but this hopefully is seen as quite different than imposing one’s own values upon a client or refusing to treat certain clients due to differences in values. There is a need to exercise professional judgment to discern to what extent personal values should influence professional conduct while hopefully working on acting consistently with the values of our profession. If one’s personal values are such strongly held convictions that they cannot be prevented from impacting one’s professional decision-making, consultation with expert colleagues is recommended to help determine the most appropriate course of action moving forward.
Asserting Personal Values in One’s Professional Role
In recent years there have been multiple court cases relevant to psychotherapists and psychotherapy trainees refusing to treat homosexual clients, stating that to do so would conflict with their religious beliefs (e.g., Bruff v. North Mississippi Health Services, Inc., 2001; Ward v. Willbanks, 2010). In each of these cases, the clinician in question attempted to refer the client to another clinician, citing a values conflict based on their strongly held beliefs and convictions. While these cases involve the counseling profession, considering the issues they raise may prove helpful to all psychotherapists.
These cases raise an important question: Should licensure as a mental health professional create an obligation to treat clients even if doing so might feel contrary to one’s personal values or religious beliefs? The APA Ethics Code guides psychologists to be aware of and respect individual differences, including sexual orientation and gender identity (Principle E: Respect for People’s Rights and Dignity) and promote “access to and benefit from” the services psychologists offer for all persons (Principle D: Justice). Further, relevant to treating clients of diverse backgrounds, Ethical Standard 2.01, Boundaries of Competence, requires that psychologists “obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals.”
This raises the question of if a conflict between the psychotherapist’s and client’s personal values can be accepted as creating a lack of clinical competence and thus necessitating referring the client to another professional. It is possible that an inability to prevent one’s personal values from intruding on one’s clinical decision-making in treatment would be seen as meeting the requirements of this ethical standard. Using this reasoning, referring the client to another professional may be the most respectful action possible.
One may also ask if entering a profession necessitates acceptance of that profession’s values and keeping one’s personal values from superseding them. In the case of Keaton v. Anderson-Wiley (2010), a student was dismissed from her graduate program after she insisted on her right to counsel LGB clients that being gay is immoral. She did not acknowledge that her personal values could have a negative impact on the client and did not seek to refer the client. Rather, she believed she had the right to assert her personal beliefs in her professional role.
Relevant Issues to Consider
It is understood that psychotherapy is not a values-free endeavor (Kelly & Strupp, 1992). We each bring with us who we are as individuals to our professional roles. Yet, the role of the psychotherapist’s personal values in psychotherapy is a highly complex and potentially controversial one. Should psychotherapists be required to keep their personal values to the side and use their clinical training and skills to meet all clients’ treatment needs for which they are appropriately trained? Or should psychotherapists be allowed to refer clients to others when they believe that to treat a particular client would violate their personal values (even when they may possess the necessary clinical competence to treat that client)? Is it appropriate to assert that such a values conflict reduces one’s competence and, thus, making a referral is the ethical action to take? The APA Ethics Code is open to interpretation on these questions. In response to the Ward v. Wilbanks case, which involved a counselor, the American Counseling Association strongly asserted (see Kaplan, 2014) that to make a referral “based solely on the counselor’s personally held values, attitudes, beliefs, and behaviors” violates the ACA Code of Ethics (ACA, 2014, p. 6). No such standard presently exists in the APA Ethics Code.
For psychologists and other psychotherapists, each of these questions can be difficult to answer, and consensus may be elusive. Case law continues to evolve in response to lawsuits being filed. An additional challenge is the recent and ongoing passage of state laws and licensing board regulations in some states that allow licensed health professionals in those states to refuse to treat LGBTQ and disabled individuals due to religious or moral objections (c.f., PBS NewsHour, 2021). This raises the challenge of laws and regulations conflicting with the profession’s ethics code and with the underlying values of our profession.
While it is desirable that all psychotherapists comply with the dictates of the code of ethics of their profession as well as their state’s licensing law for their profession, these may at times come into conflict. If such conflicts arise, psychologists are required to “make known their commitment to the Ethics Code and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code” (Ethical Standard 1.02, Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority).
As with all ethical dilemmas, to the extent that it is possible, a focus on prevention is recommended. Thus, the following specific recommendations are provided:
- Know your profession’s ethics code, your state’s relevant laws, and your institution’s or organization’s policies.
- Keep in mind that just because a law or policy may allow a certain action, that does not mean that one must act in this way.
- Clarify your values and disclose any potential value conflicts as early as is feasible. When unsure about the appropriateness of this or how to best do so, consultation with expert colleagues is recommended.
- Engage in transparent communication with the public and with clients about the nature of the professional services you provide so that they may make informed decisions when considering your services (e.g., faith-based psychotherapy that follows a specific set of religious beliefs or values) to include on one’s website and during the informed consent process.
Graduate Programs and Training Sites
- Explicitly state the values of the program and its expectations of trainees on the program’s website, in application materials, during interviews, and in policy documents.
- Ensure that all educators and trainers review expectations with trainees at the beginning of each training experience.
- Clinical supervisors should openly discuss these issues with each supervisee to encourage self-reflection and awareness about the potential impact of their values on their clients and on the psychotherapy process.
- How these issues are to be addressed in supervision and with clients should be clearly articulated in the informed consent to supervision.
Graduate Students and Trainees
- Thoughtfully consider one’s personal values and their potential impact on clinical decision-making.
- Research the values and mission of education and training programs prior to applying to them.
- Education and training programs whose values are sufficiently contrary to one’s own should not be applied to.
- When conflicts do arise, discuss them openly with your supervisor to help determine the most appropriate course of action.
Cite This Article
Barnett, J., & Teehan, D. (2022). Ethics and values in psychotherapy. Psychotherapy Bulletin, 57(2), 11-16.
American Counseling Association. (2014). ACA Code of Ethics. Retrieved from https://www.counseling.org/resources/aca-code-of-ethics.pdf. https://doi.org/10.1002/9781119221548.ch15
American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). http://www.apa.org/ethics/code
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Bruff v. North Mississippi Health Services, Inc., 244 F.3d 495 (5th Cir. 2001).
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Keeton v. Anderson-Wiley, 664 F.3d 865 (11th Cir. 2011).
Kelly, T. A., & Strupp, H. H. (1992). Patient and therapist values in psychotherapy: Perceived changes, assimilation, similarity, and outcome. Journal of Consulting and Clinical Psychology, 60(1), 34–40.
Knapp, S. J., VandeCreek, L. D., & Fingerhut, R. (2017). Practical ethics for psychologists: A positive approach (Third Edition). American Psychological Association.
PBS.org. (2021, March 26). Arkansas governor signs bill allowing medical workers to refuse treatment to LGBTQ people. Retrieved from https://www.pbs.org/newshour/politics/ arkansas-governor-signs-bill-allowing-medical-workers-to-refuse-treatment- to-lgbtq- people
Ward v. Wilbanks, No. 10-2100, Doc. 006110869854 (6th Cir. Court of Appeals, Feb. 11, 2011).