by Nicole D. Pukay-Martin, MA
In our training clinic, we see couples for an extended assessment phase that includes individual sessions with each partner in order to obtain information about each partner’s history and motivation for couple therapy. Meeting with partners individually can pose certain difficult ethical questions. For example, imagine you are a couple therapist meeting with one member of a couple individually. What would you do if that person disclosed a recent series of affairs of which the partner was not aware? Now imagine that same person disclosed that she was HIV positive and had not told her partner yet. What ethical and therapeutic issues do these disclosures raise? What would you be feeling as the psychologist in this situation? How would you proceed with couple therapy? Consider your answers to these questions as you proceed through this article.
Working with couples in a therapeutic setting can be both a challenging and rewarding endeavor. In contrast to individual therapy, the couple therapist must balance the needs of two individuals and their relationship to determine the best course of therapeutic action. In particular, the management of confidentiality within the couple raises unique ethical dilemmas. In creating policies and guidelines for psychotherapy with couples, it is important to a) consider your responsibilities to both the couple and the individuals when defining who the client is, b) decide whether to hold individual sessions with each individual involved in couple therapy, and c) determine what actions to take if one member of a couple discloses information that the other partner does not know.
DEFINING THE CLIENT
In couple therapy, it is essential to define who the client is, given that the couple therapist is most often faced with two individuals who are in conflict and a relationship that is in distress. According to Standard 10.02a of the APA Code of Conduct (APA, 2002), psychologists must “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 standard is especially significant because partners in therapy often have conflicting needs (Glick, Berman, Clarkin, & Rait, 2000). Some couple therapists define the couple’s relationship as the client at the outset of therapy and only work to improve the relationship. While this approach may appear to provide a clear-cut answer to the ethical dilemmas of working with couples, each relationship consists of two individuals who each have their own needs, thoughts, and emotions that must be considered (Epstein & Baucom, 2002). Thus, it is vital to explain clearly at the outset of therapy that the couple’s relationship and both individuals are clients in therapy, and that the psychologist will seek to have a balanced relationship with each individual while all work together to improve the couple’s relationship.
The issue of whether to hold individual assessment sessions with members of a couple at the outset of therapy is complex. On one hand, valuable information can be gathered regarding each individual’s history and commitment to the relationship and treatment. On the other hand, sometimes during these sessions, one individual will take the opportunity to divulge a secret to the psychologist, which can create an ethically difficult situation. Some couple therapists choose not to hold individual sessions at all so that they do not have to confront this issue. However, this decision may limit the psychologist’s ability to gather important data (Margolin, 1998), and so many elect to conduct individual assessment sessions with each partner at the outset of therapy.
Even if the psychologist does not routinely schedule an initial individual session, members of a couple may contact the psychologist individually between sessions or arrive for couple therapy without the other member of the couple and expect to be seen. Consistent with Standard 10.02a (APA, 2002), it is vital for psychologists to clarify at the outset of therapy the nature of their relationship with each partner and how these outside contacts will be handled. If the individual’s contact does not indicate an urgent need, one option would be to instruct the individual to hold their concern until the next couple therapy session, at which time the partner will be notified of the outside contact. Couple therapists may handle outside contact in different ways. However, limiting outside individual contact may better preserve the alliance between both partners and the therapist.
If a couple therapist does hold individual assessment sessions with a couple or has outside contact with one partner, the psychologist must determine how to manage secrets or other information that has not been shared within the couple. What does the psychologist do if one partner discloses information and asks the psychologist not to tell the other partner? The APA ethical code gives little guidance on how these matters should be handled (Bass & Quimby, 2006). According to Standard 4.02, psychologists should discuss the limits of confidentiality at the outset of treatment. In addition, Principle A suggests that psychologists should “seek to safeguard the welfare and rights of” their clients. Thus, psychologists must be clear with clients as to their policy on confidential information between partners, but psychologists may deal with this issue in multiple ways (Bass & Quimby, 2006; Thorp & Fruzzetti, 2003; Wilcoxon, Remley, Gladding, & Huber, 2007).
When confronted with secret information divulged by one member of a couple, a psychologist has three main options in managing this situation. These three options are all ethically defensible, but each has its pros and cons. First, a psychologist may decide to keep all secrets confidential in order to maintain trust with each partner and respect the rights of each individual. However, this decision places the couple therapist in a precarious position when information is shared by one member that is damaging to the relationship or may undermine therapeutic work, for example, telling the psychologist one thing in private but acting differently during a conjoint session. Second, a couple therapist may make a blanket statement that all information is the property of the relationship, and therefore no secrets will be kept between partners. However, this policy may prevent partners from sharing key information or may threaten trust between partners and the psychologist. The third option, an intermediate solution, is to only keep certain information secret. There are three criteria to consider when deciding whether to share information divulged individually. First, is the secret information currently adversely affecting the relationship? Examples of this would include an ongoing affair or current substance dependence. Second, does disclosing the information have a therapeutic benefit? For example, disclosing an affair that occurred 10 years ago without recurrence may only hurt the partner, while not furthering the relationship goals. Third, does disclosing the information put one of the partners at risk? For example, if one person shares individually that the partner is being physically abusive, informing the abuser that the individual shared this information with the couple therapist may put that person at greater risk for further abuse for disclosing. If the answers to these questions indicate net therapeutic benefit in disclosure, the psychologist urges the partner to disclose the information (Glick et al., 2000). If the partner refuses, the psychologist may discontinue treatment until the partner is ready to fully commit to therapeutic work or may disclose without the partner’s consent.
Because this third option relies on the psychologist’s personal judgment, it is critical to clearly define the limits of confidentiality at the outset of treatment. In order to do so, couple therapists can consider developing an addendum to their typical informed consent document, outlining their policies on secrets (see Bass and Quimby, 2006 for an example of an informed consent addendum). In their addendum they first describe general policies used to protect privacy (e.g., having clients enter and exit through separate doors or not greeting clients in public) before addressing secrets directly to ensure that the client understands ways the psychologist safeguards privacy. Next, their consent form clearly explains the purpose of any individual meetings with partners, delineates how the psychologist will handle secret information that may be shared in these meetings, and clarifies the client’s right to choose not to share such information, though honesty will likely facilitate treatment. Their addendum also outlines the different ways psychologists manage secret information and the reasons the psychologist follows these guidelines in order for the client to more fully understand the therapeutic rationale. Their proposed addendum also describes the potential drawbacks of this approach (e.g., hurt feelings or a feeling of betrayal when an individual learns the psychologist kept a partner’s secret) so that the client is informed of any potential negative impacts of the psychologist’s policy.
In addition, couple therapists may consider incorporating illustrative clinical vignettes into their standard informed consent process to communicate clearly to the couple how the psychologist will manage sensitive information within the couple context. For example, the consent form may describe how the psychologist will manage learning about a current affair or past drug use by one partner. Finally, the consent document should end with a clear summary of the psychologist’s policy on secrets to highlight the guiding principle the he or she follows.
When considering this third option of using professional judgment when deciding to keep or divulge secrets, the couple therapist must balance the individual’s right to privacy with the relationship’s need for safety, which requires more transparency. Glick and colleagues (2000) make a useful distinction between privacy and secrecy. Privacy is information known to one person that (s)he would prefer not to share with the partner and does not affect the relationship. This construct may be thought of as an individual’s “personal space” in a relationship. Secrecy is information held by one person that directly affects the relationship and may be kept due to fear, anxiety, or shame. If the client is defined as the relationship and two individuals then, consistent with Principle A, the psychologist should consider all aspects of the “client” when deciding whether to divulge a secret.
Whereas there are no specific practice guidelines that are directly relevant to this discussion, psychologists must act in accordance with the ethics code when confronted with confidentiality issues within the couple. No matter which approach a psychologist chooses to manage these issues, it is essential to ensure that both partners understand who the client is and limits to confidentiality within the couple. Treatment will progress more smoothly and effectively when psychologists clarify and explain their stance on these issues at the outset of therapy.
Nicole D. Pukay-Martin is a doctoral candidate in the clinical psychology program at the University of North Carolina at Chapel Hill. Her research interests include the creation and implementation of couple-based interventions for individuals with psychopathology or health problems.
Acknowledgments: I'd like to thank Erica Wise, PhD for her immensely helpful comments and editorial suggestions on this article.
This article was adapted with permission from an article originally published in the The North Carolina Psychologist.
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