sixth edition benefits from four very diverse perspectives and co-authors who worked collaboratively to create an edition that motivate us all to strengthen and inform our ethical awareness and sense of personal and collective ethical responsibility.
The poor, unloved preface achieved sad notoriety as the least read part of most books. We’ll keep this one short—limiting it to only a note on terminology. We hope the conciseness inspires you to read on, set yourself apart from the crowd, and gain elite status as a reader of the preface.
A NOTE ON TERMINOLOGY
This book discusses the varied and complex ethical issues that confront psychologists working as psychotherapists, other kinds of therapists (e.g., behavior therapists), and counselors. For brevity and convenience, we often use just one of these terms—rather than some hyphenated form of all three—in a sentence. Similarly, some therapists identify those to whom they provide services as clients; others use the term patients. Again, for brevity and convenience, we have used these terms interchangeably throughout the book.
ACKNOWLEDGEMENTS
We are deeply indebted to all those who contributed directly or indirectly to this book. We are grateful to all but have space to mention only a few. Emil Rodolfa, Ray Arsenault, Linda Campbell, Ursula Delworth, Barry Farber, Lisa Grossman, Kate Hays, Loralie Lawson, Karen Olio, and Janet Sonne are among those who read drafts of the current or previous editions and offered valuable suggestions for improvements.
We asked a number of prominent therapists with expertise in recognizing and responding to suicidal risk to discuss pitfalls of work in this area. Chapter 22 presents the advice that each of these experts gives to readers. We thank those who contributed discussions: David Barlow, Danny Brom, Chris Brownson, Marla Craig, Jessica Henderson Daniel, Norman Farberow, the late Erika Fromm, Rosa Garci-Peltoniemi, Jesse Geller, Judith Lewis Herman, Don Hiroto, Maryam Jernigan-Noesi, Nadine Kaslow, the late Helen Block Lewis, Marsha Linehan, Ricardo Munoz, David Rudd, Gary Schoener, Shweta Sharma, and Danny Wedding.
We also express our gratitude to graduate students Xochitl Cruz, Radia Mchabcheb, and Monica Zohar who helped with a laborious part of this text, its references.
We received exceptionally skillful and generous help from Rebecca McGovern and Xenia Lisanevich of Jossey-Bass Publishers in preparing the first edition; from Alan Rinzler, Katie Levine, Margaret Sebold, Joanne Clapp Fullagar, and Paula Goldstein of Jossey-Bass Publishers and Rachel Anderson of Satellite Publishing Services in preparing the second edition; from Alan Rinzler, Carol Hartland, Seth Schwartz, and Jennifer Wenzel of Jossey-Bass Publishers, along with Beverly Harrison Miller, in preparing the third edition; and from Patricia Rossi, Fiona Brown, and Kate Lindsay in preparing the fourth edition; and Marquita Flemming, Melinda Noack, and, Brian Grimm, in preparing the fifth edition; and Darren Lalonde, Monica Rogers, Arthi Kangeyan, Jo Egre, Christina Weyrauch, Patty Maher, and Ranchedha Djeassilane in preparing this sixth edition.
Chapter 1 HELPING WITHOUT HURTING
Psychotherapy holds out the promise of help for people who are hurting and in need. It can save lives and change lives. In therapy, clients can find their strengths and sense of hope. They can change course toward a more meaningful and healthy life. They can confront loss, tragedy, hopelessness, and the end of life in ways that do not leave them numb or paralyzed. They can discover what brings them joy and what sustains them through hard times. They can begin to trust, or to trust more wisely. They can learn new behaviors in therapy and how to teach themselves new behaviors after therapy ends. They can question what they always believed was a given. They can find out what matters most to them, and how to stop wasting time. They can become happier, or at least less miserable. They can become better able, as Freud noted, to love and to work. They can learn how to accept and love themselves just as they are and accept others who are different from them.
Our ethics acknowledge and affirm our profession’s responsibilities. This book was written to help strengthen, deepen, and inform ethical awareness and the sense of personal ethical responsibility. Its job is to help you hold onto the ideals—including ethical ideals—that called you into the profession to begin with, to help you develop and fulfill those ideals. There will be so much—trust us on this—that tends to dull ethical awareness, to make ethics drift out of focus, to create barriers between you and your ideals, to replace ethics with pseudo-ethics and ethics placebos. Fatigue, endless paperwork, unrealistic expectations, illness, family crises, not being able to make ends meet, burnout, threats of job loss, insurance coverage that doesn’t come close to meeting the needs of our clients, biases that have not been addressed, and so many other forces can pressure us into cutting ethical corners. This book is intended to help you develop a strong and healthy resistance to such forces, to help you weather them without losing your ethical awareness and ideals.
We can often help, but if our ethics slip, we can needlessly hurt. Mishandled, the process of therapy and counseling can waste time and opportunity. It can betray clients’ hope, good faith, hard work, and trust. It can leave them worse off than before they reached out for our help. It can erode trust in the health system and prevent people from seeking help in the future.
Realizing how much our ethical decisions can affect the lives of those who come to us for help is central to our ethical awareness. What we do can make a difference in whether a client loses hope and commits suicide or chooses to live, whether a battered partner finds shelter or returns to a toxic and dangerous relationship, whether a teenager with anorexia gets help or starves to death. Such stark examples tell only part of the story. So many people come to us facing what seem to be minor, hard-to-define problems, yet the hard, risky, unpredictable twists and turns of their therapy can lead to more meaningful, effective, and fulfilling lives.
Few therapists take these responsibilities lightly. Few forget about a suicidal client between sessions. Few sit unmoved while a client talks, perhaps for the first time, about what it was like to survive an atrocity. Few turn away untroubled when a managed care company refuses to authorize treatment for someone in desperate need of help, someone who lacks enough money to put food on the table, let alone to pay for therapy.
Recognizing these responsibilities as they appear in our day-to-day work and deciding how to respond can be stressful, sometimes overwhelming. We may feel short of time, resources, or wisdom. We may feel pulled in different directions, stretched to or beyond the breaking point. The responsibilities can weigh us down, make us feel discouraged, rattle us, and make us want to run and hide. They can make us more vulnerable to other sources of stress and leave us prone to make flawed ethical decisions.
Uncertainty causes stress for some of us. We can’t find that magical book that will tell us what to do, especially in a crisis. Research, guidelines, manuals, our own experience, and consultation help, but we can’t know the best course in all situations, or even how the “best” course will turn out. We are constantly thrown back on our own judgment. If we believe a client might kill someone but there is no explicit threat or other legal justification under the state’s law to hospitalize the client or breach confidentiality, what do we do? What diagnosis should we write down if we know that the insurance company won’t cover treatment for the client’s condition and believe that the client’s need for treatment is urgent, a matter of life or death? Will using stress-reducing imagery techniques help a client (reducing stress and increasing the client’s effectiveness) or cause harm (enabling the client to adapt to an abusive job or relationship) is a question without an instantly clear, infallible answer. Does informed consent make sense if all it accomplishes is to cause a patient to turn away from life-saving treatment or stop them from sharing information critical to their treatment? The inescapable
