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Writer's pictureJeremy Smith

My personal ethical model

Updated: 5 days ago

Integrating principle ethics, transcultural considerations, and action-oriented models for ethical decision-making in therapy

Portions of this post were previously submitted as a preclinical paper entitled Trends in Ethical Decision Making.


We frequently encounter moral ambiguities, value conflicts, and ethical dilemmas in clinical practice. Although some of these challenges – such as sexual intimacy with clients and mandated reporting of abuse or neglect – are addressed by legal mandates or clearly-defined directives in professional codes of ethics (i.e., mandatory actions and prohibitions), other situations demand critical thinking and discretionary decision-making by the therapist (Corey et al., 2014; Wilcoxon et al., 2013). Ethical codes are often aspirational: they may offer principles to guide our decisions, but they don't necessarily delineate our professional responsibilities or dictate how to carry them out in the context of moral and ethical “grey areas” (Corey et al., 2014). Many ethical decision-making models have been proposed (Annas, 2006; Freeman & Francis, 2006; Metz & Miller, 2016; Slote, 2010; Urofsky et al., 2009) and may be generally divided into:

  • Models based on expected consequences (consequentialism)

  • Models based on maximization of potential benefit to the client (utilitarianism)

  • An appeal to “highest ideals” to determine the “best” action (principle ethics)

  • Reasoning action from intention (virtue ethics)

  • Recognition of the “duty of care” and the consequent considerations of equity, compassion and communalism (relational/care ethics), or

  • Extrapolation from previous cases (casuistry).

Although these decision-making models can provide clearer reasoning and deeper guidance than professional codes of ethics, they may also be limited in their applicability to specific cases. The seminal Kitchener principle-ethics model, for example, emphasizes respect for client autonomy, the necessity to ensure that treatment benefits (beneficence) and does not harm the client (nonmaleficence), and mandates equitable treatment (justice) and honesty (fidelity). Prima facie, Kitchener's model offers a solid, quasi-objective, structured foundation for ethical decision-making. The devil, as they say, is in the details (Freeman & Francis, 2006; Hill, 2004; Sherbersky, 2016).

  • Those principles may conflict with clients’ personal or socioculturally-defined values. For example, interventions may be irrelevant or damaging to clients or their relationships due to cultural factors.

  • Our principles and interventions may even conflict with other foundational principles. Most of us would agree, for instance, that there's a clear need for involuntary hospitalization when a client has a well-defined plan for SI, the means to carry out that plan, and an intent to follow through with it. And yet involuntary hospitalization, by definition, short-circuits autonomy, even though our intent is based in beneficence.

So ethical codes, law, and decision-making models must be seen as merely contributory factors in the decisional process: ultimately, courses of action require our personal judgement and careful deliberation (Wilcoxon et al., 2013). These are, of course, going to differ from therapist to therapist, but the point of this post was to share a framework I developed throughout my preclinical training for my own use. I wanted to incorporate the aspirational, practical, and diversity aspects of the Kitchener principle-ethics, Corey, and Transcultural Integrative models, respectively (Corey et al., 2014; Garcia et al., 2003; Urofsky et al., 2009). My personal framework consists of three steps.

  1. Formulation — Determining whether a dilemma really exists, and how my own biases and attitudes might contribute to the issue.

  2. Information Collection — Identifying "stakeholders," missing information, and issues of power, privilege, client welfare, and culture relevant to the issue. This step might include consultation for legal clarification, or consultation with colleagues, mentors, and my organization to get a different perspective and clarify my organization's expectations and operating guidance.

  3. Action — Collaborating with my client to consider all possible courses of action, evaluate potential positive and negative outcomes and responses, determine the best course, and document and evaluate its implementation.

You can click the image below to zoom in.

Case application

Let's take a look at how we'd apply this framework to an example case.

Vignette: Your client is a 10-year-old adoptee who identifies as Chinese and male. His American mother referred the client following his disruptive behavior at school and at home. The father also supports the mother's decision to initiate therapy. You are able to establish a good rapport with the boy and work through some of his issues. In session with the parents, the mother reveals that she does not allow her son to speak his native language at home and that she is uncomfortable with him identifying with his culture because she feels it disconnects her from him. She begins to talk about racially biased behaviors from herself and her family with whom the son is in contact regularly.

Setting aside the details of this vignette, we'd like to address the biases of the client's nuclear and extended family. Again, you can click on the image below to zoom in.

Again, as with any model, my framework can only serve as guidance: ultimately, a therapist's course of action is at their discretion and their client's, and in any case, any rationale and selected actions should be carefully documented and evaluated. But I'm offering it here in case others find it useful.


References and Further Reading

  • Agency for Healthcare Research and Quality. (2017, 2017 Dec). Warm handoff: intervention. https://www.ahrq.gov/patient-safety/reports/engage/interventions/warmhandoff.html

  • American Association for Marriage and Family Therapy. (2015). AAMFT code of ethics. https://aamft.org/Legal_Ethics/Code_of_Ethics.aspx

  • Annas, J. (2006). Virtue ethics. The Oxford handbook of ethical theory, 515-536.

  • Baldwin, P. C. (2016). Note designer: A simple step-by-step guide to writing your psychotherapy progress notes. Mindhabits Inc.

  • Birky, I., Sharkin, B. S., Marin, J., & Scappaticci, A. (1998). Confidentiality after referral: A study of how restrictions on disclosure affect relationships between therapists and referral sources. Professional Psychology: Research and Practice, 29(2), 179.

  • Centers for Disease Control and Prevention. (2022). Health Insurance Portability and Accountability Act of 1996 (HIPAA). Retrieved Jun 29 from https://www.cdc.gov/phlp/publications/topic/hipaa.html

  • Corey, G., Corey, M. S., Corey, C., & Callanan, P. (2014). Issues and ethics in the helping professions. Cengage Learning.

  • Csizmadia, A., Leslie, L., & Nazarian, R. (2015). Understanding and treating interracial families. In Understanding and treating the contemporary family: Translating research into practice (pp. 89-107). Routledge.

  • Fife, S. T., Whiting, J. B., Bradford, K., & Davis, S. (2014). The therapeutic pyramid: A common factors synthesis of techniques, alliance, and way of being. Journal of Marital and Family Therapy, 40(1), 20-33.

  • Fivecoat, H. C., Cos, T. A., & Possemato, K. (2017). Special ethical considerations for behavioral health consultants in the primary care setting. Professional Psychology: Research and Practice, 48(5), 335.

  • Freeman, S. J., & Francis, P. C. (2006). Casuistry: A complement to principle ethics and a foundation for ethical decisions. Counseling and Values, 50(2), 142-153.

  • Garcia, J. G., Cartwright, B., Winston, S. M., & Borzuchowska, B. (2003). A transcultural integrative model for ethical decision making in counseling. Journal of Counseling & Development, 81(3), 268-277.

  • Gassova, Z., & Werner-Wilson, R. J. (2018). Characteristics of e-therapy websites involving marriage and family therapists. The American Journal of Family Therapy, 46(1), 27-43.

  • Hill, A. L. (2004). Ethical analysis in counseling: A case for narrative ethics, moral visions, and virtue ethics. Counseling and Values, 48(2), 131-148.

  • HIPAA Journal. (2021). HIPAA and HITECH. Retrieved Aug 26 from https://www.hipaajournal.com/hipaa-and-hitech

  • Ikegami, N. (2015). Fee-for-service payment–an evil practice that must be stamped out? International Journal of Health Policy and Management, 4(2), 57.

  • Lancaster, C., Ovrebo, E., & Zuckerman, S. (2017). Adoption counselors' perspectives of counseling postadoptive families. Journal of Counseling & Development, 95(4), 412-422.

  • Leslie, R. (2011). "Psychotherapy notes" and "psychotherapy records". Avoiding Liability Blog. https://www.cphins.com/psychotherapy-notes-and-psychotherapy-records/

  • Lin, T., Heckman, T. G., & Anderson, T. (2022). The efficacy of synchronous teletherapy versus in-person therapy: A meta-analysis of randomized clinical trials. Clinical psychology: Science and practice, 29(2), 167.

  • Lyford, C. (2020). The warm handoff: Therapists' expanding role in healthcare. Psychotherapy Networker. https://www.psychotherapynetworker.org/magazine/article/2437/the-warm-handoff/a3e488e0-6d4d-483c-8814-6d9169005280

  • Markowitz, J. C., Milrod, B., Heckman, T. G., Bergman, M., Amsalem, D., Zalman, H., Ballas, T., & Neria, Y. (2021). Psychotherapy at a distance. American Journal of Psychiatry, 178(3), 240-246.

  • Marlowe, D., Hodgson, J., Lamson, A., White, M., & Irons, T. (2014). Medical family therapy in integrated primary care: An interactional framework. In J. Hodgson, A. Lamson, T. Mendenhall, & D. R. Crane (Eds.), Medical family therapy: Advanced applications (pp. 77-93). Springer.

  • McDaniel, S. H., Doherty, W. J., & Hepworth, J. (2013). Medical family therapy and integrated care (2nd ed.). American Psychological Association.

  • McDowell, T., Knudson-Martin, C., & Bermudez, J. M. (2018). Socioculturally attuned family therapy : Guidelines for equitable theory and practice. Routledge.

  • McGoldrick, M., & Hardy, K. V. (2019). Re-visioning family therapy: Addressing diversity in clinical practice. Guilford Publications.

  • Metz, T., & Miller, S. C. (2016). Relational ethics. The international encyclopedia of ethics, 1-10.

  • Reamer, F. G. (2017). Evolving ethical standards in the digital age. Australian Social Work, 70(2), 148-159.

  • Reamer, F. G. (2018a, May 1). Ethical issues in integrated health care: Implications for social workers. Health & Social Work, 43(2), 118-124. https://doi.org/10.1093/hsw/hly005

  • Reamer, F. G. (2018b). Ethical standards for social workers’ use of technology: Emerging consensus. Journal of Social Work Values and Ethics, 15(2), 71-80.

  • Sampson, J. P., & Makela, J. P. (2014). Ethical issues associated with information and communication technology in counseling and guidance. International Journal for Educational and Vocational Guidance, 14(1), 135-148.

  • Shaw, E. (2015). Ethical practice in couple and family therapy: Negotiating rocky terrain. Australian and New Zealand Journal of Family Therapy, 36(4), 504-517.

  • Sherbersky, H. (2016, Jul). Family therapy and fundamentalism: One family therapist’s exploration of ethics and collaboration with religious fundamentalist families. Clinical child psychology and psychiatry, 21(3), 381-396. https://doi.org/10.1177/1359104515620249

  • Slote, M. (2010). Virtue ethics. In The Routledge companion to ethics (pp. 504-515). Routledge.

  • Georgia Code -- Reporting of Child Abuse, (2020). https://law.justia.com/codes/georgia/2020/title-19/chapter-7/article-1/section-19-7-5

  • Oregon Revised Statute Chapter 419B -- Juvenile Code: Dependency, (2021). https://www.oregonlegislature.gov/bills_laws/ors/ors419b.html

  • Turnipseed, W. (2016). Medical family therapy: Advanced applications. Journal of Marital and Family Therapy, 42(4), 754.

  • United States Department of Health and Human Services. (2017, 2017 Sep 12). Does a parent have a right to receive a copy of psychotherapy notes about a child’s mental health treatment? Retrieved Jun 29 from https://www.hhs.gov/hipaa/for-professionals/faq/2094/does-parent-have-right-receive-copy-psychotherapy-notes-about-childs-mental-health-treatment.html

  • Urofsky, R. I., Engels, D. W., & Engebretson, K. (2009). Kitchener's principle ethics: Implications for counseling practice and research. Counseling and Values, 53(1), 67-78.

  • Wilcoxon, A., Remley Jr, T. P., & Gladding, S. T. (2013). Ethical, legal, and professional issues in the practice of marriage and family therapy. Pearson Higher Ed.

  • Woo, H., Dondanville, A., Jang, H., Na, G., & Jang, Y. (2020). A content analysis of the counseling literature on technology integration: American Counseling Association (ACA) counseling journals between 2000 and 2018. International Journal for the Advancement of Counselling, 42(3), 319-333.

  • Zur, O. (n.d.). Subpoenas and how to handle them: Guidelines for psychotherapists and counselors. Zur Institute. Retrieved Jun 29 from https://www.zurinstitute.com/resources/subpoena

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