Ethical considerations in group therapy

Ethical and Professional Issues in Group Practice

Those who seek to be professional group leaders must be willing to examine both their ethical standards and their level of competence. Among the ethical issues treated in this chapter are the rights of group members, including informed consent and confidentiality; the psychological risks of groups; personal relationships with clients; socializing among members; the impact of the group leader’s values; addressing spiritual and religious values of group members; working effectively and ethically with diverse clients; and the uses and misuses of group techniques. In my opinion, a central ethical issue in group work pertains to the group leader’s competence. Special attention is given to ways of determining competence, professional training standards, and adjuncts to academic preparation of group counselors. Also highlighted are ethical issues involved in training group workers. The final section outlines issues of legal liability and malpractice.

As a responsible group practitioner, you are challenged to clarify your thinking about the ethical and professional issues discussed in this chapter. Although you are obligated to be familiar with, and bound by, the ethics codes of your professional organization, many of these codes offer only general guidelines. You will need to learn how to make ethical decisions in practical situations. The ethics codes provide a general framework from which to operate, but you must apply these principles to concrete cases. The Association for Specialists in Group Work’s (2008) “Best Practice Guidelines” is reproduced in the Student Manual that accompanies this textbook. You may want to refer to these guidelines often, especially as you study Chapters 1 through 5.

The Rights of Group Participants

My experience has taught me that those who enter groups are frequently unaware both of their basic rights as participants and of their responsibilities. As a group leader, you are responsible for helping prospective members understand what their rights and responsibilities are. This section offers a detailed discussion of these issues.

A Basic Right: Informed Consent

If basic information about the group is discussed at the initial session, the participants are likely to be far more cooperative and active. A leader who does this as a matter of policy demonstrates honesty and respect for group members and fosters the trust necessary for members to be open and active. Such a leader has obtained the informed consent of the participants.

Informed consent is a process that begins with presenting basic information about group treatment to potential group members to enable them to make better decisions about whether or not to enter and how to participate in a group (Fallon, 2006). Members have a right to receive basic information before joining a group, and they have a right to expect certain other information during the course of the group. Discussing informed consent is not a one-time event, and clients should understand at the outset that informed consent is an ongoing process.

It is a good policy to provide a professional disclosure statement to group members that includes written information on a variety of topics pertaining to the nature of the group, including therapists’ qualifications, techniques often used in the group, the rights and obligations of group members, and the risks and benefits of participating in the group. Other information that potential members should have includes alternatives to group treatment; policies regarding appointments, fees, and insurance; and the nature and limitations of confidentiality in a group. Group leaders should not overwhelm members with too much information at one time because an overly lengthy informed consent process may replace a collaborative working relationship with a legalistic framework, which is not in the best interests of group members (Fallon, 2006).

Pregroup Disclosures Here is a list of what group participants have a right to expect before they make the decision to join a group:

• A clear statement regarding the purpose of the group

• A description of the group format, procedures, and ground rules

• An initial interview to determine whether this particular group with this particular leader is at this time appropriate to their needs

• An opportunity to seek information about the group, to pose questions, and to explore concerns

• A discussion of ways the group process may or may not be congruent with the cultural beliefs and values of group members

• A statement describing the education, training, and qualifications of the group leader

• Information concerning fees and expenses including fees for a follow-up session, should there be one; also, information about length of the group, frequency and duration of meetings, group goals, and techniques being employed

• Information about the psychological risks involved in participating in a group

• Knowledge of the circumstances in which confidentiality must be broken because of legal, ethical, or professional reasons

• Clarification of what services can and cannot be provided within the group

• Help from the group leader in developing personal goals

• A clear understanding of the division of responsibility between leader and participants

• A discussion of the rights and responsibilities of group members

Clients’ Rights During the Group Here is a list of what members have a right to expect during the course of the group:

• Guidance concerning what is expected of them

• Notice of any research involving the group and of any audio- or videotaping of group sessions

• Assistance from the group leader in translating group learning into action in everyday life

• Opportunities to discuss what one has learned in the group and to bring some closure to the group experience so participants are not left with unnecessary unfinished business

• A consultation with the group leader should a crisis arise as a direct result of participation in the group, or a referral to other sources of help if further help is not available from the group leader

• The exercise of reasonable safeguards on the leader’s part to minimize the potential risks of the group; respect for member privacy with regard to what the person will reveal as well as to the degree of disclosure

• Observance of confidentiality on the part of the leader and other group members

• Freedom from having values imposed by the leader or other members

• The right to be treated as an individual and accorded dignity and respect

It is critical that group leaders stress that participation in groups carries certain responsibilities as well as rights. These responsibilities include attending regularly, being prompt, taking risks, being willing to talk about oneself, giving others feedback, maintaining confidentiality, and defining one’s personal goals for group participation. Some of these group norms may pose problems for certain members because of their cultural background. It is essential that the expectations for group members be clear from the outset and that members be in agreement with such expectations. Of course, part of the group process involves the participation of members in developing norms that will influence their behavior in a group situation.

Issues in Involuntary Groups

When participation is mandatory, informed consent is as important as it is when working with voluntary groups. Much effort needs to be directed toward fully informing involuntary members of the nature and goals of the group, the procedures to be used, their rights and responsibilities, the limits of confidentiality, and what effect their level of participation in the group will have on critical decisions about them outside of the group. When groups are involuntary, every attempt should be made to enlist the cooperation of the members and encourage them to continue attending voluntarily. One way of doing this is to spend some time with involuntary clients helping them reframe the notion “I have to come to this group.” They do have some choice whether they will attend group or deal with the consequences of not being in the group. If “involuntary” members choose not to participate in the group, they will need to be prepared to deal with consequences such as being expelled from school, doing jail time, or being in juvenile detention.

Another alternative would be for the group leader to accept involuntary group members only for an initial limited period. There is something to be said for giving reluctant members a chance to see for themselves what a group is about and then eventually (say, after three sessions) letting them decide whether they will return. Group leaders can inform members that it is their choice of how they will use the time in the group. The members can be encouraged to explore their fears and reluctance to fully participate in the group, as well as the consequences of not participating in the group. Ethical practice would seem to require that group leaders fully explore these issues with clients who are sent to them.

The Freedom to Leave a Group

Leaders should be clear about their policies pertaining to attendance, commitment to remaining in a group for a predetermined number of sessions, and leaving a particular session if they do not like what is going on in the group. If members simply drop out of the group, it is extremely difficult to develop a working level of trust or to establish group cohesion. The topic of leaving the group should be discussed during the initial session, and the leader’s attitudes and policies need to be clear from the outset.

In my view, group members have a responsibility to the leaders and other members to explain why they want to leave. There are a number of reasons for such a policy. For one thing, it can be deleterious to members to leave without having been able to discuss what they considered threatening or negative in the experience. If they leave without discussing their intended departure, they are likely to be left with unfinished business, and so are the remaining members. A member’s dropping out may damage the cohesion and trust in a group; the remaining members may think that they in some way “caused” the departure. It is a good practice to tell members that if they are even thinking of withdrawing they should bring the matter up for exploration in a session. It is critical that members be encouraged to discuss their departure, at least with the group leader.

If a group is counterproductive for an individual, that person has a right to leave the group. Ideally, both the group leader and the members will work cooperatively to determine the degree to which a group experience is productive or counterproductive. If, at a mutually agreed-upon time, members still choose not to participate in a group, I believe they should be allowed to drop out without being subjected to pressure by the leader and other members to remain.

Freedom From Coercion and Undue Pressure

Members can reasonably expect to be respected by the group and not to be subjected to coercion and undue group pressure. However, some degree of group pressure is inevitable, and it is even therapeutic in many instances. People in a group are challenged to examine their self-defeating beliefs and behaviors and are encouraged to recognize what they are doing and determine whether they want to remain the way they are. Further, in a counseling group, there is pressure in sessions to speak up, to make personal disclosures, to take certain risks, to share one’s reactions to the here-and-now events within the group, and to be honest with the group. All of these expectations should be explained to potential group members during the screening and orientation session. Some individuals may not want to join a group if they will be expected to participate in personal ways. It is essential for group leaders to differentiate between destructive pressure and therapeutic pressure. People often need a certain degree of pressure to challenge them to take the risks involved in becoming fully invested in the group.

The Right to Confidentiality

Confidentiality is a central ethical issue in group counseling, and it is an essential condition for effective group work. The legal concept of privileged communication is not recognized in a group setting unless there is a statutory exception. However, protecting the confidentiality of group members is an ethical mandate, and it is the responsibility of the counselor to address this at the outset of a group (Wheeler & Bertram, 2012). The American Counseling Association’s (ACA, 2014) Code of Ethics makes this statement concerning confidentiality in groups: “In group work, counselors clearly explain the importance and parameters of confidentiality for the specific group” (Standard B.4.a.). The ASGW (2008) addresses the added complexity entailed in coming to a mutual understanding of confidentiality in diverse groups: “Group Workers maintain awareness and sensitivity regarding the cultural meaning of confidentiality and privacy. Group Workers respect differing views toward disclosure of information” (A.6.). As a leader, you are required to keep the confidences of group members, but you have the added responsibility of impressing on the members the necessity of maintaining the confidential nature of whatever is revealed in the group. This matter bears reinforcement along the way, from the initial screening interview to the final group session.

Although group leaders are themselves ethically and legally bound to maintain confidentiality, a group member who violates another member’s confidences faces no legal consequences (Lasky & Riva, 2006). If the rationale for confidentiality is clearly presented to each individual during the preliminary interview and again to the group as a whole at the initial session, there is less chance that members will treat this matter lightly. Confidentiality is often on the minds of people when they join a group, so it is timely to fully explore this issue. A good practice is to remind participants from time to time of the danger of inadvertently revealing confidences. My experience continues to teach me that members rarely gossip maliciously about others in their group. However, people do tend to talk more than they should outside the group and can unwittingly offer information about fellow members that should not be revealed. If the maintenance of confidentiality is a matter of concern, the subject should be discussed fully in a group session.

In groups in institutions, agencies, and schools, where members know and have frequent contact with one another outside of the group, confidentiality becomes especially important and is more difficult to maintain. Clearly, there is no way to ensure that group members will respect the confidences of others. As a group leader, you cannot guarantee confidentiality in a group setting because you cannot control absolutely what the members do or do not keep private. Members have a right to know that absolute confidentiality in groups is difficult and at times even unrealistic (Lasky & Riva, 2006). However, you can discuss the matter, express your convictions about the importance of maintaining confidentiality, and have members sign contracts agreeing to it. Your own modeling and the importance that you place on maintaining confidentiality will be crucial in setting norms for members to follow. Ultimately, it is up to the members to respect the need for confidentiality and to maintain it.

Members have the right to know of any audio- or videotape recordings that might be made of group sessions, and the purpose for which they will be used. Written permission should be secured before recording any session. If the tapes will be used for research purposes or will be critiqued by a supervisor or other students in a group supervision session, the members have the right to deny permission.

Exceptions to Confidentiality Group leaders have the ethical responsibility of informing members of the limits of confidentiality within the group setting. For instance, leaders can explain to members when they are legally required to break confidentiality. Leaders can add that they can assure confidentiality on their own part but not on the part of other members. It is important to encourage members to bring up matters pertaining to confidentiality whenever they are concerned about them. The ACA Code of Ethics (ACA, 2014) identifies exceptions to confidentiality that members should understand:

The general requirement that counselors keep information confidential does not apply when disclosure is required to protect clients or identified others from serious and foreseeable harm or when legal requirements demand that confidential information must be revealed. Counselors consult with other professionals when in doubt as to the validity of an exception. Additional considerations apply when addressing end-of-life issues. (Standard B.2.a.)

It is a good policy for group workers to give a written statement to each member setting forth the limitations of confidentiality and spelling out specific situations that would require breaching confidences. Such straightforwardness with members from the outset does a great deal to create trust because members then know where they stand.

Of course, it is imperative that those who lead groups become familiar with the state laws that have an impact on their practice. Group leaders do well to let members know that legal privilege does not apply to group treatment, unless provided by state statute (ASGW, 2008). The American Group Psychotherapy Association (AGPA, 2002) states: “The group therapist is knowledgeable about the limits of privileged communication as they apply to group therapy and informs group members of those limits” (2.2). Counselors are legally required to report clients’ threats to harm themselves or others. This requirement also covers cases of child abuse or neglect, incest, child molestation, elder abuse, and dependent-adult abuse. Taking an extreme case, if one of your group members convincingly threatens to seriously injure another person, you may have to consult your supervisor or other colleagues, warn the intended victim, and even notify the appropriate authorities. The threat need not involve others; clients may exhibit bizarre behavior that requires you to take steps to have them evaluated and possibly hospitalized.

If you lead a group at a correctional institution or a psychiatric hospital, you may be required to act as more than a counselor; for instance, you will probably have to record in a member’s file certain behaviors that he or she exhibits in the group. At the same time, your responsibility to your clients requires you to inform them that you are recording and passing on certain information. Generally speaking, you will find that you have a better chance of gaining the cooperation of group members if you are candid about a situation rather than hiding your disclosures and thereby putting yourself in the position of violating their confidences.

Confidentiality With Minors In a group for children in a school setting, care needs to be exerted to ensure that what goes on within the group is not a subject for discussion in class or on the playground. If children begin to talk about other members outside of the group, this will certainly block progress and damage the cohesion of the group. As is the case for adults and adolescents, children require the safety of knowing they will be treated respectfully. On this matter, the American School Counselor Association’s (ASCA, 2010) Ethical Standards for School Counselors provides an important guideline:

Professional school counselors establish clear expectations in the group setting, and clearly state that confidentiality in group counseling cannot be guaranteed. Given the developmental and chronological ages of minors in schools, recognize the tenuous nature of confidentiality for minors renders some topics inappropriate for group work in a school setting. (A.6.c.)

Group leaders must also be careful in how they talk about the children to teachers and administrators. Those who do groups with children need to explain what will be kept confidential and what may need to be shared with school personnel. This also applies to talking with parents. Do parents have a right to information that is disclosed by their children in a group? The answer to that question depends on whether you are looking at it from a legal, ethical, or professional viewpoint. It is a good practice to require written permission from parents before allowing a minor to enter a group. It is useful to have this permission include a brief statement concerning the purpose of the group, along with comments regarding the importance of confidentiality as a prerequisite to accomplishing such purposes, and your intention not to violate any confidences. It may sometimes be useful to provide parents with information about their child if this can be done without violating confidences. One useful practice to protect the privacy of what goes on in the group is to provide feedback to parents in a session with the child and one or both parents. In this way the child will have less cause to doubt the group leader’s integrity in keeping his or her disclosures private.

Group leaders have a responsibility in groups that involve children and adolescents to take measures to increase the chances that confidentiality will be kept. It is important to work cooperatively with parents and guardians as well as to enlist the trust of the young people. It is also useful to teach minors, in terms that they are capable of understanding, about the nature, purposes, and limitations of confidentiality. In summary, group leaders would do well to continue to remind members to bring up their concerns about confidentiality for discussion whenever the issue is on their minds.

Social Media in Group Work: Confidentiality and Privacy Considerations Confidentiality and privacy issues take on special considerations when group members and their therapists communicate with each other online and when group members communicate with other members via the Internet. There is an increased risk of breach of confidentiality when members of a counseling group engage in social media (Wheeler & Bertram, 2012). Group counselors must address the parameters of online behavior through informed consent and should establish ground rules regarding members’ commitment to avoid posting pictures, comments, or any type of confidential information about other members online. Developing these rules needs to be part of the discussion about norms governing the group.

Breaches of confidentiality or privacy may occur when members share their own information online, especially if they struggle with poor boundaries. Others may lack the technological skills and knowledge to protect information that is intended to remain private. Educate members to share their experience with others outside the group by talking about their own experience, reactions, and insights rather than telling stories about other members or mentioning others in the group by name.

The Issue of Psychological Risks in Groups

Groups can be powerful catalysts for personal change, and they can also pose definite risks for group members. Ethical practice demands that group practitioners inform prospective participants of the potential risks involved in the group experience. The nature of these risks—which include life changes that cause disruption, hostile and destructive confrontations, scapegoating, and harmful socializing among members—and what the leader can do about them are the subject of this section. It is unrealistic to expect that a group will not involve risk, for all meaningful learning in life involves taking some kind of risk. It is the ethical responsibility of the group leader to ensure that prospective group members are aware of the potential negative outcomes that are associated with various risks and to take every precaution against them.

The ACA Code of Ethics (ACA, 2014) specifies that “[i]n a group setting, counselors take reasonable precautions to protect clients from physical, emotional, or psychological trauma” (Standard A.9.b.). This includes discussing the impact of potential life changes and helping group members explore their readiness to deal with such changes. A minimal expectation is that group leaders discuss with members the advantages and disadvantages of a given group, that they prepare the members to deal with any problems that might grow out of the group experience, and that they be alert to the fears and reservations that members might have.

It is also incumbent on group leaders to have a broad and deep understanding of the forces that operate in groups and how to mobilize those forces for ethical ends. Unless leaders exert caution, members not only may miss the benefits of a group but also could be harmed by it psychologically. Group leaders must take precautionary measures to reduce unnecessary psychological risks by knowing members’ limits, respecting their requests, developing an invitational style as opposed to an aggressive or dictatorial style, avoiding abrasive confrontations, describing behavior rather than making judgments, and presenting hunches in a tentative way.

Here are a few of the problems group leaders can warn members about and work toward minimizing:

1. Members should be made aware of the possibility that participating in a group (or any other therapeutic endeavor) may disrupt their lives. As members become increasingly self-aware, they may make changes in their lives that, although constructive in the long run, can create turmoil along the way. For example, changes that a woman makes as a result of what she gains in a group may evoke resistance, even hostility, in her partner, with a resulting strain on their relationship. Furthermore, others with whom she is close may not appreciate her changes and may prefer the person she was before getting involved in counseling.

2. Occasionally an individual member may be singled out as the scapegoat of the group. Other group members may “gang up” on this person, blaming him or her for problems of the group. Clearly, the group leader must take firm steps to deal with such occurrences.

3. Confrontation, a valuable and powerful tool in any group, can be misused, especially when it is employed to destructively attack another. Intrusive interventions, overly confrontive leader tactics, and pushing members beyond their limits often produce negative outcomes. Here, again, leaders (and members as well) must be on guard against behavior that can pose a serious psychological risk for group participants. To lessen the risks of destructive confrontation, leaders can model the type of confrontation that focuses on specific behaviors and can avoid making judgments about members. They can teach members how to talk about themselves and the reactions they are having to a certain behavior pattern of a given member.

4. If safety is lacking in a group, members who have been subjected to social injustices may be revictimized when they explore their experiences in the group.

One way to minimize psychological risks in groups is to use a contract in which the leader specifies his or her responsibilities and the members specify their commitment by stating what they are willing to explore and do in the group. Such a contract reduces the chances that members will be exploited or will leave the group feeling that they have had a negative experience.

Another safeguard against unnecessary risk is the ability of leaders to recognize the boundaries of their competence and to restrict themselves to working only with those groups for which their training and experience have properly prepared them. Ultimately, the group leader is responsible for minimizing the inevitable psychological risks associated with group activity. To best assume this responsibility, the leader will undergo the supervised practice and course work described later in this chapter.

The Ethics of Group Leaders’ Actions

Being a group practitioner demands sensitivity to the needs of the members of your group and to the impact your values and techniques can have on them. It also demands an awareness of community standards of practice, the policies of the agency where you work, and the state laws that govern group counseling. In the mental health professions in general, there is a trend toward accountability and responsible practice. Graduate programs in counseling and social work are increasingly requiring course work in ethics and the law.

Almost all of the professional organizations have gone on record as affirming that their members should be aware of prevailing community standards and of the impact that conformity to or deviation from these standards will have on their practice. These organizations state explicitly that professionals will avoid exploitation of the therapeutic relationship, will not damage the trust that is necessary for a relationship to be therapeutic, and will avoid dual relationships if they interfere with the primary therapeutic aims. Typically, the ethics codes caution against attempting to blend social or personal relationships with professional ones and stress the importance of maintaining appropriate boundaries.

Group counselors need to be mindful about misusing their role and power to meet their personal needs at the expense of clients. To do so is to commit an ethical violation. The role of leaders is to help members meet their goals, not to become friends with their clients. Of course, leaders who develop sexual relationships with current group members are acting unethically. They not only jeopardize their license and their professional career, but they also degrade the profession at large. For a more complete discussion of these topics, see Herlihy and Corey (2015a, 2015b).

Socializing Among Group Members

An issue to consider is whether socializing among group members hinders or facilitates the group process. This concern can become an ethical issue if members are forming cliques and gossiping about others in the group or if they are banding together and talking about matters that are best explored in the group sessions. If hidden agendas develop through various subgroups within the group, it is likely that the progress of the group will come to an abrupt halt. Unless the hidden agenda is brought to the surface and dealt with, it seems very likely that many members will not be able to use the group therapeutically or meet their personal goals.

Yalom (2005) states that a therapy group teaches people how to form intimate relationships but is not designed to provide these relationships. He also points out that members meeting outside of the group have a responsibility to bring information about their meeting into the group. Any type of outof- group socialization that interferes with the functioning of the group is counterproductive and should be discouraged. This is especially true when some participants discuss issues relevant to the group but avoid bringing up the same issues in the group itself. As Yalom (2005) explains, “It is not the subgrouping per se that is destructive to the group, but the conspiracy of silence that generally surrounds it” (p. 352).

In some cases, out-of-group contact and socialization can be beneficial. From the perspective of feminist group therapy, out-of-group socialization is not viewed as harmful. This is especially true if members are selected carefully and are able to manage out-of-group contact so that it works to their own best interests and to the good of the group as a whole. During out-of-group contact, members often have the opportunity to expand on their goals outside of the group.

One of the best ways for the group leader to prevent inappropriate and counterproductive socialization among group members is to bring this issue up for discussion. It is especially timely to explore the negative impact of forming cliques when the group seems to be stuck and is getting nowhere or when it appears that members are not talking about their reactions to one another. The members can be taught that what they do not say in the group itself might very well prevent their group from attaining any level of cohesion or achieving its goals.

The Impact of the Leader’s Values on the Group

In all controversial issues related to the group process, the leader’s values play a central role. Your awareness of how your values influence your leadership style is in itself a central ethical issue. Value-laden issues are often brought to a group—religion, spirituality, abortion, divorce, gender roles in relationships, and family struggles, to name just a few. The purpose of the group is to help members clarify their beliefs and examine options that are most congruent with their own value system. Group counseling is not a forum in which leaders impose their worldview on the members; it is a way to assist members in exploring their own cultural values and beliefs. To practice effectively and to empower members of a group, group leaders must be able to keep their personal values separate from their work with group members. Kocet and Herlihy (2014) describe this process as ethical bracketing, the “intentional setting aside of the counselor’s personal values in order to provide ethical and appropriate counseling to all clients, especially those whose worldviews, values, belief systems, and decisions differ significantly from those of the counselor” (p. 182).