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In section one I will include a brief outline of ethics and general ethical issues within a psychotherapy context. Section two considers health reforms and professional regulation legislation within New Sealant’s health sector. In section three discuss the specific ethical issues as stated above within a psychotherapeutic setting and finally in section four I outline the impact of the Treaty of Waiting on ethical practice in psychotherapy.
Section One Ethical Issues within Psychotherapy It is important to begin this assignment by briefly defining the term “ethics. ” The Oxford Dictionary (1999) describes ethics as a, “moral principle and a oral philosophy” (p. 176). This gives a simple description that gives us a basic framework to begin to work from, however, it does not clarify the issues of complexity involved when dealing with ethical issues in professional practice or in general.
Some of these ethical issues include, economic scarcity, delivery systems, different patient care, increasing information, advances in medical technology and changing interpersonally roles (Regime & Bowie, 2000). From my perspective ethics means a body of principles that we reflect on and act on both individually and corporately within a social setting. Ethics is the foundation for decision making, guidelines for professional practice and an expression of values individually and collectively.
Ethics is therefore a process of human problem solving, involving emotions and reasoning. Ethics is not to do with finding objective truths or answers (Auckland University of Technology Lecture, 2005). Comatose (1994) states, “ethics are the study of arguments regarding moral right or wrong, good and bad, insofar as the arguments concern professional matters related to the maintenance of health, as well as those principles that prescribe how practitioners will work o actualities or improve the well-being of the client” (p. 1297).
What is an ethical issue? What is an ethical decision? Why are they necessary? Who defines them? And why and how are they applied? These are important questions that are relevant to my psychotherapy practice and which attempt to answer throughout this assignment. Mitchell (1996) describes an “ethical issue” as, “concerns involving disagreements or opposing views among two or more parties (patients, families, physicians, psychotherapists, insurance companies) about what is the right or best decision related to patient care” p. 10).
An “ethical decision” is an attempt to reach a rational consensus through a systematic framework involving a diversity of individuals and opinions that possibly conflict (Comatose, 1994). Is ethics a necessary part of society? I’d have to answer yes, as ethics give us some basic guidelines, principles and assumptions with which to construct social meaning. Psychotherapeutic practice is a specialized interpersonal health practice which works with individuals and bodies of individuals who suffer overwhelming life afflictions, discomfort, pain and conflict and who are in deed of external help (Pelham, 1999).
Besides the very diverse and complex biological, physiological and psychological world of these individuals, therapists also have to be aware of the environmental sources that have significantly impacted on these individuals, such as, school, work, family, community, culture and society. In such an arena of diversity, affliction, discomfort, pain and conflict, there must be practice safeguards, such as codes of practice and codes of ethics, so that practitioners may make their decisions based on standards of the best possible practice for the client at the time.
Research, controversy, critical analysis and extensive discussions of therapeutic practice have led to the progressive changes in ethical issues, training, standards, supervision and professional body oversight generally seen today (Pelham, 1999). The diversity of humanity as seen in clients and therapists within psychotherapy creates a possibility for diverse ethical issues and standards of professional conduct in various areas.
These ethical dilemmas in psychotherapy range from, managed mental health care, cultural and religious issues, privacy and confidentiality, informed consent, training and lubrications (Pomeranian & Handedness, 2000); economic issues (fees), efficiency of psychotherapy, diagnosis and stratifications, issues of power abuse in a therapeutic relationship and sexual issues and the relationship to intimacy (She’d & Dobson, 2004); different modalities and techniques of psychotherapy, the value of brief and long term psychotherapy and risk management and suicidal issues with clients (Brown & Sleep, 1986); the self care of the therapist, group psychotherapy issues and termination of the therapeutic relationship (Liking, 1986). These ethical issues have been largely scudded and guided by social and health reforms, such as, the Health Practitioners Competence Assurance Act (MOM, 2003). Section Two Health Reforms As a trainee psychotherapist I believe it is important to have an understanding of New Zealand health reforms and legislation. The psychotherapy profession is close to becoming a registered health profession under the Health Practitioners Competence Assurance (HAP) Act.
This will influence current legislation and health care management structure in its ethical guidelines of practice. Over the past 10-20 years New Sealant’s health care systems have been the Ochs of major health reforms. New Sealant’s health care system has under gone significant changes such as, the introduction of commercialism, corporations, privations and changes to the public sector industrial relations (Gaston, 2002). These changes have raised significant ethical issues for practitioners working in the restructuring environment. In 1 984, the Labor government started transforming the economy of New Zealand from a highly regulated economy to a deregulated economy, freed from bureaucratic control (Gaston, 2001).
This was the beginning of the corporations of the public sector, if not privations. A revision of managerial and accountability mechanisms were introduced throughout the public health care system (Gaston, 2001). In 1 990, an incoming National government continued the direction of this economic reform that began in 1984. Business-like practices and market focused approaches were introduced into the public hospitals leading to some radical changes. These radical changes involved “the Health Services Attackers” to examine the health sector in general, making health service fenders and providers more efficient and responsive to consumer preferences (Davis & Gaston, 2001).
The outcomes from this attackers were monumental in forming the basis for reform proposals announced in 1 991 known as the Green and White Paper. This was the basis for the reshaping of the New Zealand health care system. Financial (2001 ) described this shift as the purchaser and provider split, “the public contract model, in this model purchases use public funds to contract competing public and private providers for the provision of health care services”(p. 48). Auckland District Health boards were reconfigured into 23 Crown Health Enterprises. Although publicly owned, these were structured as for-profit organizations, which revived the incentives, initiative and innovation to overcome the inefficiencies entrenched in the system at the time (Gaston, 2002).
These reforms from 2000 onwards have represented a progressive shift from a model encouraging competitive tendering for contract, to a focus on providing treatment services at the expense of improving the health of community. However, this restructuring of policy in 1993 and 2000 primarily focused on a system structure, rather than on a service delivery and individualistic incentive scheme (Gaston, 2002). The main focus for health care providers has been that of financial profit rather than the quality of arrive and competency of the provider. It was this reason that the consumers’ rights protection and well-being of the client became paramount in New Zealand health care.
Gaston (2002) stated, “this focus on financial and managerial issues in the health care sector has resulted in a lack of focus on service delivery, decreased and deregulated quality of health care provision and ignorance of patient- focused approach” (p. 53). Therefore, the real issue with health reforms in New Zealand is managerial versus professionalism that is service based (Gillette, 1999). These changes eave significantly impacted on the roles of health practitioners. Some of the results of this rapid adaptation to change have caused stress and intellectual and emotional fatigue for health practitioners working in the New Zealand health sector (Gillette, 1999).
In t his section I have briefly described health reforms. The following section I will be outlining and discussing New Zealand legislation. New Zealand Legislation An increased number of public concerns in relation to consumer rights and the competencies of health practitioners resulted in the Health Practitioners Competence Assurance (HAP) Act. This legislation requires all professionals covered by the Act to be accountable, maintaining and demonstrating competence (Mom, 2004). The primary purpose of the Act is to protect the health and safety of the consumer by providing legislation to ensure the competency of health providers (Atkinson, 1994).
Therefore key ethical issues are established through competence and ethical codes of practice. These principles include beneficence, professional fidelity and responsibility, integrity, justice and respect for autonomy (Béchamel, 1994). These principles are fundamental to the HAP Act. Beneficence is where health practitioners strive to benefit and take care to do no harm to those whom they work. Professional fidelity and responsibility is where the practitioner establishes a relationship of trust. Integrity seeks to promote accuracy, honesty, truthfulness in science, teaching and practice. The principle of justice recognizes the fairness of distribution.
The last ethical principle, respect for autonomy, respects the dignity and rights of individual privacy, confidentiality and self determination (Béchamel, 1994). These important ethical principles are discussed further in section three. It is important to state that psychotherapy is not a registered profession and therefore does not fall under the HAP Act. The psychotherapy profession falls under the Health and Disabilities Commission (HAD). This code states that every consumer has the right to be treated with respect (HAD, 1996). Am aware that the code of Health Disability Services Consumers’ rights (HAD, 1996) provides specific directions for psychotherapy health professionals in the provision of ethical and competent services for clients, as well as self- protection for the health practitioners.
Currently, the New Zealand Association of Psychotherapists (ANZA) is the repressions body that provides a code of conduct for associated members. The ANZA is the professional body which sets, examines and maintains standards for the safe and ethical practice of psychotherapy in New Zealand. It is well recognized that psychotherapists need to become registered under the HAP Act. This will provide practitioners with a framework of competence under the Acts scope of practice and practice ethics. This legislation will specify scopes of practice (general, specific and limited), prescribing the qualifications for practice, oversee the process for registration, review intuiting competence and her complaints (ANZA, 2004).
If the legislation gets passed through the Labor government and the practice Of psychotherapy is included within the HAP Act framework, all individuals describing themselves as psychotherapists will be required to register with the New Zealand Psychotherapists board and to work within a defined scope of practice (ANZA, 2004). This Psychotherapy Board along with ANZA will be paramount for all psychotherapy practitioners in dealing with important daily ethical principles, concerns and issues of practice as discussed further in this assignment. Section Three Basic codes of conduct have been set down for all practitioners since antiquity (Castigation, 1947).
However, it is important to note that special ethical problems affect psychotherapeutic practice which differs from those issues in physical branches of medicine (Gabby, 1989). In psychotherapy, privacy is foundational not simply in relation to an individual’s physical examination, illness related information, discussion or decision making like in the medical profession but there is a psychological element (overwhelming thoughts and feelings) that need to be considered (Karakas, 1996). It is this therapeutic relationship and the unusual emotional bond that develops between therapist and client that is paramount to these differences. Karakas (1996) wrote of this relationship, “It has been compared to that of parent and child and is unlike other professional or contractual relationships… T is distinct, not only in the intimacies of personal life that are revealed but due to deep-seated dependency, attraction and affection, including sexual feelings, that are often aroused” (p. 320). The professional ethical principle of beneficence strives to benefit the client with whom the recantation works with and taking care and to do no harm, seeking to safeguard the welfare and rights of the client with whom they interact professionally (Béchamel, 1994). The protection Of this relationship is Of fundamental importance to psychotherapy practice. Therefore, ethical guidelines that uphold client confidentiality and privacy are needed. Issues of confidentiality and privacy are issues that psychotherapists deal with constantly.
Confidentiality is the protection of patients’ disclosures in a therapeutic setting (Karakas, 1 996) and confidentiality constitutes a major patient expectation and right. This issue is currently covered by a general code of practice, the principle of respect for people’s rights and dignity under the Privacy Act (Privacy Commissioner, 1993) and the Health and Disability Service Consumers’ Rights (H DC, 1996). The respect for people’s rights and dignity is fundamental to the HAP Act. This respect empowers the client with autonomy. Autonomy is the ability to think freely and the ability to act on one’s decisions. Amelia (1994) states, “an autonomous patient has a right to self-determination (p. 8). At times a patient’s ability to fully understand may affect their capability to make autonomous decisions.
It is evident today from a medical paternalistic perspective that patient autonomy has been compromised (Bruin, 2001). This is the reason for continual development of principles, codes and interventions involving ethics within the human health care sector (Amelia, 1994). The therapist is in a highly responsible role to make judgments regarding all formal and informal verbal exchanges as well as case records and reports. The Health Information Privacy Code (1994) states, “ethically and legally, the rule Of confidentiality obligates all health care workers to not only refrain room disclosing information obtained from patients to others, but also to take every reasonable precaution to ensure that any records of such information remain confidential” (p. 1 There are some exceptions to confidentiality where as a psychotherapist we are legally bound to waiver clients’ rights. These exceptions include when a client is in danger to self (suicidal acts) or others (public peril). Exceptions also include, the client ordered for evaluation of treatment by the court, if the client is a minor, the therapist suspects child abuse and if the client is disabled or elderly and the therapist suspects some form of abuse (HAD, 996). This has created some controversy amongst the psychotherapy profession. This IS because of the therapists’ individual beliefs and values and whether they perceive breaking confidentiality as ethical or unethical (Gigs & Coin, 2000).
In the health care sector of New Zealand the practitioner is morally and legally placed in an extremely difficult position. This possibly can leave the therapist with the sense of divided loyalties. The therapist may feel conflicted between the individual needs of the client (protecting confidentiality) verses the therapists desire and obligation to protect the lifer Of other individuals in the client’s life. It seems to be standard practice in most public and private psychotherapy practices that ethical issues of confidentiality are detailed and outlined at the beginning of the therapeutic process. This declaration protects the clients’ consumer rights and also safe guards and protects the therapist and practice.
It is important to have awareness about how this discussion of the limits of confidentiality may influence or hinder the development of trust in the therapeutic relationship and the clients’ willingness to self-disclose (Vasquez, Another important issue to discuss is the intensity of the therapeutic relationship and bond and how this relationship can activate sexual feeling and fantasies while potentially weakening objectivity needed to retain ethical boundaries. It is essential that I am aware of the potential dynamics that can occur within the therapeutic relationship particularly in relation to sexual issues and boundaries (Karakas, 1996). In relation to sexual boundaries in the therapeutic relationship it is important to note the principle of professional fidelity and responsibility which upholds professional standards of conduct.
Clarifying professional roles and obligations, accepting appropriate responsibility for behavior, seeking to manage conflicts of interest that could lead to exploitation or harm is fundamental when working in relationship with a client. This principle protects the client and his/her rights and dignity (Béchamel, 1994). Under ANZA Codes of Practice, the client/therapist relationship is foundational; therefore a sexual relationship within this client/therapist framework is considered unsafe, incompetent and unethical (ANZA, 2005). However, codes of practice ate ill defined in relation to when a therapist/client allegations is ethically allowed.
These ethical issues include, what constitutes mutual consent with the therapeutic relationship, what is the nature of the therapeutic alliance and how does it differ from other professional and personal relationships, legally the right to privacy interfaces with the nature of consent and empirically what are the effects of such criminal actions (Gabby & Pope, 1989). In psychotherapy there is a theoretical emphasis on sexuality being a major driving force, however, there is a greater emphasis on actual sexual misconduct and abuse (Schultz-Ross, Goldman & Guthrie, 1992). My struggle as a trainee psychotherapist involves how do we as professionals define the grey areas of ethical issues. For example, if the client doesn’t disclose how responsible is the therapist for predicting and preventing danger or harm to self?
At what point must confidentiality be compromised by informing authorities, professionals and family members? Where and when do we as practitioners draw the line? How these questions will be answered by individuals is according to their own subjective experiences and decisions. This is why I believe in the interpersonally cooperation of professional bodies, such as ANZA and HAD. This provides a platform for discussion and collaboration over ethical grey areas. These ethical issues do provide professionals with challenges. However, more strategies and the development of better client care will emerge as psychotherapists take up the challenge to work through, process and face these issues.
Another ethical dilemma seen in our westernizes bureaucratic health care system involves a stronger economic emphasis as opposed to the increase of the quality of service and client treatment. The ethical principle of integrity promotes honesty and truthfulness. This principle discusses how recantations are obligated to the consumer not to steal, cheat, or engage in fraud, subterfuge, or intentionally misrepresent the facts (Béchamel, 1994). Mitchell, Cordoned & Owen (1996) writes, “health care professionals are challenged to balance quality care verse balancing the financial books” (p. 14). How do we as psychotherapists balance the clients and the organizations It seems difficult to practice from a holistic perspective in a positivistic health- care context undermined by bureaucratic and economy driven issues.
In New Zealand the rising economic pressure often favors short term therapy over Eng term therapy which at times can put the client at risk of being subject to insufficient or superficial treatment (Sciatica, 2002). For example, in relation to Accident Compensation Corporation services (AC), when a sexually abused client presents for therapy, a limited time frame of ten sessions is given to complete the trauma-based therapeutic process. It is evident that short term psychotherapy seems to be more economical and popular and the importance of an individuals care, safety and development and facilitation of self awareness dissolves in such a context.
Pharmacology, behavioral, cognitive and group approaches are all in the direction of cost efficiency and are becoming preferred modalities in the managed health care context (Karakas, 1996). So the ethical concern is the reduced availability to deal with individual themes and enduring problems, the trading of long term goals for short term goals, professional decisions at times based on financial efficiency rather than the therapeutic outcome. Mitchell, Cordoned & Owen (1996) states, “the change is altering the role Of the psychotherapist from serving as an agent for the patient’s welfare to balancing the patient’s needs against the need for cost intro” (p. 77).
As trainee psychotherapist working for the Whitman District Health Board in the Community of Drugs and Alcohol Services (CADS), recognize and experience the rigid time frames; financial subsides, on doing audits and the emphasis on paper work and how these distract the attention away from the client to meet the requirements of the health care system. Section Four Ethical issues of Psychotherapy in Relation to Bicameralism and the Treaty of Waiting In order to truly understand psychotherapy practice within a New Zealand framework we must understand cultural practice within our society (Fay, 2004). Psychotherapy has had to adapt and attune itself to the local conditions of culture and the diversity of people in order to stay relevant. These differences reflect and effect different professional ethical practices whereby each profession may define and/ or explain any situation in qualitatively different ways (Irvine, Kedgeree, McGee & Freeman, 2002).
Although New Zealand society has fundamentally been dominated by westernizes bureaucratic and positivistic systems, bicameralism is an important part of the New Zealand public services ethos and has been promoted within a health care system as a desirable goal (Durries, 2003). In an attempt to increase the strength of bicameral practice through the Treaty of Waiting principles, psychotherapy is committed to upholding unifying frameworks which accommodate protection, partnership and equal power and development (Durries 2003). Incorporating Maori values and beliefs into psychotherapy and healing has been an active and important goal since the early sass’s.
Fundamentally it is important to consider cultural ethics in relationship to, mental health care, confidentiality and privacy, qualifications, training and professionalisms, religious and spiritual issues, informed onset, issues of power and abuse in the therapeutic relationship, economic issues, diagnosis and stratifications, sexual issues, different modalities and interventions of psychotherapy, termination of therapy and the self care of the therapist (Brown & Sleep, 1986; Pomeranian & Handedness, 2000; She’d & Dobson, 2004). Believe that the respect of rights, dignity and worth of all people is a fundamental ethical principle that needs to be upheld in our bicameral society. This ethical principle makes practitioners aware of the need for the respect for culture, individuals, and role differences. These include differences based on age, gender, race ethnicity, religion, sexual orientation, disability, language and socioeconomic status. According to Sheikh (2005) New Zealand contemporary health care does not address cultural ethics and issues effectively today.
According to statistical data, Maori people are overrepresented among mental health care patients as well as with life long illnesses (Sheikh, 2005). They appear to be more disadvantaged in relation to financial support, academic qualifications and health problems. It is a concern to think of how our westernizes, eructation social arena has had significant impact on shaping these issues in relation to Maori identity and cultural distortion today. For example, too many Maori are unable to have meaningful contact with their own spirituality, language, customs or inheritance, including Hannah involvement and traditional healing or therapies, while too few institutions in modern New Zealand are geared towards the expression of Maori values.