As history shows, there are a number of legal and ethical issues that have arisen in counselling, particularly in the area of clinical supervision. These have led to problems and challenges with patients, but also causes counselors to assess whether the work they do is beneficial, and what can be done to overcome such issues. In particular, these include the main ethical issues of transference, countertransference, multicultural malpractice, and also confidentiality. These issues, and how they are handled by counselors, as well as recommendations for future approaches are discussed herein.
Commonly defined as unconscious directions of feelings between one person to another, transference is often observed between children and adults. It becomes negative once one person forces another to see something with the same feelings. For example, it has been observed that patients redirect their feelings for a ‘significant other’ to the counselor when being examined.
These feelings, which are mostly feelings of attraction, but also can be of hatred and distrust, are not usually reciprocated by the counselor in question, but since the patient sees the counselor as a friend or enemy, in their particular case, leads to situations in which both are placed in jeopardy.
Recent research shows that transference is more likely to occur when patients are given less attention (Pierro, Orehek and Kruglanski, 2009).This is shown to have negative connotations when also observed in the light of social perception. Patients often exhibit high signs of transference, such as irrational panic, anger, and similar emotional instability, when not adequately cared for by their assigned counselor. Although partly to blame, counselors are not the main cause of these signs of transference.
Usually, patients behave in these ways due to physical stimuli in their past, such as a childhood experience or a similarity between the counselor and a ‘significant other’; a person who has impacted their life negatively. Although not totally negative, these emotions of distrust and hatred are observable between most patients and their counselors.
Another transference effect that patients exhibit is infatuation for a counselor for resembles a former partner. This can lead to uncomfortable situations for both the patient and the counselor in question, especially if such feelings are not reciprocated. As often the case between male patients and female counselors who show signs of transference, the situation may escalate, depending on the signs of transference.
In the case of clinical supervision, counselors should be aware of such effects that transference resemble, and should take precautions to guard against any ill effects that the behaviour of patients may bring about.
Counselors should ensure that the relationship between the patient should be purely cordial, and nothing more; and the patient should be made to understand their rights and responsibilities if any transference effects cross the boundaries regarding the patient-counselor relationship.
The patient’s influence on a counselor’s feelings is described as countertransference, and is often considered as a redirection of internal feelings towards a person based on what the expert is feeling. This is sometimes known as the reversal of the roles, referring to transference. However, both countertransference and transference contain the same issues regarding the impact of the patient-counselor relationship.
As this has escalated over time, particularly in the past few years, the professional and personal responsibilities delegated to counselors have become blurred with the patient’s, thereby making it more difficult for proper prognosis on the counselor’s part, and proper improvement on the patient’s part, to be readily observed.
In such cases, a counselor is observed to feel pity for a patient who has been affected by trauma, and is obliged to help that patient, but often extends beyond the line of duty. Although this may seem acceptable in some circumstances, it also helps in further complicating the patient-counselor relationship, and ends up doing more harm than good.
Tapping into the emotional side of the expert counselor is one of the main ways in which countertransference takes place, as feelings of infatuation or hate are also displayed toward patients that remind them of children they have or adults they have been acquainted with before. As the opposite effect of transference, it can lead to further difficulties if the patient continues to use their physical or emotional state to their own advantage.
A recent study shows that clinical counselors show two sides to countertransference; objective and subjective (Cartwright and Read, 2011; Hofsess and Tracey; 2010). A number of counselors were tested on their knowledge of countertransference in relation to their response in various clinical situations, and were reported to have demonstrated a shift in understanding, particularly due to their personal involvement in the patient’s situation. This shows that countertransference has a widespread affect on counselors across the board.
Despite the feelings of the counselor mostly being unconscious, the behaviour that they exhibit paints a picture to the patient that they are more concerned about their wellbeing than anyone else, leading to a false sense of security. As the patient resembles a loved one or a close friend, this can further extrapolate into territory beyond that of the patient-counselor relationship.
There is also a closed threat in countertransference, in terms of its suitability for the counselor and its influence on the patient. As is often the case, the counselor begins to build the relationship upon past failures or successes, especially since the patient is in a vulnerable state.
This behaviour on the counselor’s part does not usually lead to healthy relationship with the patient, although if it is a positive emotion displayed on the patient, it can have some beneficial effects.
As a clinical supervisor, it is important to ensure that the professional duty to the patient is always prioritised over the personal connection. Although certain feelings, such as sympathy and perhaps empathy, are allowable, these should never dominate or overrule the patient-counselor relationship. It is the counselor’s duty to provide a service to the patient, and it is the patient’s duty to receive such a service for their own benefit.
As one of the most prevalent amongst practicing professionals, multicultural malpractice is a serious issue that should not be dismissed imperturbably. Although the workplace is steadily becoming more multicultural, the area of psychology has been slow to embrace change, mainly due to fear of the unknown.
This has also filtered into the counselor-patient relationship. As open as many Western countries are to those of different races and backgrounds, their knowledge on psychological matters is often passed off as limited. This leads to a strained relationship, with the patient as the victim and the counselor as the bearer of bad news.
Such multicultural malpractice often impacts both the patient and the counselor in a negative way. For the patient, it leads to higher levels of mistrust of counselors, especially in terms of their opinion of the counselor’s job.
This also undermines the relationship and can lead to further issues along the way. For the counselor, it broadens the gap between themselves and the patient, and makes the patient feel more distanced from the counselor, who feels that the patient is burdensome.
However, there is some progress being made in this area. Recent research shows that creativity in embracing both cultures of the patient and counselor in a cross-cultural sense has a positive impact on the relationship (Leung and Chiu, 2010). Initially, the relationship between the patient and counselor was seen to improve when there is a transfer of ideas between individuals, and both embrace the receptiveness of each other. This also links both the patient and the counselor in a multicultural bond, by relying on the receptiveness of each to either culture.
Although this is a positive step in the right direction, not all counselors have the same outlook towards patients of different ethnicity. Patients are often wary of counselors who consider them to be unreliable, and these feeling are reciprocated in often harsher ways if the relationship continues to destabilize.
Recent research shows that the code of ethics and standards of practices put in place by professional associations do not adequately address the demands of working with patients of different race and background (Frame and Williams, 2005). Such organisations are partly to blame, in regards to insufficient training or encouragement for counselors to embrace multiculturalism; instead leading to malpractice.
As the patient population continues to increase, and more patients of different race and backgrounds enter into counselors’ care, it is imperative that counselors respect their patients despite any differences they may have, and the patient should also be open and able to communicate on a level that both the counselor and patient are content with.
From a clinical supervisor’s perspective, the counselor is responsible for the wellbeing of the patient while in their care, and it is the patient’s responsibility to trust the counselor for the best care possible. Anything that negatively escalates outside of this relationship should be treated as malpractice, and should not be tolerated accordingly. Therefore, multiculturalism should be embraced at the counselor-patient level.
Regarding the ethical issue of keeping information and personal history between the patient and the counsellor, confidentiality has increasingly become a major point of difference involving both parties. Such confidentiality has to do with solidifying the patient-counselor relationship on the basis of trust.
Although the patient and often the counselor take confidentiality as a given in the therapeutic sense, it can also be a detractor from the relationship if the patient mistrusts the counselor or has no prior relationship with the counselor. In addition, the counselor may have reason to believe that certain patients are more problematic than others, which can also lead to tension.
There are certain situations were some professional counselors have been known to bend the rules in an ethical sense for the greater good. For example, a patient may have a serious health complication or mental health issue that prevents them from thinking rationally. The counselor has a duty of care to provide them with the best course of action and ongoing treatment. However, if the patient becomes resistive and threatens the counselor, it is in the best interests of society to end the relationship, for the good of the patient and the preservation of the counselor’s service.
Health professionals may at times be legally and ethically required to breach confidentiality on the basis of broader societal interests (McSherry, 2009). In such a case, the counselor may have to involve a supervisor or superior to intervene or provide assistance and advice to both the patient and the counselor themselves.
In a superivosry role, it is required that confidentiality is maintained at all times, unless there are high risk cases in which certain interventions are allowable, as aforementioned. The duty of care to a patient should be kept as a high priority, especially in light of the counseling profession.
It is clear that the ethical issues raised above are to be analysed and explained for further development in the area of psychology. Counselors should be aware of such effects that transference resemble, and should take precautions to guard against any ill effects regarding the behaviour of patients.
It is imperative that the professional duty to the patient is always prioritised over the personal connection, especially in light of the fact that it is the counselor’s duty to provide a service to the patient, and it is the patient’s duty to receive such a service for their own benefit.
Anything that negatively escalates outside of the patient-counselor relationship should be treated as malpractice, and should not be tolerated accordingly; thereby enabling multiculturalism to be embraced at the counselor-patient level.
In a superivosry role, it is required that confidentiality is maintained at all times, unless there are risky cases in which certain interventions are allowable, as per the opinion of the counselor dealing with the patient and the supervisor’s expert opinion.
Supervision in counselling often raises questions of transference, countertransference, multicultural malpractice and confidentiality in the ethical dilemmas of the patient-counselor relationship. Therefore, caution should be taken to ensure that these are avoided by examining the rights, responsibilities and boundaries of such a relationship, in light of the evidence presented and recommendations aforementioned.
Cartwright, C., and Read, J. (2011). An Exploratory Investigation of Psychologists’ Responses to a Method for Considering “Objective” Countertransference. New Zealand Journal of Psychology, 40(1), 46-48.
Frame, M., and Williams, C. (2005). A Model of Ethical Decision Making from a Multicultural Perspective. Counseling and Values, 49(3), 165-170.
Hofsess, C. and Tracey, T. (2010). Countertransference as a Prototype: the Development of a Measure. Journal of Counseling Psychology, 57(1), 52-67.
Leung, A. and Chiu, C. (2010). Multicultural Experience, Idea Receptiveness and Creativity. Journal of Cross-Cultural Psychology, 41(5), 723-741.
McSherry, B. (2009). Health Professional-Patient Confidentiality: Does the Law Really Matter? Journal of Law and Medicine, 15(4), 489-491.
Pierro, A., Orehek, E. and Kruglanski, A. (2009). Let there be No Mistake: on Assessment Mode and the Transference Effect in Social Perception. Journal of Experimental Social Psychology, 45(4), 879-883.