Ethical Concerns About Client-Centered Therapy

Reader’s Question

What are some NASW Code of Ethics issues raised by client-centered theory? Are there any unintended consequences of the intervention? Thank you.

Psychologist’s Reply

I can’t speak to the NASW Code of Ethics as that group has multiple position publications on various topics. As for unintended consequences, I can offer a bit about that. I began my career in psychology (in the US) prior to the licensure of psychologists, social workers, and counselors. Psychiatrists were the primary “private practice” providers of mental health treatment and intervention at that time. As licensure emerged, all three groups became identified as mental health professionals in the community. Gradually, in my experience, psychologists moved into private practice followed now by social workers and counselors. This move into private practice has created several practice and ethical issues for client-centered therapy.

In my 36 years of clinical practice, no patient/client has ever sought my services to “chat”. In private practice, consumers are seeking diagnosis, advice, guidance, treatment, and aggressive intervention. These consumer needs are typically not considered part of client-centered therapy/counseling.

As these professions have moved into providing mental health treatment in the community, the standards and obligations for practice have also increased. With our licensure, we are now required to practice on a model used by physicians, dentists, nurses, etc. Private practice procedures must now meet the “standard of care” in the profession and should be evidence-based. We now talk about outcome studies and what works best based on research.

Private practice professionals must now have a collection of skills and knowledge. In the human condition, there is no one-size-fits-all treatment approach. A single-focused approach to all treatment is inappropriate in modern community practice.

The field of psychiatry has been through a similar transition. While psychoanalysis often serves as an educational foundation for psychiatrists, it is now practiced by only a small percentage of psychiatrists. Those who practice only psychoanalysis publicly identify themselves as specializing in that treatment orientation. In private practice, that’s known as informed consent. Therapists who only use client-centered therapy should publicly emphasize their scope of practice and clarify the limitations of their treatment interventions and activities. To suggest that client-centered therapy alone can adequately treat the wide variety of patient/client concerns, symptoms, and situations that appear in private practice is professional negligence. That’s my two cents.

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Editor’s Note:

As someone who originally trained in the person-centred tradition myself, I couldn’t resist the opportunity to add a quick note about ‘interventions’ and ‘unintended consequences’.

I’m guessing you would be hard pressed to find any person-centred practitioners who characterize the bulk of what they do as ‘intervening’. Rather, person-centred practitioners aim to provide an environment that is conducive to the client’s own resources taking centre stage. Typically, a person-centred practitioner is not aiming to control what the client is going to do, and so in that sense, yes, person-centred practice undoubtedly yields consequences that have not been intended or anticipated by the therapist. I think it would be a pretty serious mistake, though, to equate what is ethical with what has been decided by the therapist to be what ought to occur — don’t you?

So how does this prioritisation of clients’ own capabilities stack up empirically in an era of ‘interventions’ and ‘treatments’? Pretty well, actually…

It turns out that with regard to the evidence base for clinical effectiveness, around 4 decades of therapy outcome studies suggest very strongly that the theories and techniques of professional therapy have very little to do with therapeutic outcome. Here’s an estimate of the how we can attribute outcome variance (from Hubble, Duncan and Miller; also see Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, now it its 5th edition):

  • 40%: client and extratherapeutic factors (such as ego strength, social support, etc.)
  • 30%: therapeutic relationship (such as empathy, warmth, and encouragement of risk-taking)
  • 15%: expectancy and placebo effects
  • 15%: techniques unique to specific therapies

Or to sum it up: “the client is responsible for 70% or more of the outcome variance” (Hubble, Duncan and Miller, p. 95).

So do I think the person-centred approach is the fix-all for every client problem? Certainly not! But I doubt any other empirically-minded practitioner — in any of the fields we’ve considered above — would believe that of any other individual approach either.

— Dr Greg Mulhauser

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