ETHICS COLUMN
MARITAL AND FAMILY THERAPY WITH DIVERSE CLIENTS:
AN ETHICAL DILEMMA

Written by MaryAnna Domokos-Cheng Ham, Ed.D.

An Asian immigrant couple, Mr. and Mrs. Quan, begin marital therapy with Jay, a Caucasian marriage and family therapist working with the Employment Assistant Program (EAP) of a large company that makes computer parts. The couple was referred for marital therapy by the company's EAP counselor. His supervisor noticed that Mr. Quan was not meeting his production quota and referred him to the EAP counselor who, after an initial meeting to evaluate him, concluded Mr. Quan needed to go with his wife to marital therapy. In the first session Jay discovered that Mr. Quan spoke English minimally and Mrs. Quan spoke only Khmer. Mr. Quan spoke in a quiet, controlled voice while Mrs. Quan cried but said nothing. Jay thought he was culturally sensitive but, in this situation, he felt helpless and confused.

Jay, as many of us who are practicing family practitioners, would perhaps stop at this point of the session, reflect, and then ask a few questions: How can I communicate with this couple when I do not speak Khmer, and the husband speaks for the couple in minimal English? How can the couple find therapy useful when I do not appear to know what their problems are? How should I proceed with therapy when I can only sense their feelings, but cannot fully comprehend their meaning?

This marital therapy case is a composite of many clients I encountered when I worked as a therapist and supervisor in a community clinic where a large Southeast Asian population came for medical and mental health services. Often a feeling of uneasiness occurs whenever I work with families like the Quans, or whenever I supervise therapists seeing culturally and ethnically diverse clients or teach family therapy students. I identify my feelings of discomfort as a red flag, a signal of grappling with a personal and professional question: How can a couple or family whose normative behaviors and values deviate from those of mainstream US find my work helpful when the professional and ethical principles guiding my work are derived from US mainstream norms and values?"

This question has more recently led to a profound professional dilemma: As therapists we can apply the cultural values and moral principles of our clients to the situations they present to us,

OR

we can apply the prevailing professional ethical standards with their underlying values of mainstream culture to our clients' situations,

OR

we can substantially modify mainstream professional ethical standards and encourage our clients to modify their own codes for living in order to create an inclusive set of values.

This dilemma, like any other dilemma, is resolved by choosing one option from among many that are all flawed. The complexity of this dilemma lies in the divergent set of philosophical assumptions underlying each option. However, the weakness of professional ethical guidelines is that they do not explicitly articulate philosophical principles and, thus, are not accountable for their choice of a moral framework. Without directly stating their assumptions, these ethical codes assume a dominant culture perspective and generally minimize or trivialize the role of culture in ethical decision making. Pedersen (1995) has identified six implicit assumptions as sources of bias and exclusionary judgment:

1. There is a bias toward an individualistic perspective that would not be appropriate to collectivistic cultures.
2. There is a bias toward the culturally different client who must accommodate or adjust her/himself to a majority culture standard of behavior.
3. There is an elitist bias favoring the more powerful care providers' obligation to protect the profession.
4. There is an assumption that cultural issues can be dealt with in relatively simple and objective ways.
5. There is an assumption of absolute standards for right and wrong behavior in a "one-size-fits-all" perspective.
6. There is an underlying assumption that what is good for the counselor is good for everyone.

In addition to the lack of explicit discussion of the ethical and philosophical principles underlying the professional ethical codes (American Association of Marriage and Family Therapy Code of Ethics, 1991; Ethical Principles of Psychologists and Code of Conduct, American Psychological Association, 1995; Code of Ethics, National Association of Social Workers, 1996; Codes of Ethics and Standards of Practice, American Counseling Association, 1995), text books used for teaching professional ethics use as the philosophical basis for professional ethical standards the moral principles and theories of such Western moral philosophers as: Socrates and Plato (egoism), Saint Thomas Aquinas (natural law), John Stewart Mill (utilitarianism), Kant (respect for persons).

Since moral and ethical standards are based on consensual norms of a culture and society, I often wonder if my students and supervisees will be able to accept a set of cultural and societal ethical norms outside the Western philosophical tradition and to acknowledge norms different from those they have been socialized and trained to follow. Moreover, I reflect deeply whether my work with diverse populations has been affected by the traditional Western education I have received. I ask myself the question: How can I, my students, and my colleagues reconcile the dissonance between Western ethical principles based on rights, primarily the right to protect the value of individual thought and choice, and other culturally based ethical principles, such as: the ethic of duty, the conformity of individual action to a code of proper conduct; or, the ethic of social justice, the commitment to general human welfare and human rights (Shweder, 1991).

If we are to resolve the dilemmas and determine an ethical position to take in working with couples and families like Mr. and Mrs. Quan, perhaps we may have to acknowledge that the act of helping may be harmful. Therapy does not occur in isolation from our culture and society, or from socio-political events in history. We cannot be naive to the control and power exerted by one set of values over another.

To think about morality, deeply and honestly, is the main business of practicing ethical therapy. Our moral integrity suffers when our principles are allowed to remain underground, undefined and unexamined, or when our principles are inconsistent with each other and with our actions. Have I resolved this dilemma? I have posed questions; I raised the issue that there are inconsistencies between our work with diverse clients and the philosophical principles underlying our professional ethical codes. Our effectiveness in helping clients from divergent cultures will depend on our knowledge of and sensitivities to their philosophical values and their levels of adaptation to our dominant culture.

REFERENCES

• Corey, G., Corey, M.S., Callanan, P. (1993). Issues and ethics in the helping professions (4th edition). Pacific Grove, CA: Brooks/Cole.
• Harris, C.E., Jr. (1997). Applying moral theories (3nd Ed.), Belmont, CA: Wadsworth.
• Herlihy, B., Golden, L.B. (1996). AACD Ethical standards casebook (5th Edition). Alexandria, VA: AACD.
• Ibrahim, F.A. (1991). Contribution of cultural worldview to generic counseling and development, Journal of Counseling & Development, Sept./Oct. Vol. 70, 13-19.
• Pederson, P. B. (1995). Culture-centered ethical guidelines for counselors. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling pp. 34-49. Thousand Oaks, CA: Sage.
• Shweder, R. A. (1991). Thinking through cultures: Expeditions in cultural psychology. Cambridge, MA: Harvard University Press.

MaryAnna Domokos-Cheng Ham, Ed.D. is an Associate Professor and Director of the Marriage and Family Track in the Department of Counseling and School Psychology, Graduate College of Education at the University of Massachusetts Boston. She has combined her interests in Asian American issues, empathy, and family therapy in her writing and research. Her latest research and clinical interest is in the study and treatment of biracial couples.