Value structures – a method for the ethical inclusion of value exploration in the therapy room

June 2011 Featured Article

by Edward Thomas, Converse College

The concepts of values and moral character have long played a central role to marriage and family therapists in clinical settings. With historical amendments to the AAMFT code of ethics and the increasing postmodern “zeitgeist”, concerns for inappropriate dissemination of therapist’s values systems to clients in a position of vulnerability have resulted in a conscious effort amongst MFT leaders to emphasize caution in journal articles, text chapters, and university graduate programs. This article, while affirming the necessity of these efforts, proposes a values structure methodology for discussion and debate whereby values, morality, and character development can be openly and transparently addressed in the place of therapy in a manner that encourages client led autonomy, discovery, and decision-making. This approach allows for value dispositions to be openly considered by the client and therapist in a similar way as function or process determinations and in a manner consistent with socially constructed or postmodern therapy models. Sample values and ethics discovery worksheets that can be completed and discussed by therapist and client, is appended.

Prevention of Values Imposition

The field of marriage and family therapy has been enmeshed in an internal debate about the ethical and practical role of values in therapy, in clinical training, and in research methodologies. Values have historically been a component of psychotherapy in important ways:

1.) Because society adopts many norms and mores based on moral values, clients will often seek therapy because of a perceived shortcoming in this regard.

2.) “At the level of client–therapist interaction, every aspect of the therapy process (i.e. model, technique, exploration) is also value laden”, with therapists actively engaging in conversations about morality and moral responsibility.

3.) To the degree that it is often a source for moral values, spirituality is foundational and cannot be easily redacted from any discussion of moral values or personal ethics.

(Woody & Woody, 2001, p. 153)

Therapists have tended for some time to avoid overt “preaching” of personal values in clinical conversations (Jensen & Bergin, 1988; Thomas, 1994). Never less, in the past two decades, leading voices and researchers in the field of family therapy have more stridently warned about the inherent dangers of subjective values transmission between therapist and client. Several important considerations are at play in this valid call for restraint. First, the degree to which a therapist’s conveyance of moral advice inherently limits a client’s autonomy to make moral and ethical decisions is of critical concern (Woody & Woody, 2001, p. 156). In fact both sub principle 3.12 and 3.13 of the AAMFT code of ethics warn of potential misuse of therapist perspective. Second, postmodern perspectives call into question any deliberate conveyance of absolute truth in the clinical setting, as from this perspective, a therapist must not act as expert or omniscient force, but as navigator of a recursive multiverse of perceptions and constructions (Becvar & Becvar, 2009, p. 85). Third, families that are structurally distinct or diverse (same sex marriages/couples, single parent households, extended families) pose challenges to therapists whose explicit or implicit biases can interfere with empathic treatment. Fourth, multicultural assimilation and unprecedented global mobility means that therapists must also take into consideration significantly different value systems and family structures. Ethnic minorities may make up nearly 48% of the population by the year 2015. Therapists who operate from a simplistic monocultural and ethnocentric perspective may find their therapeutic effectiveness limited. Traditional therapeutic approaches and techniques when applied to racial and ethnic minority populations are ineffective (Sue, 1991; Bermüdez, 1997, p.254). Fifth, emerging data on latent forms of bias and values transference deserves consideration here. “Implicit bias is a possible explanation for the dissociation between intentional and unintentional discrimination manifested in aversive racism and microaggression. Researchers have distinguished between attitudes that occur at the explicit and implicit levels” (Petty, Fazio, & Briñol, 2008; Wittenbrink & Schwarz, 2007). Explicit biases are conscious and can be measured by self-report. Alternatively, implicit biases are “actions or judgments that are under the control of automatically activated evaluation, without the performer’s awareness of that causation” (Greenwald, McGhee, & Schwartz, 1998, p. 1464; Boysen, 2010, p. 211). In short, self of therapist training as it relates to “submerged” biases is warranted.

The Values Paradox

Hyperactive reflexes, in physiological terms, are over-responsive tendon reflexes usually originating from disordered central nervous system stimuli. Is it possible that the strong emphasis on minimizing therapist value imposition in the field of family therapy has produced a sort of hyper-reflexivity about the entire subject of morals, values, and value systems in family therapy? Is there a danger of throwing the baby out with the bath water?

In Chapter 1 of Ethics in marriage and family therapy, the authors claim that “values permeate therapy, primarily because all therapy involves value-laden goals” (p.4). In Chapter 2 of the text, the authors elaborate that “in therapy, ‘good’ or ‘desirable’ goals, behaviors, and outcomes for clients are primarily expressed in not so much moral terms, but as scrubbed ‘psychological virtues,’ such as the client will become more ‘effective or successful in life’, have ‘improved mental health,’ be more ‘insightful’, have ‘healthy relationships,’ etc.”(p. 18-19). Herein lays the paradox. What if the client, in utilizing their “autonomy” and “right to make personal decisions” (AAMFT ethics code, Sub principle 1.8), determines that therapy will include overt discussion of their personal values and moral codes. What if the therapist, in taking seriously the client’s right to beneficial services, determines that overt discussion/analysis about the client’s values and moral system is essential in developing an effective treatment plan? Could the fear of subjectivity be inadvertently obscuring a viable tool for therapy? Some researchers think so.

A fear of imposing values on clients also has led some therapists to sidestep values issues (Tjeltveit, 1986). Others have attempted to avoid values because of clinical training or because they are unsure of how to address values with clients (Fife & Whiting, 2007, p. 72). In training and in supervision, counselors and therapists have been taught to be aware of their values, yet they have been either explicitly or implicitly enjoined to exclude them from practice. From the perspective of a spiritually centered therapist, Bergin (1980) related, “I felt constrained from full expression of my values by [mentors’] assumptions or faiths and the prevailing, sometimes coercive, ideologies of secular universities” (p. 102); (Grimm, 1994, p. 154. ). Legendary systems theorist Paul Watzlawick mused, “You cannot not communicate.” In this light, perhaps an overemphasis on value exemption is in and of itself a value position.

Evolving Thought Regarding Values

Why are values relevant to family functioning? Current research and findings are giving new perspective on the age-old considerations of morality that the mental health field has so often relied. First, neuroscience research is discovering that morality and value expression is not simply philosophical abstraction, but utilizes dedicated brain pathways, is implicated in genetic expression, and can be effected biologically (Braun, Léveillé, & Guimond, 2008). Research in the social sciences also points to values and values attainment as a chief variable for healthy family functioning. In addition to the importance of a value system to an individual, family value systems are often separately identified by members within families; if incongruence in values or morality is perceived interpersonally, dysfunction often follows (Perrewé & Hochwarter, 2001). Third, empirical data point to significant reduction in behavioral problems and improved classroom functioning in those schools which have implemented character and values education programs (Parker, Nelson, & Burns, 2010). Fourth, cross-cultural epidemiology studies reflect a set of core values that are shared proximally amongst many cultures despite profound socioeconomic, religious, geographical disparities (Peterson & Seligman, 2004). Values are truly an integral part of the human experience, and thus must have a role in mental health counseling.

The Values Dilemma

The postmodern perspective that has infused many of the social sciences over the past thirty years has profoundly improved our ability to relate to a multi-cultural globally connected world. Nowhere is this more apparent than in the mental health profession, where therapy has moved to a more reflective, respectful and humble position. However, in the attainment of postmodern ideals and for the protection of the client, the concepts of morality and value systems are at risk of being viewed defensively (How can I assure that my personal value biases are not projected into the place of therapy?) rather than constructively (How can I balance the ethical position of not imposing my values, while also being able to frame a comprehensive values discussion with my client or patient?).

Value Structures: A Construct for Ethically Incorporating Values and Personal Morality into Family Therapy

With the hopes of stimulating further discussion, debate and research, this paper proposes a balanced approach to morality constructions that respects both a client’s autonomy and the crucial role values play in the health and functioning of individuals, couples, and families.

Admittedly, the prevailing notion of values and value systems as abstract and highly personal serves ironically to limit its relevance in the therapy room- arguably a place of personal awareness and healing. A potential method for mediating this phenomenon is to structure the definition, discussion and treatment components relating to values constructions at the beginning of the therapist-client relationship. By defining and structuring value considerations, therapists can integrate them into assessment and treatment in a similar way as family “process” components (i.e. feedback loops, family of origin connectivity, triangles etc.).

The lynchpin in this approach is therapist transparency. Is there truly any way to except values and spiritual beliefs from the therapist-client experience? “One could make the case that a therapist who tries to keep his or her values hidden is far closer to imposing values on a client, than a therapist who transparently exposes his/her value system to a client. With value transparency, the client knows the values upfront, and then can make the choice to see….or not to see….a therapist before spending any money, and before investing any energy or trust. Which scenario is better for a client?

1.) Client reads the transparent values of a therapist. The values of the therapist are against the values of the client. The client avoids making contact with that therapist, and finds another.

2.) Client contacts a therapist whose values are “hidden.” There is no obvious conflict of values, client makes an appointment. Client invests money, time and energy into therapy, and only later learns, over the course of therapy, that the therapist has strong personal opinions in direct opposition to them which may be expressed in latent ways.

In Scenario 1, the client was empowered. The client had information about the therapist, and avoided spending money and energy on ineffective therapy. In Scenario 2, the client only discovered, over the course of paid therapy, that he/she could not have the kind of beneficial relationship with the therapist because of a deep chasm in personal value systems” (Theravive, 2010). Pastoral or Spiritual counseling, for example, provides a perspective where value transparency is helpful and ethical. Although full therapist disclosure of values, principles, and/or biases is rarely if ever indicated, it might be helpful to explore moderate disclosure, where a therapist provides enough insight into their personal perspective to help a client render better informed consent, build trust, and give credibility and perspective to the therapeutic interventions they may recommend.

Drexel University’s Dr. Harry J. Aponte, provides a set of guidelines helpful when considering values in the family systems context: “1.) the therapist should not usurp the family’s role as primary agent in grappling with how to construe their problems and to remedy them; 2.) the therapist participates in this process by sharing expertise when this is apt but the main task is to encourage family members themselves to exploit their resources, individual and collective; 3.) the therapist resists, through active self-monitoring, imposing his/her values, and avoid at all costs declaring what is “good” or “right” or “desirable” for the family; 4.) conversely, the therapist can assume responsibility in pointing out, if necessary, the need for the family to re-appraise specific values in order to achieve associated functional change; 5.) therapist should assist members to recognize disparities in their adherence to values when they are clearly a source of conflict, for example, parents and adolescent children discordant in relation to experimenting with recreational drugs” (Bloch & Harari, 1996, p. 280).

Incorporating these perspectives, six proposed guidelines to “frame” the subject of values are posited in this paper:

(1) Transparency-there are clients for whom a therapist’s value system disclosure is warranted in order to optimize client choice/consent and improve treatment efficacy.

(2) However, the concept of values must be defined from the client’s perspective in therapeutic interventions.

(3) To help structure value considerations, the therapist must help investigate (discover) the value system from the perspective of the individual, couple or family.

(4) The purpose of value discovery and implementation/integration must relate to the health and functioning of the client system.

(5) Although assisted by the therapist, the process of value discovery should be primarily conducted by the client in a deliberate and mindful way.

(6) The client is ultimately responsible for integrating any moral basis or value system into their life relationships.

Although it is beyond the scope of this paper to propose a specific values assessment, discovery and treatment modality, several assumptions may helpful in the process of designing these components:

(1) The predominant ethic of minimizing imposition of therapist’s values on a client must be of primary consideration

(2) Values Structure Therapy is intended for therapy that is of a certain duration (not extremely brief models)

(3) This approach must be included in client consent forms for treatment

(4) A supervisor or trusted associate review case periodically to insure objectivity of therapist.

(5) The Values Structure approach must be regularly assessed for efficacy and ethical considerations by therapist and client, mutually.

(*Two sample value discovery worksheets are attached after the body of the paper.)

Discussion

It is the goal of value structures to provide an ethical means by which values and morality can be considered in the etiology of dysfunction. Given the interpersonal dynamic that is a hallmark of family systems therapy, the marriage and family therapist is a logical clinician to help in both values exploration and integration and the resolution of values incongruence. The purpose of this paper is to provide an overview for critique, analysis, and further insight into how concepts of values and morality can be incorporated into toolbox of a contemporary family therapist keenly aware of not only his or her abilities, but also his or her own limitations.

Figure 1.1:

Values Discovery Worksheet: Reflecting on Your Values

  1. Think of all the people you admire. Real or fictional, preferably real. Write them down. Take time to do this.
  1. Then put an adjective next to each of the names, and the reason for admiration. As many adjectives or qualities as you can think of. (For example, Mother Teresa-selfless, Winston Churchill-courage, boldness, leadership.)
  1. Then combine all the qualities, so each unique quality appears only once. You would be left with a list of all the qualities that you admire.
  1. Next, ask why they are important to you. Reflect on them. (Understand that this is a list of things that resonates with who you really are, and what you want. This forms a picture of what you admire, some of which will comprise your core values.)
  1. Next, think of your faith, your religion or spiritual life. What are the values that resonate with your core, your being? Do you fully agree with what your faith teaches? If not, why and if so, why?
  1. Next, think of the values of your family of origin. What are the family values that resonate with your core, your being? Do you fully agree with what your family’s values? If not, why and if so, why?
  1. Picture yourself as a bystander at your own funeral, a fly on the wall listening to people’s private conversations. What would you like your friends and family to say about you and your life? (“He/she was a terrific parent and teacher… generous to people whose lives were challenged….an intelligent and fair businessperson etc.) Jot these down.
  1. Review the entire list. What are the qualities and core values that you truly resonate with and what are those that don’t? (It could be love, justice, fairness, not returning evil for evil, forgiveness, competence, gratitude, doing good to others who cannot return the favor, trust, faith, hope etc.) Those that resonate with you are your core values. Yours alone.

Take some time to really reflect on this. You may want to keep the list and review it over the next few days.

Figure 1.2:

VALUES WORKSHEET

Please read over all the values below. You may define some of these values differently, as they apply to you. You may also add values to this list if you think of any that are not included. Using the list and your additions to it, pick the three values that are most important to you. Circle a selection(s) or write them down. The three values that you’ve identified are considered your core values. In theory, the absence of these values in any area of your life (personal or professional) might be cause for re-evaluating choices and making potential changes.

Social Contribution: Work for the good of society, advance the common good.

Accomplishment: Make a lasting contribution; produce results; reach goals

Aesthetics: Appreciate and contribute to the beauty of your surroundings, of objects, of ideas.

Altruism: Give top priority to the interests and needs of others.

Belonging: Be accepted as a worthwhile member of a group.

Compassion: Stand with and support others in their need and distress.

Creative Expression: Express ideas in novel, innovative and original ways.

Diversity: Value and respect differences in people, ideas, situations.

Exciting Life: Maintain a stimulating and active life; take risks; try new things.

Fairness: Distribute benefits and burdens to others appropriately.

Family: Protect and care for those you love and are related to by birth or by law.

Friendship: Develop intimate and caring bonds with others.

Happiness: Feel joy and emotional well-being.

Health: Maintain soundness of body and mind.

Honesty: Telling the truth to yourself and others.

Independence: Take actions free from the control of others.

Inner Harmony: Develop inner peace, free of internal conflicts and confusion.

Integrity: Consistency of thought/words/actions: ‘what I think is what I say and do’.

Justice: Treat everyone the same unless there are relevant moral reasons to treat them differently.

Loyalty: Do one’s duty, honor allegiances and commitments to obligations.

Pleasure: Seek enjoyment and satisfaction of the senses.

Power: Exercise control, authority and influence over others.

Recognition: Gain positive feedback and perhaps notoriety for a job well done.

Respect: Treat other people, animals and the environment with dignity and care.

Responsibility: Accountability for actions relating to people, things or results.

Security: Be free from fear or danger; exist in a stable environment.

Self-Respect: Treat yourself with dignity and care, develop self-esteem.

Stewardship: Care for resources and processes entrusted to you.

Spirituality: An inner sense of something greater than oneself.

Teamwork: Act with others toward a shared goal.

Time Freedom: Have a flexible schedule with flexible responsibilities.

Variety: Engage in frequent changes in activities, locations and people.

Wealth: Accumulate money and possessions.

Wisdom: Understand what is true, right and lasting.

Academic Internship Program, University of California, San Diego

 References

 AAMFT (2007). Legal guidelines for family therapists with selected ethical opinions. Washington D.C.: The American Association for Marriage and Family Therapy.

Becvar, D. & Becvar, R.J. (2002). Family therapy: a systemic integration. Boston: Allyn & Bacon

Bermüdez, J. (1997). Experiential Tasks and Therapist Bias Awareness. Contemporary Family Therapy: An International Journal, 19(2), 253.

Bloch, S., & Harari, E. (1996). Working with the family; the role of values. American Journal of Psychotherapy, 50(3), 274-284.

Boysen, G. (2010). Integrating Implicit Bias into Counselor Education. Counselor Education & Supervision, 49(4), 210-227.

Braun, C., Léveillé, C., & Guimond, A. (2008). An orbitofrontostriatopallidal pathway for morality: Evidence from postlesion antisocial and obsessive-compulsive disorder. Cognitive Neuropsychiatry, 13(4), 296-337.

Fife, S., & Whiting, J. (2007). Values in Family Therapy Practice and Research: An Invitation for Reflection. Contemporary Family Therapy: An International Journal, 29(1/2), 71-86.

Grimm, D. (1994). Therapist spiritual and religious values in psychotherapy. Counseling & Values, 38(3), 154

Parker, D., Nelson, J., & Burns, M. (2010). Comparison of correlates of classroom behavior problems in schools with and without a school-wide character education program. Psychology in the Schools, 47(8), 817-827.

Perrewé, P., & Hochwarter, W. (2001). Can We Really Have It All? The Attainment of Work and Family Values. Current Directions in Psychological Science (Wiley-Blackwell), 10(1), 29-33.

Peterson, C. & Seligman, M. E. P. (2004). Character strengths and virtues: A handbook and classification. Oxford: Oxford University Press.

Theravive (2010). website www.theravive.com

Woody, R. H. and Woody, J.D., Eds. (2001). Ethics in marriage and family therapy. Washington D.C.: The American Association for Marriage and Family Therapy.

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2 thoughts on “

  1. This is very much needed. I am a Pagan, and have been for over 35 years. As a consequence, I naturally see quite a few clients who are also of a Pagan spiritual orientation. I’ve heard many horror stories of therapists in the Upstate South Carolina region imposing their own values on Pagan clients. In one instance, a client was told by a former therapist that her problem was that she ‘didn’t have Jesus in her life,’ and that this was the cause of all of her issues.
    I freely disclose my spiritual orientation if a client asks, but I don’t make my particular spirituality the center of the therapy. Instead, I dialogue with the client about his/her own values and beliefs, and simply look for beliefs that are supportive and that achieve the goals the client is trying to achieve.

    • Thanks for the feedback; you summed up the issue beautifully. I too agree that the balance between value exploration and value imposition is a self of the therapist issue that requires awareness and reflection. Please feel free to submit articles, research or perspective pieces that you would like to share with the community to edward.thomas@converse.edu.

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