Professional Competence and Integrity

By James Morris, PhD and George Stone, MA

How do you know if you’re a competent MFT? If you complete a graduate MFT degree and pass the AMFTRB National Exam, are you a professionally competent MFT? Do years of experience with client systems lead to improved therapeutic competence and better clinical outcomes? How do you know if you maintain high standards of professional integrity?
The competence and integrity of the marriage and family therapist may well be the most important and fundamental components of ethical behavior and practice. Ethical standards, such as the AAMFT Code of Ethics (2015), define professional expectations and rules of practice. Competence embodies professional knowledge, skills, and clinical decision making. Integrity refers to the character, or the qualities, reasoning, and morality of the marriage and family therapist.
Competence is largely assumed to be in place (as in competent to practice) once a marriage and family therapist (MFT) has completed graduate training and is under clinical supervision during the post-graduate period. An MFT is assumed to be competent once an independent license (LMFT) to practice is attained from a state regulatory body. It is important to note that the focus of state regulation of the MFT profession is to ensure that the public is protected, and thus to recognize that the licensed MFT meets minimum standards of practice competency (as opposed to professional organizations, such as AAMFT, which seek to promote the highest standards of practice).
Integrity in terms of ethics and ethical practice refers to the character, values, and morals of the MFT. The MFT’s character or level of integrity is central to the process of ethical decision-making. Integrity is bound up in the MFT’s commitment to the moral concepts of autonomy, beneficence, nonmaleficence, justice, and fidelity, all in service of the client system’s welfare.
There are several components in Standard III of the AAMFT Code of Ethics that speak to the process of maintaining competency. Marriage and family therapists are expected to keep abreast of new developments in the field through required continuing education and training (and through supervised experience for those at the beginning stage of their career). Further, MFTs should also take the necessary steps to ensure the competence of their work when developing new skills in specialty areas through education, training, and/or supervised experience. MFTs must maintain accurate and adequate clinical and financial records (in accordance with applicable laws). Ensuring accurate and adequate clinical and financial records reflects competency by assuring client systems that both the treatment process and accompanying financial records are properly documented. Should any potential concerns arise regarding the treatment, these records could be scrutinized by state licensing boards, and any inadequacies therein would necessarily reflect a potential compromise in competence.
Maintaining integrity involves therapist self-care, being engaged in supportive practice environments, developing strategies for managing risk, imparting meaning to clinical work, and enjoying client contact (Clark, 2009). Being aware of developmental processes and maturational changes that occur as the MFT grows is important in maintaining integrity. The melding of the personal and professional lives over the course of an MFT’s career requires the skillful negotiation of ethical gray areas, maturity, experience, and ongoing supervision/consultation. Maintaining integrity as an MFT requires self-nurturance, balance, connectedness, and awareness of family of origin (Protinsky & Coward, 2001).
Being a marriage and family therapist necessarily entails a commingling of one’s personal and professional life. Patterson, Williams, Edwards, Chamow, & Grauf-Grounds (2009) note that “therapists need to be aware of their personal boundaries and clear about how their personal lives can affect their work” (p. 264). The personal and professional attributes that an MFT embodies are central to maintaining integrity in the treatment process. Sparks and Duncan (2010) state that “it appears that the person of the therapist, his or her own style of engaging with others and appreciating clients, and general attributes of warmth and communicated caring are strong contributors to success, as is the therapist’s ability to form strong alliances” (p. 370).
Threats to competence may take several forms. Hurlburt, Garland, Nguyen, and Brookman-Frazee (2010) reported that therapists working with child/family problems in community-based settings held more inflated perspectives about the relative intensity and number of goals which they pursued clinically with client systems compared to how trained observational coders rated the same variables. The authors note that “if therapists do tend to overestimate the intensity with which goals and strategies are pursued in sessions, this could also impact efforts to improve care quality” (p. 240). That is, it would be important to help family therapists develop more accurate perceptions of the goals and strategies pursued in the clinical treatment process. Further, Goldberg et al. (2016), in a longitudinal study, challenged the assumption that therapists improve with time and experience (that is, become more competent) by noting that “in the aggregate, therapists did not improve with more experience, operationalized as either time or number of cases” (p. 7).
Karam, Blow, Sprenkle, and Davis (2015) highlight the potential drawbacks of focusing too exclusively on MFT models to the relative exclusion of including a focus on common factors in psychotherapy in general, and importantly in MFT specifically. The notion that specific models are superior relative to other models for disorders has been largely debunked (Duncan, Miller, Wampold, & Hubble, 2010). An ongoing focus on a particular MFT model, to the relative exclusion of a common factors approach, may well hamper MFTs from more competently delivering clinical services.

Marriage and family therapists who may face issues that could impair their work performance or clinical judgment are expected to seek appropriate professional assistance. Maintaining an ongoing professional relationship with other MFTs for clinical discussion, consultation, and support is an important feature of helping to maintain clinical competence.
Standard III of the AAMFT Code of Ethics points to several areas that may be potential threats to integrity. Marriage and family therapists are warned to avoid providing services that create a conflict of interest, resulting in impaired work performance or clinical judgment. For example, when an MFT begins individual work with one partner of a couple relationship, and then subsequently includes the other partner in couples therapy, whilst continuing to see the initial client in individual therapy, the MFT is amid a conflict of interest (Gurman & Burton, 2014).

While MFTs are expected to make financial arrangements with clients that conform to accepted professional practices, there may come a time when an MFT is faced with receiving a gift from a client, or even the possibility of wanting to give a gift to a client. MFTs have a responsibility to advance the welfare of clients and should take into consideration both cultural norms and the potential effects that receiving or giving gifts may have on clients and on the integrity of the therapeutic relationship.
Marriage and family therapists may be invited or called upon to offer their professional recommendation or opinions in a public forum or through testimony. While the chance to advance MFT in the public square may be enticing, caution should be exercised to ensure that the MFT agree to speak only about that with which they are qualified and prepared. The MFT should take care to ensure that the sponsor is both reliable and respectable and should understand how their words will be presented and the intended audience (Gladding, Remley, Jr., & Huber, 2001).
Marriage and family therapists do not engage in harassment or exploitation of clients, supervisees, employees, colleagues, or research subjects. For example, MFT supervisors avoid exploiting supervisees’ trust by engaging in efforts to sexualize the relationship (Ryder & Hepworth, 1990). Additionally, Standard III highlights the critical area of professional misconduct that may result in termination of membership in AAMFT or other disciplinary action (Coy, Lambert, & Miller, 2015).
The hegemony of biological psychiatry and its accompanying document of classification, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013), present a challenging and ongoing threat to the integrity of every family therapist. For example, the adverse side effects of SSRI antidepressants (including sexual dysfunction) are well established. The conventional wisdom is that psychotherapy + drugs is the optimal course of treatment for couples with a depressed partner. Yet, the inclusion of antidepressants with psychotherapy produces inferior results to psychotherapy alone (Jackson, 2005).
The aspirational core values of AAMFT, as identified in the AAMFT Code of Ethics, include a commitment to integrity as evidenced by a high threshold of ethical and honest behavior, as well as excellence in the delivery of systemic and relational therapies. Marriage and family therapists are thus committed to maintain high standards of professional competence and integrity. Competence embodies professional knowledge, skills, and clinical decision making. Integrity refers to the character, or the qualities, reasoning, and morality of the marriage and family therapist. Practices to maintain competency and integrity in professional practice include continuing education, consultation, supervision, incorporating client feedback, tracking clinical outcome, and keeping abreast of clinical and research developments. The marriage and family therapist must be vigilant in defending against potential threats to competence and integrity such as avoiding conflicts of interest, exploitation, and harassment.

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