Ethical Considerations for Treating the Old Order Amish (2024)

The publisher's final edited version of this article is available at Ethics Behav

Cultural Attributes

Along with the unique lifestyle factors that distinguish the Amish from other religious subgroups, there are also cultural characteristics to be mindful of when working with Amish clients. The Amish have an extremely strong emphasis on humility, which influences everything from their style of dress to their beliefs about education. For example, the Amish emphasize the importance of the untrained mind, and believe that excessive knowledge of the world is a form of pride, or in more extreme cases, an effort to imitate God’s omniscience (Hostetler, 1993). This emphasis on humility was illustrated through a personal communication¹ with an Amish elder in which the author asked the elder about how the Amish treat medical problems within the community (November 2, 2019). The Amish elder, after a period of contemplation, admitted somewhat hesitantly that he had “occasionally helped with [medical] matters.” Later in the conversation, after more rapport had been established, it became clear that this particular elder had treated potentially life-threatening wounds. However, because saving a life could be considered a point of pride, the elder was reluctant to admit his role in the process. Along with this focus on humility and de-emphasis of self, the Amish strongly embrace group-oriented, collectivistic beliefs. These beliefs are protective and beneficial in many ways but can make it difficult for a psychotherapist to accurately assess individual strengths or difficulties an Amish person may experience ().

Another cultural factor that may arise in the psychotherapy setting is the Amish preference for disclosure and straightforwardness. Most American healthcare professionals tend towards subtly implying disapproval and using nonverbal styles of confrontation (DiMatteo, 1979). This American style of indirect communication can be off-putting to the Amish, as they typically prefer to have a more direct, personal style of interaction with professionals. In a personal communication (November 2, 2019), one Amish man described an experience with an English doctor that he found unpleasant. The man’s wife did not speak very much, especially to the English, and so the man was answering questions for her. The doctor apparently made his disapproval clear with his tone and expressions, but never directly stated that he wanted the wife to answer for herself. The man understood, and let his wife answer for herself, but he found the style of communication quite unpleasant and expressed that he would have greatly preferred that the doctor had told him directly that his wife should answer for herself. In line with the Amish’s reluctance to criticize, the man finished this disclosure by stating, “…he was a good doctor,” and expressed gratitude towards the doctor because he correctly identified his wife’s condition.

Amish culture has traditional gender roles that typically begin at birth (e.g., Johnson-Weiner, 2001; Kraybill, 2013). Typical tasks for Amish men include chopping wood and working in the field, while women are responsible for preparing meals, cleaning the home, and tasks associated with child rearing. Amish society is highly patriarchal, but as Kraybill (2013) notes, “that label does not capture the fullness and nuance of gender roles.” While men take leadership roles and are unequivocally the “head” of the household, women are held in high regard in the Amish community and marital relations are often characterized by mutual support and equality (Kraybill 2013). Although Amish women are typically limited to gendered roles, most embrace their conception of womanhood and tend to feel confident and valued in their roles as women. Furthermore, Amish women report strong social support, and low levels of intimate partner violence and perception of unfair treatment relative to the general population (Miller et al., 2007).

The Amish practice shunning, or meidung, a ritual shaming and exclusion of those who disobey the church or the Ordnung (Kraybill, 2001). When members of the church are placed under the ban, they are ignored by their entire community, even their own family, as failure to shun a member under the ban can jeopardize one’s own position in the Church. Because the Amish live in isolation from the outside world, this effectively eliminates the shunned individual’s entire social support structure. The shunning is not intended to be malicious, but rather it is said to be performed out of love and an especially fundamental interpretation of the Bible verses Matthew 18:15–17. The Amish community generally wants the banned individual to repent, and often welcomes back the shunned member if the individual is willing to return and ask for forgiveness. Individuals who are placed under the ban and do not return may experience intense trauma and a loss of identity, and many report a lifelong struggle with their decision to leave the community (Cates, 2005; Garrett 1998; Kraybill, 2001). As with many of the Amish characteristics described in this article, the nature and severity of the shunning varies considerably between different Amish communities.

Competence

Standard 2.01(c) of the Ethics Code requires psychotherapists to have sufficient training and education before providing services to a special population. While Standard 2.01(c) provides an ethical “floor” for psychologists, there is an abundance of literature demonstrating the benefits of cultural competence that goes above and beyond simply having “sufficient” training (e.g., ; Sue, 1998). This is especially relevant with the Amish due to their distrust of outsiders. A psychotherapist working with the Amish, even using his or her best clinical skills and judgement, may fall short and could potentially do harm to the therapeutic alliance. For example, the psychoanalytic tradition of the therapist acting as a “blank slate” with professional poise and minimal disclosures influences much of how psychotherapy is conducted today. However, the therapeutic boundaries that serve psychotherapists in normal clinical practice can hinder progress with an Amish client. Instead, the Amish client would usually prefer an open, straightforward conversation with a therapist whom the client feels that they know and trust. Cates (2011) reports that a phrase sometimes heard by psychotherapists who treat the Amish is, “We don’t care how much you know until we know how much you care.” Many of the unique cultural factors that may influence psychological treatment with an Amish individual have been reviewed elsewhere in the literature (e.g., Cates, 2005). Psychotherapists should become familiar with this literature to obtain a level of cultural competence before beginning a professional relationship with an Amish client.

Competence – and, consequently, cultural competence – is often viewed as a goal, the permanently attained status achieved at the culmination of an individual’s training (Johnson et al., 2008). However, as noted in the multicultural literature (e.g., APA 2017 Multicultural Guidelines; ) and the Ethics Code (Standard 2.03), competence is a process of ongoing effort and training. The Amish continually update and adapt their Ordnung to the needs of their community (Hostetler, 1993), so a culturally competent psychologist should attempt to remain aware of changes in Amish communities that they may serve. If a psychotherapist encounters Amish clients from a nearby community, it can be helpful to consult elders within the community for more specific details about the Ordnung within that community.

Psychotherapists should also be mindful of personal views and values that may interfere with their ability to provide competent treatment to this population (Standard 2.06a). Given the educational attainment requirements and the sociopolitical culture of professional psychology, psychotherapists are at an elevated risk for holding biases against fundamentalist religious groups (; ). As the Amish are an extremely conservative Christian sect, psychotherapists should earnestly assess their feelings about religion prior to engaging in work with an Amish client (). Additionally, strict conformity and compliance practiced among the Amish are inconsistent with Western values of individualism (Wittmer, 1995; 2001). Relatedly, many psychotherapists may feel uncomfortable with the seemingly subordinate role of women that is often a part of Amish culture. These factors of the religion and culture, along with perceptions of the Amish being “old-fashioned” or “uneducated,” may tempt well-meaning therapists to adopt a paternalistic (or unintentionally condescending) style during therapy. This creates a tension between ethical Principle A (beneficence and nonmaleficence) and Principle E (respect for client autonomy), which has been discussed in detail elsewhere in the literature (e.g., ; Engelhardt, 2001; Tjeltveit, 2006)

At first glance, the gender hierarchy of Amish culture appears inherently at odds with some ethical approaches (e.g., egalitarianism, feminist ethics). However, as previously noted, the role of Amish women is complex and they often enjoy equality and partnership within their own homes and marriages (Kraybill, 2013). Amish women may appear quiet or submissive in public, but they generally report feeling happy, confident, and self-respecting (). As such, it is important that psychotherapists remain mindful that Amish culture, while likely viewed as seemingly regressive by contemporarily trained professionals, is not necessarily detrimental. Amish women take pride in their roles, and a well-meaning psychologist may considerably damage rapport by directly or subtly devaluing the role of the “homemaker” or implying that women should strive for “greater” positions. Ultimately, psychotherapists should strive to be tolerant of Amish views and be mindful that their views on gender are nuanced and are not inherently harmful to the members of their society. The interested reader can learn more about this paradox in Olshan and Schmidt (1994) and Kraybill (2013).

Although it is important to incorporate cultural knowledge and competency into all practice, psychotherapists should be mindful of the balance between culturally informed practice and stereotyping. This balance can be particularly important when working with Amish clients due to the large degree of variability between different Amish communities. Every Amish community likely contains some unique elements, and some of the differences between Amish groups are quite substantial. Incorrectly assuming that one Amish person has similar lived experiences to another Amish person may damage the therapeutic alliance. Additionally, it is important that the psychotherapist does not assume that the client’s presenting concerns are related to their cultural identity. Psychotherapists should take time with each Amish client to understand the culture of that particular client, and the extent to which their culture is related to the presenting problem.

Confidentiality

The right to privacy is an important value in Western society, and client-practitioner confidentiality is a central tenant in Western medical and psychology ethics (e.g., Higgins, 1989; Kottow, 1986). However, such concepts mean little in the Amish community where the affairs of an individual are the affairs of the Church, and affairs of the Church are the affairs of the community. While this communitarian lifestyle is not entirely unique to the Amish, the extent to which the individual’s life is intertwined with the Church and community far exceeds what a therapist would encounter in mainstream populations. As such, therapists should be prepared to face situations in which they are asked to disclose sensitive client information to the client’s family, church officials, or even the entire community (Cates, 2011).

When working with an Amish client, there will potentially be several breaches of confidentiality. The client may have to take an English taxi, the Amish term for an English person who can be hired to drive the Amish to run their errands in the community, to the psychotherapist’s office. It has been suggested by some (e.g., Cates, 2011), that it can be helpful to simply meet the Amish in their community for psychotherapy. In the case that the psychotherapist chooses to meet the Amish client in his or her home, several situations might create a risk of breaching of confidentiality. Standard 4.01 of the Ethics Code states that “Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium…” and Standard 4.04b states, “Psychologists discuss confidential information obtained in their work only for appropriate scientific or professional purposes and only with persons clearly concerned with such matters.”The Ethics Code states in Standard 4.05a that a psychologist may disclose information about the patient with consent, which means that psychologists are not necessarily breaking the Ethics Code in these interactions if the psychotherapist discussed the situation and obtained consent during the informed consent process. However, given the emphasis on confidentiality in ethics training, psychotherapists may initially feel discomfort in such situations. Cates (2011) describes an episode in which an Amish client asked him to describe information from their therapy to a large portion of the community and discusses how the situation was navigated. Cates notes that after a period of internal struggle and consultation, he acquiesced to the client’s request, which resulted in a rewarding experience.

When working with multiple clients from a rural setting, ethical challenges can arise due to the intertwined nature of individuals’ relationships when living in a small community. While not a “multiple relationship” as traditionally defined, these inter-client relationships can result in ethically challenging situations such as a psychotherapist inadvertently learning information about a client or situation from a third party. As such, psychotherapists should be mindful of where they learn information, carefully consider how and when to utilize the information, and consider if doing so would violate the confidentiality of another client (). These issues may be especially common when working with Amish clients, as referrals are often made via word-of-mouth and a psychotherapist who is trusted by the Amish may become the single “go-to” clinician for that community. While such situations are not inherently unethical, psychologists should be cautious about treating multiple clients who are very closely associated (e.g., family members) as treatment goals and client needs may come into direct conflict. While some of these dilemmas are unavoidable due to the nature of Amish communities, Schank and colleagues (2010) recommend raising these issues as part of the informed consent process.

Informed Consent

Standard 3.10 requires psychotherapists to obtain informed consent before conducting work with a client. Regarding therapy, Standard 10.01a states, “…psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers.” Informed consent, one of many clinical-ethical challenges, requires therapists to inform the client of any possible consequences of treatment, without placing unnecessary barriers in the rapport-building process (). This tension is acutely present in the informed consent process with Amish clients. Standard 3.10 states that informed consent must be obtained “using language that is reasonably understandable to that person.” The Amish, with lack of secondary education and unfamiliarity with the customs and ways of worldly psychotherapy, may need additional time and more easily accessible explanations of informed consent. Conversely, the Amish are generally distrusting of the English, and an elaborate and detailed explanation of every potential consequence of psychotherapy could deter the client from continuing with treatment. Informed consent should be explained in easily understood language, with careful consideration for the client’s trust in the therapist. As the Amish culture emphasizes compliance, it should be confirmed that the client is actively affirming consent, rather than just agreeing with the therapist. Due to the patriarchal structure of Amish culture, this may be especially important in dynamics in which the therapist is male and the client is female. It should also be noted that Amish partners often make decisions jointly with their spouse rather than independently (), so psychotherapists may choose to also discuss informed consent with the client’s husband or wife, if the client wishes.

As previously noted, when working with clients in a small community, clients should be informed at the outset of therapy of the likelihood of incidental contact (encountering one another outside of the context of therapy) and unintentionally obtaining information about the client from an outside source (Schank et al., 2010). Werth and colleagues (2010) recommend having a standard protocol at the start of every case which includes a discussion on how the therapist might respond to seeing the client outside of the therapy context. This process is especially important when seeing Amish clients in their own homes or communities. If seeing couples or families, it is also recommended that relationship dissolution and the roles of the psychologist in any future public or legal action is discussed in the initial session ().

Discussing the limits of confidentiality (Standard 4.02) may be a particularly difficult situation to navigate. The Amish are not ignorant of the law and governing forces of the United States, but their ultimate authority is God and the Ordnung. Furthermore, many Amish may feel distrust towards English intervention due to historical injustices and oppression. The Amish came to the United States to flee from persecution and have since had several conflicts with the United States government regarding their schooling, social security, conscription, criminal justice, and a variety of other realms (Kraybill, 1993). In a case described by Nolt (2011), a cultural misunderstanding resulted in an Amish woman with mental health problems being confined to a state mental institution for 24 years and her caretaker receiving a harsh prison sentence. Tragedies such as these are likely remembered by members of the Amish community, and psychotherapists should be clear but delicate when discussing the legal constraints of the limits of confidentiality.

Assessment

Given the lack of studies on the Amish and their low, but increasing levels of treatment seeking, there is a dearth of validated assessments for use with Amish clients. Standard 9.02 of the Ethics Code requires that “…psychologists use assessment instruments whose validity and reliability have been established for use with members of the population tested. When such validity or reliability has not been established, psychologists describe the strengths and limitations of test results and interpretation.” Furthermore, Standard 9.02c requires psychologists to use measures appropriate to the individual’s language preference. There are very few validated measures for assessing the Amish, and it may be difficult to obtain these measures in their preferred language of Pennsylvania German.

Although the Amish are geographically American, their culture varies significantly from normative American culture. Given the lack of measures validated in Amish samples, psychotherapists should seek measures with high cross-cultural equivalence. Cross-cultural equivalence concerns the extent to which a measure validated in one cultural sample (typically Western culture) can be equivalently applied to individuals belonging to another cultural group (van de Vijver and Tanzer, 1997). For example, many common intelligence tests developed for Western cultures are designed based on western ideals of reasoning, acquired knowledge, and memory, as well as education standards. As such, they may not be valid indicators of individual differences in intelligence among Amish individuals (see , and , for more information about general cross-cultural psychometric equivalence; see , and , for more information about psychological assessment of the Amish specifically).

Risk Management

Another concern for psychotherapists is the assessment and management of risk. In a rather extreme example, Cates (2005) describes a game practiced by some Amish called “Cows n Bulls” in which male adolescents and preadolescents simulate or physically engage in anal intercourse. From a multicultural lens, this behavior is benign and culturally normative, but from a risk management standpoint, failure to report this behavior could violate mandated abuse reporting laws.² The ethical debate between cultural relativism and universal human rights is longstanding (e.g., Donnelly, 1984; Macklin, 2014; Smith, 1998), and the current article does not aim to resolve this controversy. To summarize, regarding risk management, there is no blanket rule that could apply to all cases; therefore, it is recommended that a psychotherapist in this situation should seek consultation from other professionals who work with Amish clients and aim to make the most culturally and professionally informed decision.

Payment

As mandated by Standard 6.04 of the Ethics Code, psychotherapists should work out a payment plan with clients at the outset of therapy. This may be complicated when working with Amish individuals, as they are unlikely to be enrolled in any government or commercial insurance plan. Furthermore, they generally do not use electronic payments, preferring to pay with cash or bartering (payment for psychological services with goods, services or nonmonetary remuneration). While cash payment for services is relatively straightforward, bartering can create more ethically complex situations.

Standard 6.05 of the Ethics Code states that bartering is acceptable if “it is not clinically contraindicated and the resulting arrangement is not exploitative.” However, psychologists should be mindful that some states have laws or ethics codes that forbid the practice of bartering for psychological services. Even if a psychologist is operating in a state that permits bartering, some further ethical considerations should be made. Bartering in any psychotherapy setting can be challenging to ethically navigate, and exploring the benefits and risks of this practice has been covered elsewhere in the literature (e.g., Hill, 2000; Zur, 2008). As a general rule, it is recommended that barter be for goods rather than services, and that an outside party appraises the value of the goods (Woody, 1998). Despite the challenges, the author encourages psychotherapists to be flexible and to develop payment plans that are both ethical and accommodating for Amish clients.

Incorporate Spirituality/Religious Aspects into Treatment

The intersection of religion and psychotherapy has been the topic of many discussions in the psychotherapy literature and opinions regarding the integration of religion into psychotherapy are mixed. Although many agree on the benefits of incorporating the client’s religion into practice when warranted (e.g., Hodge, 2011; ), effectively incorporating spirituality into psychotherapy is a skill itself, and therefore psychotherapists must ensure they can competently provide this service (Richards, 2009). Even if the psychotherapist is not comfortable or competent with this degree of religiosity, the psychotherapist should not avoid the topic. Religion is the cornerstone of Amish culture, and failure to address this fact adequately could be invalidating for the client. On the other hand, therapists need not feel confined to an approach of pastoral counseling or spiritual healing, as Amish clients may be aware or may be taught about English psychological diagnoses and are sometimes willing to take prescribed medication (personal communication, November 2, 2019). Additionally, psychotherapists should avoid challenging the Amish client’s beliefs, as an inappropriate attempt to change a single belief can trigger negative feelings and backlash (; Conlin & Boness, 2018). Consistent with Principle E, the beliefs of the Amish should be acknowledged, respected, and considered in treatment appropriately and to the extent of the therapist’s competency.

Consider the Community

As previously discussed, the Amish have a tight-knit, supportive community that emphasizes taking care of one another. Given the positive effect of social support on a variety of outcomes, including psychological well-being (e.g., ), psychotherapists should consider using the built-in support structure of the Amish community. There are Amish/Mennonite mental health treatment centers (e.g., Rest Haven, Green Pasture, Oaklawn; for more comprehensive reading, see Nolt, 2011) in areas where the majority of the Amish are concentrated, and many Amish communities have unofficially designated members in the Church who can help provide counseling (Cates, 2005). As the communitarian mindset dominates Amish culture, the process of healing may be as much about repairing their status in the community as it is about internal states of distress. As such, it can be expected that members of the family, Church, or community will be interested in understanding or even participating in the treatment of the client (Cates, 2011). On the other hand, stigma regarding mental health conditions exists in some Amish communities, and the client may be seeking treatment in an English setting specifically to avoid the scrutiny of the Church. It is recommended that clients be asked about their interest in making use of intra-community support systems, and psychotherapists should use this support if it coincides with the client’s wishes.

Even if the community is not directly involved, any decision regarding an Amish client should be made with consideration of the effects that it will have on the client and their relationship with the Amish community. Although client welfare is generally the focus of treatment, Amish clients’ standing in their community may be inextricable from their individual welfare. For example, imagine a client that is on rumspringa and visiting a psychotherapist regarding anxiety and ambivalence about returning to the Amish community. A culturally informed psychotherapist could help the client explore the consequences of this decision (shunning, loss of family, community, home, etc.), and assist the client with finding resources or other individuals who have made similar decisions. As such, it is recommended that psychotherapists remain mindful of the both the client’s needs and the client’s relationship with his or her community.

Prepare for Amish-Friendly Work

Modern society and the Amish society have been described as two different worlds (Kraybill, 2001). As such, psychotherapists should be mindful that Amish clients visiting a modern psychotherapy clinic are stepping far outside of their comfort zone. Of course, it would be impractical to attempt to model one’s office in a way that mirrors an Amish farmhouse, but some simple measures can be taken to reduce the discomfort an Amish person might feel in this “worldly” interaction. For example, in the digital age, iPads and computerized assessment are increasingly used in psychotherapy settings (e.g., Garb, 2007; ). When working with an Amish client, psychotherapists should administer paper-and-pencil assessments and print out physical copies of any forms that would otherwise be delivered electronically. Although some Amish are not immediately averse to seeing an English person using technology (personal communication, November 2, 2019), psychotherapists may consider refraining from using digital devices in sessions for note taking or other purposes. Many training clinics also use video/audio recording for supervision purposes (), and most English clients are comfortable with this practice (). However, many Amish are prohibited from being photographed (Kraybill, 2001), and being fully recorded would likely be deeply unsettling or outright refused.

The Amish view time differently than modern Americans, and the Amish pace of life can seem incredibly slow (Kraybill, 2001). As such, it is recommended that psychotherapists adjust their time-management as necessary to foster a feeling of comfort and avoid making the client feel the “rush” of modern Western society. Expect that a normal 50-minute session might take closer to 90 minutes or adjust the expectations of what will be covered and accomplished in the 50-minute session. As previously mentioned in this article, many of these challenges can be avoided by simply meeting an Amish client in their home or community. If this is not a feasible option, these adjustments regarding technology and time may help the Amish client feel more comfortable in an English treatment setting.

Use Appropriate Self-Disclosure

Self-disclosure is a thorny topic and has many ethical considerations of its own (Barnett 2011; ). Different theoretical orientations have differing views about self-disclosure, ranging from the psychodynamic view of virtually no therapist disclosure (Goldstein, 1997) to feminist views that encourage some forms of self-disclosure (). It is worth considering that increasing one’s willingness to self-disclose on some subjects may prove beneficial when working with an Amish client. As previously mentioned, the Amish live in communities in which disclosure is the norm, and they tend to value honesty and straightforwardness. As such, therapist failure to divulge any personal information may seem odd, or even give the impression that the therapist is “withholding secrets” (Cates, 2005). Cates (2005) suggests that divulging basic facts about oneself may sufficiently give Amish clients a sense of “knowing” the therapist, and this may be extended to what Knox and Hill (2003) describe as “disclosure of facts” (e.g., I have a Ph.D. in counseling psychology, I have 2 children, I grew up on a farm). However, it is also recommended that psychotherapists use discretion when self-disclosing information to Amish clients and psychotherapists should not deviate far from their comfortable levels of disclosure.

A particularly challenging area related to self-disclosure involves the therapist’s spirituality. There is evidence that matching on religious beliefs can be beneficial to psychotherapy (; McMinn, 1984), and that disclosing religious status to Amish clients can have a positive impact (Cates, 2005). However, this is contingent on the psychotherapist holding relatively mainstream Christian beliefs, and disclosure that the psychotherapist holds non-Christian beliefs (including atheism/agnosticism) may potentially be harmful to treatment with an Amish client. For cultural reasons, it is unlikely that an Amish client will ask directly about the therapist’s religious beliefs, but if the situation does arise, Aten and colleagues (2010) recommend giving a straightforward answer.

Consultation

Consultation may be especially important when working with Amish clients. Working with Amish clients may introduce ethically complicated situations that do not have clear solutions. Furthermore, cultural differences can shade therapist’s opinions and unknowingly bias the therapist’s perspective. Ideally, one would consult with a colleague who has experience working with the Amish, although many psychotherapists may not have any colleagues with this experience. In such cases, psychotherapists should seek consultation from a colleague with experience working with diverse religious groups, particularly with fundamental and/or conservative groups.

¹Personal communications generally provide the name of the individual with whom the author was communicating. However, due to the cultural emphasis on humility, the Amish individuals’ willingness to interview with the author was contingent on the author keeping all statements fully anonymous. As such, names are omitted from personal communications in this article.

²Mandated reporting laws vary from state-to-state, especially concerning sexual activities involving minors under 14 years of age. Individual state law, the ages of the parties, and the nature of the act are all important factors to consider. As such, this case does not highlight a specific discrepancy between culture and law, but rather provides an example of an ethically unclear situation.

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