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In looking at our ethical scenarios, we need to remind the trainee of the context within which the analysis will occur. These are not real life situations, although the inspiration for many of the scenarios came from clinical situations that occurred in real life. There is not an opportunity to interact with the clients presented in these situations, in the same way a clinician would in real life.

What we are looking to do is to increase the trainee's level of understanding of the process of approaching ethical dilemmas, including: 1) What elements are involved; 2) What principles come into play; 3) How you engage in the process of sorting through the competing principles and elements, including elements of cultural diversity.

Scenario One: Introductory Scenario

Jenny P. is a mental health clinician working as a contract clinician for a company that provides Employee Assistance Programs on the West Coast. One of the client companies that she serves has made a management referral of a key employee with work performance problems, Jula M. Jula is a mid-level executive who was recruited and moved from his home in the South Sea Islands to develop business in the Pacific Rim. His family is descended from royalty, and is very influential, with extensive business and personal connections in an area that provides certain raw materials vital to one of the company's most important products. The company spent several years and an enormous amount of money recruiting and developing him as an executive, and has made very clear that he is a very unique and valuable commodity for the company. They are very concerned about his decline in performance and emotional disinvestment from the company. The Director of Human Resources for the company is personally supervising the referral, and has expressed concern about whether there might be a possible substance abuse or other serious personal issue that is causing his performance to slip. The client is being referred to Jenny because she is one of the most skilled and experienced EAP providers that the company has working for them. When the referral was made, the President of the company called Jenny personally to tell her of the importance of this employee, and the care with which this case should be handled. Not far into the interview when Jenny meets with Jula, he reports to her that is in the process of deciding whether to leave the company and return to his homeland. He is simply unhappy living in the United States, as there are many aspects of American culture that are disturbing and distressing to him as a father and husband. He expresses his concerns about the consumerism, the lack of community, and the American obsession with sex, including the unnatural ways in which Americans handle such an important and natural subject. He goes on to tell Jenny that his two children, male and female fraternal twins, are almost 14 years old. He has been struggling to protect them from the readily available flood of pornography around them, while also trying to protect them from other elements of American culture that are trying to make them feel guilty and ashamed of their sexuality. As the session proceeds forward, he goes on to say that this has made it difficult for them to remain grounded in their culture while they prepare for their initiation into their adult sexual life, which is to occur in the next several weeks. In accordance with the customs of his people, the grown-ups in the community will be initiating the two teenagers into the ways of sex at a ceremony to mark their fourteenth birthday, as they welcome them into adult life. A trusted adult male from the community will be initiating the daughter, and a trusted adult female from the community will be initiating the son, providing a joyful and safe first sexual experience to be celebrated by the whole community. He only hopes that they have not already been too damaged by American culture to be able to enter into this key part of their adult life in a healthy manner - in accordance with the history and culture of his people.

What are the practical, legal and ethical considerations here, and how might you instruct Jenny to proceed?

To this point, we have tried to examine the basic conflict between competing systems of values that this scenario presents. These two competing value systems are, to a large degree, relatively incompatible with regard to the central question of the scenario as presented.

People whose ideas and beliefs about sexuality have been shaped by Western thought in the United States will, for the most part, have difficulties in seeing sexual contact between adults and fourteen year old adolescents as normal and appropriate. Conversely, the non-dominant community we are examining, whose members have likely held this tradition of sexual initiation for time immemorial, will see it as wholly normal and healthy.

Because there are legal considerations from this fundamental clash between two systems of values, beliefs and perceptions, the clinician's task will be a little more complicated. In addition to the conflict of interests between the two value systems, the clinician will also need to balance the competing legal and ethical interests.

To begin the examination, we will refer to the stages or steps of the ethical decision making process, first introduced in's introductory course on ethical decision making: Ethical Decision Making: A Primer for Mental Health Clinicians. These are shown below.

The Steps or Stages of the Ethical Decision Making Process

The Knowledge Stage

The Identification Stage

The Evaluation Stage

The Selection Stage

The Assessment Stage

The Adaptation Stage

To handle this scenario, the clinician must have – or gather – the knowledge that would create a sufficient degree of cultural competence in working with this population. The clinician would want to ensure that the practice of sexual initiation is actually a historically and culturally based practice that is perceived as normal within the culture in which it is occurring – not deviant by that culture's own definitions and standards.

One would also want to have knowledge of the effects on the sexual and emotional well-being of the adolescent participants in this rite of passage – both in terms of the adolescents' responses within a "pure" culture, and the adolescents' responses if they have been transformed by exposure to Western culture. The meaning and effects of the initiation rites may be different if the adolescents have been westernized to any significant degree.

This knowledge base of cultural competence is necessary over and above the usual knowledge required to handle ethical dilemmas: laws and statutes, codes of ethics, competing principles and interests, and one final key component – a thorough knowledge of oneself, including one's own values, prejudices and perceptual biases.

The second step or stage is concerned with identifying the ethical dilemma, and the range of potential solutions to that ethical dilemma. The dilemma at this point has been fairly well identified. Therefore, let's look at some of the potential solutions.

Given a thorough base of understanding about the culture of the client, the details of the law concerning reporting requirements, and a clear sense of one's own comfort level in terms of placing oneself in legally questionable positions, there are essentially two ethically different approaches that one could identify in attempting to resolve the dilemma presented by this scenario.

There may be clinicians who would elect to view the actions of the client's community within the framework of the client's own cultural standards, and the effects of those behaviors on the adolescents as being defined by the cultural standards under which they were occurring. In such a case, there is a valid argument for not viewing the behavior as suspected exploitation or abuse towards the adolescents in question, and there would be no report of suspected child abuse that needs to be made.

Treatment of the client could then proceed without the complications from this issue.

Given the complex issues contained in this scenario, it would be very wise for the clinician to solicit the opinion of a least one – and preferably several – of his or her trusted fellow clinicians in reaching this conclusion. Given the relative lack of consensus found in the presentation of this scenario to almost two hundred clinicians, it would not be surprising to find a variety of opinions of how to proceed on this front. However, the support of one or more fellow clinicians would be very helpful should legal or ethical proceedings be initiated subsequent to a decision not to report.

This perspective - and this potential solution - would still receive further scrutiny in the evaluation stage of the ethical decision making process. The evaluation would, again, be more powerful if done in concert with other clinicians.

The other option would be to view the behaviors of the client and his community in light of the standards of the larger community, as well as prevailing legal standards. The potential solution to this dilemma would then most probably consist of planning to engage in a well-constructed dialogic process with the client. In this dialogue, the client would need to be advised of the potential legal implications of the initiation rites.

Within this dialogue, the clinician would attempt to have both parties work together to look at the cultural differences, as well as the adaptive challenges – including potential legal issues - arising from those cultural differences. Later in this section, we will examine what this might look like in action.

The evaluation process might include running the potential solutions through the various ethical tests noted in an earlier section: the consequential test, the light of day test, etc. It would also involve use of the ethical decision making tree, with examination of all aspects of the conflicts in question, including the conflict between the potential harm that may be done to the client versus the potential harm that may be done to the larger society when a law to protect its most vulnerable citizens is not stringently applied.

When all evaluation has been completed, the clinician ultimately must make a selection of a course of action to take. With some ethical dilemmas, clinicians will have a longer period of time before they need to move forward with complicated ethical decisions. However, in this case the clinician will have a limited amount of time to weigh the complexities of this decision making process before having to decide. Normally, states will allow a clinician only up to twenty-four hours before a report of suspected child abuse must be made.

If the clinician elects not to report, the assessment stage will involve watching for further information that may suggest harm is coming to the adolescents through the initiation rites. The clinician can then adapt his choices to respond to new information that is being received.

If the clinician elects to address the initiation rite as a source of reportable actions, the assessment phase will begin in concert with the selection stage, as the process of dialogue with the client begins. Adaptations – in the adaptation stage - will be ongoing, occurring in the context of the dialogue that has been initiated with the client.

What would the clinician's side of this dialogue look like? While it is difficult to predict, since it would be interactive with the client, the clinician might take a stance similar to what is presented below:

"Jula, I know that you have had a great deal of concern about how issues of sexuality are handled in this country. As a mental health clinician, I see many of my own clients struggling with some of the same inconsistencies and uncertainties about sexuality that you have noted in your time in America. In fact, your culture's way of handling sexuality may work out better for people when all is said and done.

But we have a problem we need to figure out together, and I'd like to have your help in looking at it. In our country, we have had problems with adults exploiting children sexually. It has been so important to prevent this from happening that we have put laws in place to protect our children from being mistreated. One of the parts of that law is that people like me are required to report it any time that inappropriate sex is happening between adults and children.

The problem is that this law doesn't take into account situations that involve people from a culture like yours, where sexual initiation rites are normal and in all likelihood quite healthy. It is one of the complications of different cultures coming together with different ideas about how certain things are supposed to be handled.

I'd like to see if we can't figure out something that makes sense in terms of handling the challenge posed by this law and your situation. I don't want your culture to be interfered with by a law that hasn't really been designed for your culture, but the law had to be extended to all people in this state to protect children that were being harmed by sexual exploitation in our culture.

Can we put our heads together to come to some decisions about what to do? Then we'll take a look at what might happen if we decide to go in one direction versus another."

Please note the great care with which the cultural issues are addressed, following the principles of Transcendent Discourse. Respect is accorded to the client's cultural material, while at the same time some of the functional purposes of the reporting statutes are explained.

Please also note how closely the presentation and staging of the discussion follows Brown's Diversity Ethics Process Model. If appropriate, the emotional, residual and transcendent aspects of the choices both cultures have made concerning sexuality can also be examined. This would occur in accordance with the sixth step of Brown's model, as Jula and the clinician look together at the assumptions of each culture and the effects of those choices from a consequential perspective.

The adaptive challenge of reconciling the legal issues and the cultural differences is not avoided. However, the client is engaged in the decision making process in ways that increase the likelihood of the therapeutic relationship surviving a report to Child and Family Services, should it be determined that a report is necessary.

In the course of the dialogic process, there will be an opportunity to gather additional information on whether the adolescents might be harmed by the initiation rites, how acculturated the adolescents might have been, and other aspects of the scenario relevant to a determination of whether a child abuse report is more clearly required.

There is also an opportunity to acquaint the client with skills in understanding and handling cross-cultural differences in a way that decreases some of the tensions for the client arising from the cultural conflict. Like the dominant culture, Jula's culture faces the reality of increased cultural interaction that will necessarily push for adaptation and discourse.

If Jula is unwilling to enter into a constructive dialogue, it may be useful for the clinician to attempt to voice both sides of the dialogue in his presence, offering at all times an opening for him to join the dialogue and help the joint exploration process move forward. If the clinician determines that a report must be made concerning the initiation rite, this exploration of his cultural elements may help to reduce the negative impact of the intrusion of the legal system into the traditions and customs of his culture.

Let's move on to an examination of our next scenario to see how well our tools work with another of the most vexing issues that occur in cross-cultural work.

Scenario Two

Marcy P. is a mental health clinician specializing in geriatric work. She has been working for several years with Irma S., a ninety-three year old female who has just been diagnosed with a terminal form of bone cancer, which has disabled her to the point where she requires a considerable amount of assistance in the tasks of daily living. In visits to Irma’s house, Marcy has been preparing Irma for the difficult road that lies ahead, with the prospect of a considerable amount of medical intervention and pain medication. One day in their session, Irma stops Marcy’s supportive interventions to ask for a simple favor: she wants Marcy to help her purchase an airline ticket to Oregon. When Marcy asks why, Irma smiles and reports that Oregon has the most liberal laws in the country concerning doctor assisted suicide. Irma goes on to say that she has led a full and rich life, and wants to depart her life with dignity, and without the need for all the attendant medical care that she is going to have to go through with her cancer. She says in the country and culture where she was raised, people who were ready to die would be allowed to do so, and she thinks this is a good thing. She says she would like for Marcy to help her make arrangements to find a temporary residence in Oregon, and travel arrangements. She reports that she has contacted the office of a doctor in Oregon whom she saw on television, and has made an appointment with him. She thinks this doctor would be willing to help with an assisted suicide. What are the legal and ethical principles at stake here, and how would you recommend that Marcy should proceed?

Outside of issues dealing with sex and sexuality, the most emotionally heated ethical dilemmas will likely be concerned with values around death and dying. These issues may tie into deeply felt transcendent values, quality of life issues, and the most personal concerns about the meaning of one's life.

There are many ways that different cultures approach death and dying and integrate their own death and the death of loved ones into the context of their whole culture. The ideas from these cultures are frequently interwoven with deeply held spiritual beliefs that provide meaning and purpose for the larger community within that culture.

Because mental health practice in the United States has generally been tied to the medical model, there are some biases that are likely to be present as ethical decisions get made where death and dying are concerned. There are also biases that have evolved as the larger culture of the United States has struggled with integrating the various religious, ethical and cultural values around death and dying.

The biases that have emerged in the dominant position have been formalized into laws meant to define how parties within the culture are supposed to address issues of death and dying. Failure to follow these guidelines – even if one has fundamental disagreements with them -can result in consequences through the legal system.

The development of the Doctor Assisted Suicide laws that have been forwarded in Oregon represent a voice of dissent against a uniform set of guidelines in this area. The laws define very specific conditions under which a patient may ask a doctor to hasten the advent of death. This allows the patient the right to choose the time and circumstances of his or her own death.

In the scenario that has been presented, the clinician is being asked to consider several things that create ethical conflict. First, is it more ethical to honor the client's autonomous request to die in the manner of her choosing, or to honor the medical definition of the obligation to do no harm?

Next, if Marcy decides that greater harm would come from denying Irma the right to die with dignity, should Marcy respect Irma's rights in this matter more than the law of the state in which they both live? There is a possibility – depending on the state in which they both reside – that Marcy may be held accountable for contributing to the death of Irma should she facilitate her journey to Oregon for the purposes that have been proposed.

(The clinician would certainly want to get some clarity on the legal issues here. The reality of the legal circumstances would obviously be a key factor in examining the consequential aspects of this ethical dilemma.)

Finally, would Marcy be personally comfortable in providing this kind of support, or should she consider referring Marcy to another clinician if this does not align with her own beliefs and values? Are Marcy's own values and beliefs about doctor assisted suicide appropriate to impose upon the client in any way? If it is not possible for another clinician to become involved in this case due to practical considerations, would that affect Marcy's thinking and actions?

Let's address this last set of considerations first. What are the boundaries or limits to the obligations one has as a licensed clinician? Is a clinician required to do things that he or she does not agree with from a personal moral perspective?

To some degree, yes. The choice to accept one's licensure does signify agreement to follow professional guidelines and relevant laws and statutes. Depending upon how far from the defined professional standards one's own personal beliefs are, there will be some degree of conflict for almost all professionals in this area.

For instance, if one's personal beliefs allow for discrimination against certain groups or categories of clients, one is expected by the profession to put aside those personal beliefs in order to act as an appropriate representative of the profession. This is in line with protecting the integrity of the profession.

(Each clinician does maintain the right to enter into a dialogue with the guardians and definers of the professional standards in order to advocate for changing those standards and guidelines.)

This is to say that Marcy would face some ethical pressure to place her own personal beliefs in this area to the side in order to examine her professional responsibilities towards Irma and the profession. If there would be no other clinician to whom Irma could be transferred, Marcy would be stuck with sorting through the cultural issues to protect Irma's interests.

Does this mean that a clinician is required to subscribe to a client's cultural values and beliefs to the exclusion of the clinician's own beliefs and values? In a word, no. This is where we find the real importance and power of following dialogic models of ethical problem solving.

Because clinical work is adaptive work, it is the business of change. However, it is not just the clients who must engage in the work of change. Clinicians must understand that they too will be changed in these complex interactions with clients. Clinicians who remain too fixed and too firm in their positions – no matter how deeply held those positions are - will have a difficult time creating a forum for finding dialogic solutions with clients.

Even when it is emotionally difficult to do so, clinicians are asked by their professions to be willing to hold their own personal beliefs in abeyance long enough to engage in complex interactions with their clients. This aspect of being a licensed clinician, as we have mentioned before, is sometimes the most difficult part of the work.

This scenario represents a perfect circumstance to utilize Brown's model, which allows Marcy and Irma to explore the complications of this issue together. Let's look at this model again:

1. Make a proposal (What should we do?)
2. Identify observation (Why should we do it?)
3. State values (Why is this the right thing to do?)
4. Align personal, client, professional, societal values
5. Explore the alternative views (with the participation of the client)
6. Uncover the assumptions (for the client's values, the clinician’s values, the profession’s values and society's values)
7. Find the best option (in concert with the client)
8. Perform a consequence analysis (in concert with the client)

In following this model, there will be an opportunity for Marcy to examine her own personal values with the client. There will also be an opportunity to discuss with Irma the relevant laws and statutes, why those laws and statutes exist within this particular culture, what the biases are within those laws, and what adaptations the laws might require of all parties. As they uncover and evaluate the assumptions together, both parties can make clearer what may be the best choice to follow.

Depending upon some of the unknown variables in this case – such as the state statutes where Marcy practices – it may be that Marcy and Irma will determine that a trip to Oregon is out of the question. However, it is much more ethical for Marcy to help Irma to reach that understanding through the use of this kind of dialogic process.

Let's move forward to the last of our scenarios.

Scenario Three

Alan C. is a social worker who specializes in issues related to sex and sexuality. He has just agreed to meet with a new client, Ali M., who provided only sketchy information on the phone, saying the nature of the sexual concern was so personal he needed to discuss it in person. In the first meeting, Ali reports that his sexual concern is this: he is a devoutly religious person, and he has been fighting his impulses to engage in a ‘homosexual lifestyle’. His impulses run deeply contrary to his strongly felt religious beliefs, and to the beliefs of his culture. He is going to be returning to his home country in a few months, and he is worried about his safety and well-being if he cannot control his homosexual urges. He wants Alan to help him become straight. Alan’s very thorough study and research in this area has led him to a belief that efforts to “convert” homosexuals away from their sexual orientation are largely unsuccessful and can lead to additional emotional damage and disappointment, and such attempts are therefore inimical to Alan’s ethical obligations to promote more healthy approaches to sexuality and self-acceptance. What are the ethical considerations here? What issues related to values and diversity are at stake? What recommendations might you make to Alan regarding his handling of this situation?

In addition to addressing some important cross-cultural issues, this scenario is designed to remind the clinician of the importance of remaining both humble and fluid in the expert knowledge that is required to handle complex decisions in treatment. It also will point out the pitfalls that await the clinician who is unaware of value bias.

There was a  2003 study by Robert Spitzer, MD, of Columbia University. In 1973, Dr. Spitzer headed the committee responsible for removing homosexuality as a diagnosis from the Diagnostic and Statistic Manual. His study seemed to indicate that for some clients, sexual orientation conversion therapy may be able to produce changes in sexual orientation. (24)

Dr. Spitzer's study immediately drew political comment from both those forces aligned with the gay rights movement and those forces aligned with those religious groups who oppose gay rights. By 2012, Dr. Spitzer had completely withdrawn his support for his own study, noting that there were essential flaws in the design that did not allow for the results to be reliable. He also reported a severe case of "battle fatigue" in responding to the furor that had been unleashed from his attempt to apply the scientific method to a highly contentious area.

In the midst of the tremendous energy that has been unleashed from the value bias contained here for both sides, there is information that the expert clinician must evaluate and use to formulate his/her ethical decisions.

The clinician whose career has spanned a long enough time will have seen many fads, trends, new and inventive treatment approaches, and shifts in thinking and understanding about "the facts". This is an ever evolving process, and will create shifts in what we "know" at any fixed point in time.

What would Alan do in this scenario if his client came to the next treatment session with Dr. Spitzer's study in hand? What would it mean for his use of professional authority?

We do not know if Alan is motivated in his treatment position by his own political considerations, or value bias, or by not keeping sufficiently current in area of specialization. Each of these represents a problem for a clinician whose authority is generated by following the right mission driven by professionalism and expertise. A similar dilemma would exist for a clinician who took the diametrically opposite approach from Alan - that homosexuality can always be treated so as to convert the client back to a position of heterosexuality.

Sexuality, like many areas of study in this profession, contains complexities whose full expanse and measure will probably not be grasped in our lifetime. We will always be gathering new facts to refine what we know. This is reason for entering into this leadership position with a sense of humility that is commensurate with how much we don't yet know.

There is something very uncomfortable about admitting that our knowledge will change and move forward. This humility runs contrary to deep personal yearnings for certainty and more absolute states of being. This, however, is an area in which the trap of value bias lays in wait for the clinician who lets down his/her guard. This is one of several aspects of ethical practice that demands such a high level of emotional control.

The clinician must strike a workable balance between leadership - which demands decisive action - and humility - which reminds us that yesterday's best practices would often be grounds for lawsuits and loss of license today.

Alan's position in this scenario would be strengthened if he prefaced his expert opinions with the provisional statements that clinicians must humbly learn to add to their clinical vocabulary: "As far as we now know...", "Here is what we have learned to date...", "What the latest information is saying..." This approach is wholly consistent with the principle of operating within one's scope of competence.

He will also strengthen his position if he remains open to the possibility of having his clinical knowledge and understanding changed through the process of having his clients disagree with his professional opinion. Leadership entails a fearless search for what is right. If the client is the party who is right, good leaders will need to protect the integrity of the knowledge, not their own egos.

In very powerful ways, authority - and clients' trust for you - is actually increased by acknowledging openly and honestly when you don't know something or are unsure of something. This represents good leadership and ethical practice.

This set of understandings is particularly relevant to cross-cultural practice and the dialogic processes that work best in difficult ethical situations. It is not enough to know the scientific "facts" in any treatment area. It is also necessary to try to anticipate how these "facts" will be perceived, interpreted and responded to by the client.

Based upon the information given, Ali likely comes from a culture in which the "facts" about homosexuality may not be the dominant item of importance. As stated earlier, there are cultures for which every action is considered primarily in light of its spiritual significance. In cultures where this is the case, the journey of the individual may be to discover and align him or herself with the most important spiritual principles – not to pursue one's individual pleasure, personal growth, or individuation.

The relationship between scientific "fact" and spiritual directives will often create difficult adaptive challenges under these circumstances. The culturally competent clinician will not take as a starting point that the process "should" be driven by scientific fact. The points of view and perspectives of scientific inquiry may be inserted into the shared therapeutic process, but only as a part of the dialogue. In this instance, the leader's role is not to lead, but to explore - with the client's cultural material helping to define what the challenges are and what potential solutions might be found to address those challenges.

As we close out this section of the training, we will complete one more task. We will begin the preparation for the next level of advanced ethical decision making. At the highest level of ethical decision making, leaders will be faced with creating resolution to complex value conflicts.

In this process, the most difficult questions about values will be addressed. In anticipation of this, we will leave the trainee with one final scenario to examine and ponder. No response is required, and no analysis will be provided at this time. It will, however, quietly reinforce the understanding that we all enter into this field of work with much to be humble about. Following this, you may move to the test section of this course.

Scenario Four

Rita S. is a mental health clinician who works at the community mental health center serving a rural area. She has been referred a case through the county court system, Jenna M. Jenna’s parents and grandmother run a small store in the largest town in the area. They emigrated from a far eastern country almost 20 years ago, and now have three children, Jenna being the oldest. Jenna has been in trouble with the law, engaging in a number of petty misdeeds and misdemeanors, including vandalism, truancy, and running away from home. With the intervention of the court system, the family has been required to seek counseling. In the course of the assessment, Jenna reports that the major source of the friction between her parents and her has to do with the fact that an arranged marriage has been set up for her when she is 16, the legal age for marriage in the state in which they live. Jenna is adamantly opposed to this, as she has her mind set on going to college and developing a professional career for herself, and a life away from the family. Her parents insist that they have the right to do what is best for her daughter in keeping with their traditions, and the marriage will take place. What are the ethical and legal considerations in this scenario, and how will they interact with the treatment concerns?