ETH8283 - SECTION 8: ANALYSIS OF THE SCENARIOS
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.
This will include both the Stages of Ethical Decision Making, as well as leadership issues involved in the process of making ethical decisions. We will also look at some very tentative options for resolving the dilemmas, taking us in particular through the Identification and Evaluation Stages.
In order to fully evaluate the options as part of the Evaluation Stage, however, we would generally need to have much more detailed background information about the clients and their circumstances than we would be able to present in these brief scenarios. With this clarified, let's look again at our first scenario and its analysis.
Scenario One
Ron B. is a clinical social worker who specializes in Attention Deficit Disorders. He has seen Arthur M., a 10 year old with ADD with hyperactivity, for two assessment sessions. At both sessions, Arthur’s mother and father have been present. During these assessment sessions, both parents have made it very clear to Ron that they expect that individual counseling for Arthur will be the approach taken. Ron has explained very gently and diplomatically that individual therapy is not usually recommended for children with ADD, as it has been shown to be not particularly useful in creating change, as opposed to a combination of family therapy, support, and education. At the start of the third session, Arthur’s father shows up with Arthur and tells Ron to see Arthur individually, saying that the family would drop out of therapy if Ron “couldn’t do his job and fix Arthur’s problems”. What is the most ethical course of action in this situation, and what ethical and leadership principles are at stake?
Scenario 1: Purpose and Key Issues
Present scenario that highlights complete decision making process
Highlight issues of leadership and professional authority
Highlight pursuit of mission in spite of outside pressures
Highlight the importance of discerning value bias in ethical decision making
In this one seemingly simple scenario, we will find a wide array of the most important principles related to the whole process of ethical decision making, as well as a number of concerns related to leadership in clinical practice. There will be several levels of understanding that we will come to in this analysis. We will spend the greatest amount of time on this first scenario to introduce a wide range of issues relevant to ethical decision making and leadership.
At the surface level, there should be some fairly ready accord with regard to some basic principles of clinical practice familiar to all clinicians. The deeper we delve, however, the more we will get into the complex territory that leaders must face in ethical decision making.
If you found easy answers to this scenario when you read it on your own, let's see how well your analysis agrees with ours. Let's also see how many of the most complex issues you uncovered. Let's begin by looking this scenario in relation to the stages of ethical decision making.
We'll start, as one always does, at the knowledge stage. In the knowledge stage, Ron brings to the table some expert understanding about the clinical and ethical issues at hand. This knowledge informs each part of the decision making that is to follow. Included in this knowledge will be several nuts and bolts issues with which clinicians, in their leadership role, must keep up to date.
He will need to know, for starters, certain laws and guidelines for determining who the identified client is. Why is this necessary? Client status confers certain privileges that are not accorded to non-clients. This is a factor with legal ramifications - and it will be different from state to state. By example, in some states, the right to privileged information is only conferred to the identified client.
He will also need to know who the client is because treatment goals will be focused upon moving that identified client towards a better place. More importantly, though, the needs of the identified client are central to deciding what the mission will be. As the knowledge stage moves to the identification stage, Ron will need to have a clear sense of who the client is.
Those clinicians who are inclined to view a child's problems in terms of systems issues might well define the whole family as the client. Ron's attempt to work with the family, in fact, is working within a systems approach. There are, however, important reasons why Ron might be inclined to identify Arthur as the primary client, and why this would be important for the ethical decision at stake.
Arthur's parents are placing Ron in the difficult position of having to choose between their right to make autonomous decisions for their son - and Ron's understanding of what would be best for Arthur's interests. The mission, as autonomously defined by them, is for Ron to fix Arthur and leave them out of the treatment.
As parents are - in most states under most conditions - the decision makers for the minor members of their family, their right to autonomous decision making would need to be respected. Ron, however, might be inclined to look more strongly at other competing interests in this scenario, especially if he takes his leadership responsibilities seriously.
The principles that seem to be in conflict with parental autonomy are those concerned with forwarding the well-being of the client (if Ron designates Arthur as the client) and protecting the integrity of the counseling profession. If Ron is clear that Arthur's well-being will be better served by advocating for the most effective approach to treatment, then this is the correct position for a leader to take.
From an ideal perspective, this best protects the integrity of the profession and the mission in which the profession is engaged. Ron, from his leadership position, is then going to act as an advocate for taking care of the long-term needs of Arthur, even where it may create discomfort for the family.
To some degree, Ron is going to be supported in taking this position by the actions of the family. When Arthur's parents bring their son into treatment, they are implicitly saying that they want Ron to assume some leadership responsibilities for the well-being of their son. In this, they are allowing Ron a certain degree of professional authority that justifies his attempts to work towards what he sees at the correct mission, performed in a manner that best strives for the fulfillment of that mission.
The problem is that - in addition to this implicit understanding - there may be a competing explicit message: they do not want the change process to move forward if it means that they must be involved in it.
Where does this leave Ron in terms of balancing the implicit and the explicit message received? (The implicit message advocates for valuing the well-being of the client, while the explicit message advocates for valuing the autonomy of the parties who have decision making rights for the client.)
Referring back to our diagram of competing interests and principles, client autonomy and forwarding the well-being of the client are relatively equal principles, neither of which necessarily supersedes the other. How does Ron move forward?
In his analysis, Ron may choose to look at this problem from a clinical perspective. What are some of the possible reasons for the family taking the position they are taking?
The parents may have unrealistic expectations about what therapy can accomplish, hoping - at a feeling level - that Arthur can be "cured" without effort and input on their part. They may be worried that unpleasant truths may be uncovered about their parenting approach and skills. They may resent authority figures telling them what to do. They may view their needs as more important than Arthur's. These factors may be items of value to the parents that shape their thinking and actions.
To Ron, none of these reasons for avoiding the hard work of change may seem to be more valuable than the goal of helping Arthur to improve his functioning. The items of value for Arthur may be more important than the sacrifices the parents are asked to make.
The problem is that the most direct beneficiary of the efforts - Arthur - is not the party who may be most directly asked to make the sacrifices. The parents, on the other hand, are likely to be asked to do something that they may find very difficult - change - in exchange for something that they might not necessarily find particularly valuable to them. Does Ron have the right to ask them to make this choice?
Before you consider your answer to this question, be aware that, as a clinician, you probably work within an ethos with very specific value biases. You probably value an orientation towards personal development, insight, and evolving towards higher states of individuation. In the words of a former client, this is the particular "cult" to which clinicians belong. Not all people belong to this "cult", nor have a deep and abiding faith in this particular ethos.
There is a wholly deeper level of understanding of ethical decision making that begins to get teased out by these difficult questions and issues. Since a decision of how to proceed must be made, there must ultimately be some understanding by the clinician, in his/her leadership role, of how to resolve the deeper levels of value conflict here.
There are, in fact, some guidelines for how to resolve these difficult value conflicts. Unfortunately, the process is complicated, and will lead us far afield from the defined goals of this training. Time constraints, therefore, will not allow for a full and thorough examination of this process here. We will, instead, focus on more limited goals in this regard: to utilize this scenario to show the trainee where this deeper level of analysis will begin.
As we have briefly discussed earlier, certain groups of professionals are assigned both rights and responsibilities that are not assigned to the general public. Doctors, clergy, safety personnel, and people in the field of mental health are among those groups of people who are set apart for special consideration.
Each of these groups of professionals has their work shaped by certain kinds of value biases that are supported and championed by the professions as a whole. For mental health clinicians, that bias is oriented towards valuing good mental health, striving for it, and encouraging it in other people.
This bias shapes the work in which mental health engage. It also shapes the thinking - and the actions - of mental health clinicians in important ways. As mentioned previously, though, not all people, and certainly not all clients, subscribe to the values held by these professions. People outside the field of mental health, in fact, may hold to values that are incompatible with the values of the field of mental health.
The bias of mental health clinicians to value the furthering of clients' well-being is, however, generally supported and championed by the society at large. Society offers this support as an acknowledgement that the mental health ethos generally serves to protect and improve the common good. The society at large, therefore, sanctions and supports the idea that mental health clinicians - in their leadership role - should operate with this bias towards promoting client well-being.
The support from society to place this value bias in a pre-eminent position, however, is not absolute. There are other, competing value biases that will enter into ethical analysis in complicated ways.
In the scenario as presented, the rights of Arthur's parents to protect their own self- and parental interests are also supported by larger elements of society. The broader society has a stake in advocating for parents' rights to make decisions on behalf of their minor children - even when those decisions do not necessarily protect and enhance the well-being of those children.
There are complicated pressures to maintain these parental rights, and therefore to reinforce and champion certain value biases in parents. Parents are given, to some degree, the right to balance the competing needs and interests within their own families, by default giving them the option to place their own interests above the needs and rights of their children.
Likewise, there are complicated pressures to maintain individual rights to choose one's own cultural, or religious and spiritual path, and to have one's children follow that same path. This is true even when the defining values of that path run contrary to the ideals espoused in the field of mental health.
Clearly, there is complex territory here concerned with defining the right mission. When faced with client values that are incompatible with the values at the foundation of the field of mental health, how does the clinician proceed in a way that respects the client's values while also moving towards a mission that allows mental health work to get done?
These competing value issues are present and active in this scenario. They raise some difficult questions that will require the clinician to be aware of his/her own value bias, and seek to understand the other party's value bias.
For instance, does a child's vulnerable status require that parents make significant sacrifices for the well-being of their children, or should parents be allowed to choose whether they want to do less parenting work and enjoy their own lives more? Does Ron have the right to ask Arthur's parents to work harder on their parenting in order to improve Arthur's well-being? Or would it be the parents' choice about whether they will value the well-being of their own lives over the well-being of Arthur's life?
There is no ready and unbiased answer for any of these deepest questions. Like it or not, each clinician is at this vortex of deep value conflicts. As clinicians and leaders, we are vehicles for examining and working to resolve these complex value conflicts for which society itself has no easy answer.
Moreover, these kinds of deep value questions - and value biases - are likely to be present (although sometimes very well-hidden) in even the most mundane clinical situations. The clinician's responsibilities as an expert do not allow him/her to avoid the hard work of searching out and understanding the values - and value biases - that shape each complex decision to be made.
Even though it may be a more instinctive response for Ron to automatically advocate for his own value bias - by advocating for Arthur's well-being - he would necessarily have to tread very carefully and with great humility in this collision with the competing wishes of Arthur's parents.
Clients have very powerful methods for convincing less humble clinicians to respect client autonomy - they can drop out of treatment. If Ron confronts the family too directly about their resistance, they may drop out of treatment, or take out their anger on Arthur. In the final analysis, it must be understood that ethical decision making is not a matter of following abstract rules of engagement; it is a living process, in which the process elements are part of the decision making.
In this orientation towards process, Ron's work in the ethical aspects of this situation will converge with the clinical. He will need to gather additional information about why the parents are taking the position they are taking. This will allow him to understand what the items of value are for the parents, and whether they are cultural and value elements that must be granted deep respect, or clinical elements that must be worked through.
This difference between clinical and cultural value elements is a key concept in terms of the process of value engagement and value resolution. Cultural values tend to be those which are aligned with the client's ideal ethos - there is no disparity between the client's operational values and the client's ideal values. The client is holding those values because they conform to the ideal values set forth by his/her culture.
Clinical value elements, on the other hand, are found in values that drive the client's behavior, but are different than the values he/she would set forth as his/her ideals, or the ideals within his/her culture or subculture. There is a built-in tension within the client him/herself about defining his/her actions in terms of the values.
The tension within the client about following values that may not fit his/her own ideals allows the clinician greater authority in addressing value conflicts. There is a kind of implicit permission for the clinician to take a stronger leadership stance in changing or reshaping the values.
This is not to say that there will be no internal tensions in cultural values. Because people are much more transportable than their cultural values, people often live in several different cultures at the same time. This creates a different kind of value tension. As previously discussed, the resolution of these value tensions at a deeper level, however, will be deferred in this training.
There are also practical considerations within this situation, which will help us return to the task of following this scenario through the stages of ethical decision making. What if Ron's assessment is that the family would really drop out of treatment if he continued to press them to pursue what he saw as the right mission? What practical implications does this have for Ron's use of professional authority?
(As a reminder, the professional authority in this case - as in every case - is oriented towards acting in the service of the mission. A proper use of leadership authority means that Ron will operate in whatever manner is needed to move the mission forward.)
Ron's use of professional authority may lead to a strange and almost paradoxical set of circumstances. It may end up directing him towards a choice of either of two completely contradictory approaches. It may end up being better to insist that family therapy be used, or it may be more ethical to give in to the parents' request for individual therapy. How is this so?
This paradox exemplifies how ethical decision making is a living process. The answer is found in the connection between the Identification Stage and the Evaluation Stage.
In the Identification Stage - after identifying the competing elements in conflict - the good clinician will look at multiple options for moving towards the best results. The more options that are discovered, the more likely that a successful option may be found. Each of the options discovered will have possible outcomes. In the Evaluation Stage, the clinician will then attempt to predict the possible outcomes of each option for moving forward, based upon the available evidence at hand.
What are possible options in this scenario? There are two obvious ones: 1) Advocate for family therapy, and hold to that position; 2) Go along with what the family wants, and provide individual therapy, though it is less effective.
There are other, less obvious solutions: 3) Offer the family other possible approaches, including engaging in both kinds of therapy; 4) While agreeing to see Arthur individually, continue to build a case over time for working with the family in the way that best serves the client's needs. This last approach speaks to a key point of leadership: leaders understand that things do not transpire as discrete events; they are part of processes that evolve over time. In the ethical aspects (as well as in the clinical aspects) of most situations, the process is always an important part of the solution.
Based upon his in-depth assessment of the family, Ron would need to make a selection of which of these options would work best in fulfilling the defined mission. This would represent the Selection Stage of the ethical decision making process. Depending upon a number of real-life variables, he may end up choosing to work flexibly with the family. The determination would be made by evaluating the complex information the family would provide to the clinician over time, and aligning this information with the mission.
On the other hand, he might also refuse to accede to the parents' position, even to the point of being fired. This might represent good leadership. At this point in time, the trainee may have an important question. How could getting fired be good leadership?
In the business literature, it is said that a great leader is one who is willing to "die for his/her cause". Strange as it may sound, under some conditions, a willingness to stand for the integrity of the profession - to do the right thing even if it means getting fired - can be a very powerful intervention that creates an enormous amount of professional authority.
Many clients have very little experience with people who exercise true leadership and put the mission ahead of their own selfish motives. The essence of parenting that produces healthy children is very much based upon values that direct the parents to put aside their own selfish motives and fulfill the mission of raising healthy children.
Ron, in choosing to stick to the mission he has outlined in his role as a leader, is exemplifying what mission driven behavior is to this family - even if it leads to the negative consequence of his getting fired. In this commitment and integrity, there may be an expression of what professional authority is that the family will directly experience.
The professional authority generated might then be passed on to the next clinician to see the family - hopefully in a way that reduces resistance and supports a movement towards positive change. Done right, this can represent leadership at its highest level, where the mission is defined as being more important than the personal interests of the parties involved.
Standing your ground and getting fired, of course, must be done with a process in which the well-being of the client is clearly articulated in the clinician's actions and approach. It must also be done with a family that will actually continue to seek therapy. Otherwise it may be used by the family as another way to avoid the hard work of treatment.
The willingness to "die for your cause" for clinicians, of course, does not always involve getting fired. It is much more concerned with the idea of projecting integrity. It has some interesting short-term and long-term implications for the clinician. In the short-term, it can create some harm for the clinician's well-being. At times, it may result in some cases being lost and income forfeited.
In the long run, however, good things are more likely to follow. A reputation for integrity in one's clinical work will usually result in many more good things than bad. The gains in the long-term will usually more than compensate for any short-term losses in pursuing a more mission driven course.
To finish this scenario, there is really no way of knowing what would be the right solution for this family without a great deal of additional information - information that would be gathered in an ongoing way as part of treatment. Ethical decision making, however, is not just an intellectual exercise. Decisions affect real people in real ways, and must be carefully done, and then carefully followed for their real results.
It may be helpful, just to bring some resolution to this situation, for the trainee to get some information about how a case like this was resolved.
In a case very similar to the scenario described, the actual solution was to spend more time explaining to the parents why family therapy is more effective. Given clearer information about the reasoning involved, the parents agreed that family therapy would be the better approach. That family, however, took their position out of concern for their child having more time with the clinician. They did not display the more aggressive resistance that was incorporated into this made-up scenario.
It is also important to note that the real situation was handled very calmly with regard to the parents' challenge to the professional authority. In accordance with what was stated previously, the process was one in which the professional authority was used to educate the parents - over time - and help them see that this approach would align better with their own defined mission. The process was cooperative, not competitive, in nature.
There are other important leadership issues in taking this approach. There may be considerable personal frustration experienced by a clinician when a family or patient questions the clinician's judgment and authority. The clinician may experience a threat to his/her value bias. There may be a temptation to quiet that personal frustration by coercive attempts to push the family towards the clinician's position.
The process of using professional authority (in accordance with principles of leadership) is more effective when authority is used to convince, rather than to coerce or force. This is the principle of creating buy-in. Professional authority and buy-in are built - and can be used - over time to work towards the mission.
As we move to end the analysis of this scenario, a reminder is in order that this is not a real life situation. There are many other possibilities that could be searched out, given more detailed information. The goal for our first analysis, though, has been to create an entry point for looking at the ethical decision making process with greater knowledge. Let's move to our next scenario.
Scenario Two
Ellen P. is a social worker specializing in chronic medical problems. For several years she has been running a support/therapy group for people with chronic medical problems. The group often receives new members from people Ellen has seen first in individual counseling. Her group has instituted a rule that prohibits members from having romantic relationships with other people in the group, a rule that Ellen has championed for a number of important clinical and boundary reasons. Recently, a member of the group, Gary G., has stopped attending without providing the group or Ellen with any reason for his departure. Shortly after this, another member of the group, Jill C., also drops out of the group and asks to start seeing Ellen again in individual counseling for some “urgent things that have come up.” In the first individual session, Jill reports to Ellen that Gary had dropped out of the group because he wanted to begin a romantic relationship with Jill. Jill has since begun to date him, and they have gone out on a couple of occasions. Ellen is concerned, because, although Gary has acknowledged to the group that he has Hepatitis C, he did not disclose that he also has HIV. Ellen, however, is aware of his HIV status, since the information was disclosed in Gary’s individual sessions. Ellen is aware that, if the couple becomes sexually active, Gary’s HIV status holds serious risks for Jill. What are the leadership and ethical responsibilities here, and how should Ellen address them?
Scenario 2: Purpose and Key Issues
Highlight need for expert knowledge in key areas
Highlight difference between legal and ethical dimensions
Highlight competing interests and principles of ethical decision making process
The leadership issues in this scenario will be very straightforward, and will be found in the Knowledge Stage of the ethical decision making process. It is important for a mental health clinician working with medical problems to be aware of the latest legal rulings with regard to confidentiality and protected categories of clients.
In this scenario, Gary is HIV+, and therefore falls into a category of clients with special rights with regard to confidentiality. In order to protect the integrity of the counseling profession, the clinician is under special obligations to protect the right to confidentiality that Gary is granted with this special status.
On the other hand, there may also be imminent risk of life-threatening harm coming to Jill if she engages in unprotected sexual relations with Gary. This imposes certain demands upon a clinician to break confidentiality in order to protect the life and safety of a client.
Adding another level of complexity to this scenario, it is very likely that Ellen could be sued whether she discloses Gary's HIV+ status. Jill could sue Ellen if she does not disclose, and Gary can sue her if she does! Outcomes for either law suit would be uncertain, given the current state of case law in this arena, and depending upon the venue in which the suit came to trial.
It is extremely important - when faced with a situation of this complexity - to have great clarity about the most current laws and statutes with regard to confidentiality and protected classes of clients. These laws may vary slightly from state to state, and may change without the clinician being aware of the change.
It may, on occasion, be necessary to request the advice of an attorney who specializes in this kind of law, so information may be current. This understanding of one's own limitations and the willingness to utilize other resources as a system of back-up operate in accordance with the idea that a good measure of humility is required to perform ethical practice.
There is, however, another issue here. As we have mentioned, the legal and ethical realms are not exactly the same. Whereas there is not a clear legal solution to this, the ethical solution may be easier to find.
In looking to identify our competing interests and principles, the first principle has to do with protecting the client from harm. This principle is even more important than protecting the integrity of the profession, under which guidelines for maintaining confidentiality are found. Even with the advent of better medications for treatment of HIV/AIDS, the harm that would come to Jill from possible transmission of HIV would in all likelihood outweigh Gary's right to confidentiality. A more ethical course would like be to place safety above confidentiality.
Ellen, of course, would first like to look for options in which both principles are followed. She could, for instance, try to gather information from Jill about whether Gary has told her of his HIV status. She could also contact Gary to tell him of her intention to disclose to Jill his HIV status, and try to convince him to reveal this information first.
Ellen, however, will not necessarily have too much time in which she could explore the possible options. Once Jill reveals her information, Ellen would need to proceed very quickly to actions to address the dangers involved to her client. Experts, in their leadership role, need to accept the demand for quick decision making, and the responsibility and accountability that follow these decisions.
Ellen may want to discuss her difficult choice with another experienced clinician, who might be willing to share the burden of decision making. The choice, however, will still primarily be Ellen's, and it would be a difficult choice indeed. While patience may be useful as a leadership tool in other scenarios, in this one decisiveness is more important.
The primary purpose of adding this scenario was to highlight the very real importance of keeping abreast of changing information of which every clinician is expected to be aware. As this training is being completed, HIPAA guidelines in a number of areas related to clinical practice are moving towards full implementation. Each mental health clinician will be expected to have expert knowledge in every area as outlined in the HIPAA standards.
This expectation of expert awareness is a very heavy burden in terms of continuous learning. Just as the process of working through every ethical dilemma is a living, moving thing, so is the process of staying continually abreast of changes in information.
Without a willingness to accept the responsibility for staying abreast of these changes, however, the clinician will find him/herself unprepared to respond quickly to emerging ethical difficulties where decisiveness is needed to protect the well-being of the client. Let's move to our next scenario.
Scenario Three
John R. is a clinical social worker with an established relationship with a managed care panel. A new client, Pamela B., has just been referred to him and she calls him to set up an appointment. When John begins to talk to her, it becomes very clear that she is in crisis. She is extremely depressed and gives John information that lets him know that she is actively and presently suicidal, with clear indicators of imminent risk. Pamela tells John that the managed care panel knew about her suicidality, and told her to try to get in to see John as quickly as possible for an assessment. John tells Pamela that he is not the most appropriate party to provide the level of immediate care that she obviously needs. He tells her to hang up and call the emergency number on her insurance card and tell the care manager about her suicidal ideation and plan. Pamela agrees to do so, and terminates the call. What are the ethical and leadership issues at stake here, and what, if anything, would you have done differently?
Scenario 3: Purpose and Key Issues
Highlight leadership responsibilities in special cases
Highlight issues related to when professional responsibilities begin
Highlight competing issues of clinician autonomy and client well-being.
What are the key issues here? It is very possible that the managed care company has not fully accepted its responsibilities in this case for the care of this client. A client with this level of suicidality probably should have received better assessment and more intensive intervention than was set in motion by the managed care company.
Furthermore, John has not clearly been assigned responsibility for this case. He has not autonomously agreed to see Pamela, so she is not yet his client. Any actions on John's part will not be billable until that client-clinician relationship is established. From the perspective of John's autonomy and self-interest, he should not be assigned any burdens in this case without the establishment of that defined relationship.
Yet, John does have responsibilities in this case, responsibilities that he does not meet. However much the managed care company may have dropped the ball in this case (and that cannot fully be determined by the client's reports - since clients have been known, on occasion, not to always tell the whole truth), John is in the position of a professional, with obligations to the integrity of his profession.
John's responsibility is to make sure that this client is connected to the proper level of care, either by assuring a proper re-direction back to the managed care company, or by directing the client to a hospital, or by contacting emergency services to have a safety check performed on the client, depending upon the information John receives from the client about the level of imminent risk.
It is possible that John may eventually be able to bill the managed care company for his time. It is also possible that he will spend time that is never billable. The safety of the client, however, is an issue that supersedes John's personal interests in this case.
This responsibility to put self-interest aside is required in certain professions, including the field of mental health. In exchange for this obligation, mental health clinicians are accorded certain special rights not available to non-professionals. The right to practice in a restricted field is the key right in this case. The rights are not granted without the concurrent responsibilities, including the responsibility to protect a client's safety even when the hours are not billable.
Clinicians should make an effort to take care of their own well-being. Their ability to fulfill a very difficult mission requires that their energies be used well, and that they have time to restore themselves.
From the perspective of the profession, however, and therefore from an ethical perspective, the obligations to protect the integrity of the profession supersede the clinician's right to take care of him/herself at the expense of the safety of the client. Let's move to the next scenario.
Scenario Four
Sheldon J. is a social worker in a community mental health center, specializing in work with adolescents. He has begun to see Will A., who will be 17 in two months, and whose mother has brought him in for oppositional and defiant behaviors. Sheldon works very hard with Will for several weeks, establishing a good therapeutic relationship. Two weeks before his seventeenth birthday, Will confides to Sheldon about a “problem with drugs” that he has never brought up before. The reason he hasn’t brought it up is that his mother kicked Will’s older brother out of the house when she found out he was doing drugs, and he knows his mother will do the same with him if she finds out. In Sheldon’s assessment of Will’s mother, he concludes that Will is almost certainly right. Sheldon also concludes that Will needs Intensive Outpatient treatment for the drug problem, which would probably require payment by Will’s mother. What are the ethical and leadership principles at stake here and what course of action would you recommend?
Scenario 4: Purpose and Key Issues
Highlight the need for remaining abreast of important legal information
Highlight need to make ethical decisions applicable to real world
This scenario raises several important issues. First, once again there is expert knowledge that the clinician must know in order to proceed in an ethical manner. Substance abuse, like HIV, is a disorder that has protected status in terms of confidentiality.
This protected status, which is covered under the Federal Statute 42 CFR Part 2, places severe restrictions upon the release of any information related to the treatment of substance abuse. Since Sheldon works in a community mental health center, he is going to be required legally to follow the very strict guidelines established by this statute.
However, Will is also a minor. This means that there will be state guidelines that work with the federal statute to determine to what extent Will is covered under CFR 42 Part 2. In some states, minors as young as 12 years old can have virtually the same rights as adults in terms of privilege for confidential information around substance abuse treatment. In other states, Will does not have the same rights as adults.
Depending upon the state, Will may already have the right to privilege, or may be eligible for it when he reaches 17 in a couple of weeks.
These are the legal concerns. There are, however, also ethical concerns related to pursuit of the mission. The mission, in this case, is concerned with forwarding the well-being and safety of the client. Depending upon the state in which Will lives, these ethical concerns may dovetail with the legal statutes, or be in conflict with the state statutes.
What if Will lives in a state in which parental notification is required for any substance abuse treatment? What if the determination is that his mother really would kick him out of the house if she became aware of his substance abuse? What would be the implications to his well-being if he were to be kicked out of the house at an age where he was unprepared to look after his own well-being?
These are not abstract concerns when you are dealing with a real client who lives in a real family. In the Identification Stage of the ethical decision making process, Sheldon would need to do a very thorough examination of the competing elements, concerns and interests before moving forward with any decision about how to proceed.
The clinical issues, in this case, would also be involved in the ethical decision making. How serious a substance abuse problem? How willing and able is Will to confront his substance abuse? How dysfunctional a relationship between Will and his mother? Sheldon would need to examine all of the possible options for addressing this situation in light of how these questions affect the safety and well-being of the client.
There may also be issues related to consent to treatment, as defined by state statutes, as well as what was agreed to when Will's mother brought him in to treatment. If Sheldon had agreed to provide information to Will's mother concerning any problems with implications for life or safety, what would Sheldon need to reveal about the drug use?
If Sheldon elected to withhold information about the drug use, and Will ended up overdosing on drugs, this would clearly present legal problems for Sheldon. If, on the other hand, Sheldon told Will's mother and she followed through on kicking him out of the house, then Will would be very likely to drop out of treatment. This might put him in greater danger with regard to his drug use.
As before, there is plenty of opportunity for the clinician to run into problems either way he/she chooses. In this scenario, Sheldon may have a more extended period of time to perform a careful evaluation of these competing elements, taking time to see how information shifts and changes over time.
If Sheldon is presented with information that Will may be at more imminent risk from his drug use, it will change the landscape, and change the shape of the decision that is made. While this active, organic process is occurring, he would engage in that same continuous process of trying to identify as many options as possible, then selecting the one that best serves the mission, defined as improving Will's well-being and protecting his safety.
Sheldon would want to consult regularly with an experienced clinician in this case, particularly if the degree of substance abuse put Will's safety at risk. If Sheldon determined that it was necessary to inform Will's mother of the substance abuse problem, he would also probably want to inform Will of this decision in a manner that maximizes the chance that the therapeutic relationship will be preserved.
The amount of evaluation and decision making in a case like this is very high. It again points out the need for the clinician to approach these difficult situations from a position of expert knowledge and information. Let's move on to the next scenario.
Scenario Five
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, Jared 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, Jared 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 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 leadership and 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?
Scenario 5: Purpose and Key Issues
Highlight the need for remaining abreast of evolving information
Highlight issues of humility in ethical practice
Highlight importance of looking for one's own value bias
This scenario is designed to highlight 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 has been a recent 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 most recent study has concluded that sexual orientation conversion therapy may be able to produce changes in sexual orientation. The facts in this study stand apart from any values considerations.
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. 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 always an 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? Would Alan be prepared to address this issue? Would he have noted the follow-up information that Dr. Spitzer had later withdrawn his report, and that numerous organizations have noted that it is unethical to attempt conversion therapy?
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.
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 three additional scenarios 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.
Bonus Scenarios
Marcy P. is a social worker 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 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. What are the ethical principles at stake here, and how would you recommend that Marcy should proceed?
James S. is a mental health clinician in private practice. For the past three years, he has been working with Richard P., a very wealthy client who suffers from schizotypal personality disorder. James began this case by providing family therapy with Richard and his daughter, Rachel, who had a very conflicted and difficult, hostile-dependent relationship with each other. Due to her father’s personality disorder, Rachel had spent much of her early life serving as a de facto caretaker for her father, but in the course of therapy she successfully individuated herself, eventually moving 3000 miles away to Washington State. With the agreement of all parties, Richard continued to address his own individual concerns in treatment with James, with whom he had a trusting relationship. Recently, Richard was diagnosed with terminal cancer, and the treatment focus shifted towards helping him make preparations for end of life issues and settling into a hospice facility, with healthcare and counseling responsibilities transitioning to the hospice’s treatment team. In order to facilitate some of the practical aspects of this case, James and Andrea K, the social worker from the hospice facility, determine it is important to make phone contact with Rachel in Washington State and engage her in important discussions about the care. She is listed as the executor of Richard’s estate and will assume power of attorney for making any end of life decisions that are required. Knowing that this is likely to involve some delicate work in pulling Rachel back into her father’s life, James would like to invite her to engage in telemental sessions in order to work through some of the practical decisions that will have to be made, particularly if and when Richard is no longer able to make responsible decisions for his own well being. What are the legal and ethical concerns that would need to be considered if James was to engage Richard’s daughter in this treatment process, and what steps would needed to be made in order to make adequate preparations to move in this direction?
Edward G. is a social worker who specializes in child and family issues, with special expertise in the field of trauma. He is trained in and uses EMDR successfully in his work. He has been working with Emma C, a sixteen year old whose father was killed recently in a drunken driver incident with Emma sitting in the back seat of the car. It has taken Edward a number of months to build up trust with Emma sufficient to allow the trauma work to proceed forward successfully. Over spring vacation, Emma and her mother travel home to visit relatives in Oklahoma. During the time that they are there, a major storm front travels through their town. The house where Emma was staying with her relatives was completely destroyed, as were most of the houses in their town, and several neighbors were killed. Emma’s mother is injured, but alive, although she is unable to travel, necessitating that she and Emma remain in Oklahoma during the recovery period. Because of the damage to the town and the obstacles that the family will face after the tornado, Edward knows that it will be a while before services are available to respond to Emma’s trauma. He also knows that earlier intervention with a trauma might be able to prevent a re-traumatization of his client. Edward therefore has to weigh whether he could provide telemental health services to Emma in another state in order to respond to the immediacy of the trauma. What are the ethical and legal considerations here as Edward weighs this decision?