ETH8385 - SECTION 9: ANALYSIS OF THE SCENARIOS
Jim P. is a licensed clinician, specializing in work with adolescents who have Attention Deficit Disorder. He works in a small town where there are few counselors and therefore few treatment options. He receives a call from Rhonda M., who is requesting services for her oldest son. Several minutes into the conversation, Jim realizes that his own son is in the same school class as is Rhonda's younger son. He also realizes that he has served as a sports coach for Rhonda's younger son, and has met Rhonda numerous times in that capacity. Are there any ethical concerns with Jim providing services to this family? Upon what principles related to ethics in counseling do you base your opinion? What options does Jim have to find the best ethical solution for this scenario?
From our knowledge of the ethical codes, we understand that there are special dangers in dual relationships with clients. Dual relationships can confuse the nature of the therapeutic relationship and interfere with the smooth course of counseling. We would identify this as a potential ethical problem in this scenario.
We would also identify as a problem the fact that there are not too many treatment options in this small town. In some very rural communities, there may be only a single clinician in a radius of 50 or 100 miles.
We would also identify as a problem the fact that the potential client's problems may require a special competency. This raises questions about possible referral to another clinician if the clinician would have to operate outside of his or her area of competence.
This highlights the importance of identifying and then evaluating all aspects of the ethical dilemma and of the potential solutions to the dilemma.
The best treatment option for this case would be a referral to another clinician who has the competence to work with the special issues involved. If there is such a clinician available to take this case, this would best balance the competing interests and principles.
If there is not a clinician with the competence to handle this case, the evaluation process must be engaged in to look at other options.
How much harm to the therapeutic relationship will be created by the presence of a pre-existing, personal relationship? Will it outweigh the potential harm to the client if no treatment is available?
Often, clinicians in small communities are comfortable and familiar with confronting the issue of dual relationships. At PTA meetings, in the doctor's office, at the grocery store, clients are likely to be everywhere, and the clinician must work hard to protect confidentiality and the integrity of the profession.
It places an extra burden on the clinician to act responsibly in his or her personal life - to be in the ethical mode at all times - since there is a reduced degree of anonymity in these communities.
It is a more difficult life for the clinician, as his or her professional responsibilities intrude into the personal sphere, but it is possible to serve the community while living among it.
When the clinician has done and does a good job of acting responsibly in the community, he or she can better balance the personal and professional relationships when they conflict in this way.
This is also likely to be a situation in which Jim would want to involve the client and the client's mother in the decision making process, to assure that they are comfortable with the dual relationships.
What about Jim's autonomy in this scenario? What if he is uncomfortable about working with this family? What if he resents having another intrusion into his personal life from a personal contact requesting services from him? Remember, as yet he has not agreed that this family will become a client.
When Jim takes this phone call, he assumes a certain degree of responsibility for evaluating the risks to the potential client from his choices. If his refusal to provide services creates substantial harm for the potential client, he may be placing himself in an ethically difficult position.
Again, in evaluating an ethical dilemma, it is important to look at all aspects of the situation and the options for resolving the situation.
In a small community such as this, Jim's refusal to treat a client in need may also have ripple effects to the other clients that he is treating. It may alter the level of trust accorded to him by the other clients who look to him for responsible decision making. In small communities, it may not take too long for information of this sort to be distributed to most of the town.
If no other reasonable treatment options exist for this client, and if harm may come to the client should Jim refuse to treat him, it is probably more ethical for Jim to assume responsibility for the case, in spite of the dual relationship issues.
This is in accordance with the ordering of the principles shown in the decision tree; the principle of doing not harm outweighs the concerns about the dual relationship.
Please note, however, that if there is not the likelihood of substantial harm to the client from Jim declining to offer treatment, then the balance may be evaluated differently.
Suppose that the potential client had mild ADD, that was, for the most part, being handled successfully. Suppose the treatment was not so apparently a clinical necessity. Then suppose that Jim was more personally involved with the family, for instance a close personal friend of the potential client's father.
These changes in the different aspects of this scenario would change the results of the evaluation process, and may suggest a different outcome to the situation. With the removal of the potential harm to the client, the dual relationship aspect of the situation begins to carry more weight.
It is important not to rush to a quick decision on difficult ethical dilemmas such as this. It is important not to look at one section of the ethical code to provide a simple answer for a complex problem.
It is important to think the dilemma through, to follow the stages and arrive at the most solution that finds the best balance of the competing principles and interests, and best conforms to the primary purposes of the counseling profession.
Julie R. is a licensed clinician. She has been seeing Gloria K. in counseling for about a year. Among other issues, Gloria has been discussing her relationship with Bob O., a local real estate developer. Gloria has reported to Julie that her boyfriend is unscrupulous, and has been bragging about the shoddy construction he has been using to build units cheaply in a new development, while still selling the units for a high price. Quite coincidentally, Julie has another client who is thinking of purchasing a unit in this development. Would it be ethical for Julie to warn her client about making a purchase in this development? Upon what principles related to ethics in counseling do you base your opinion?
In this scenario, two competing principles and interests can be identified. The first is the issue of confidentiality, which has implications both for the integrity of the counseling profession and for the well being of the client, Gloria, who is revealing confidential information.
The second principle or interest at stake is the well being of Julie's other client, who may become the victim of the possible unscrupulous activities of Gloria's boyfriend.
This scenario again highlights the importance of looking at all aspects of a situation as you begin the process of evaluation. It also highlights the principle of expanding your range of options when you look for possible solutions.
It is important to remember, in evaluating all the aspects of this scenario, the difference between fact and hearsay. Because Gloria is repeating what she has heard her boyfriend say, the information she is giving may be colored or tainted by the nature of the relationship with her boyfriend. It may not contain the truth, the whole truth and nothing but the truth. This must be considered in the evaluation.
That being said, because some kinds of harm to clients outweigh other considerations, we still must decide whether this information reaches a threshold for breaking confidentiality.
The harm that could come to Julie's other client is not life threatening, nor or is likely to cause irremediable emotional distress. On the surface, it does not look sufficient to warrant a break in confidentiality.
Moreover, it must also be considered that harm could come to Gloria if Julie breaks confidentiality. Gloria's boyfriend is likely not to have told many people of his unethical actions. It may not be too difficult to trace back the lines of communication to Gloria if a potential buyer confronts Bob about this situation.
It is unclear, given the information we have to work with, what the effects of this might be for Gloria, but it is probable that some harm may come to her through her relationship problems. This harm may be equivalent to the harm from which Julie's other patient is spared.
In this situation, the more ethical solution is to protect confidentiality. Are there other options here that may be considered in terms of offering protections to both clients?
It is possible for Julie to warn her other client of potential risks in her choice of housing purchases without breaking confidentiality, if she is willing to expand her range of options and come to a creative solution.
The way for Julie to do this is to express the concern, and possible solutions to the concern, in general principles, rather than through using specific knowledge of the actual decision involved.
Julie could simply tell her other client that housing purchases are important financial decisions, and as such require great thought, research, planning and other steps. Julie could then, using these abstract concepts, help her client organize an approach to this purchase decision that would protect her.
While the impetus for this careful approach is information that Julie should not necessarily have available, nothing in this approach presents a risk in terms of violating confidentiality. Julie must be careful how it is presented to her other client, but it is an intervention that would make sense even if the confidential information was not a factor.
Once this approach is presented to her other client, Julie has armed her client with the tools to approach this decision in the right way. If her client autonomously does not follow this advice, Julie is not responsible for the harm that follows.
After selecting this, or any other approach, Julie must continue to assess its effects and adapt the intervention as needed.
Jessica P. is a licensed clinician. At a party one night, she meets a former client, Edward G. She saw this client for a single assessment session ten years prior, when she was working as a counselor for the Employee Assistance Program offered by the client's company. Due to the public nature of the party, Jessica is not at liberty to notify Edward of this prior client/counselor relationship, and he appears not to remember their session together. At the time of this session, the client was seeking help for grief issues related to the death of his father. During the single session, the client reported that he had had a very good relationship with a counselor when he had been fifteen, and had resolved most other emotional issues during that treatment. Towards the end of the party, Edward asks Jessica if she would like to go out on a date with him. Is it ethical for Jessica to accept a date with this former client? Upon what principles related to ethics in counseling do you base your opinion?
This scenario provoked the greatest amount of disagreement among our panel of experts. This is partly due to the different opinions around this issue to be found in the codes of ethics for different licensures for clinicians.
The central issue that was identified was whether Edward could still be considered a client ten years after a single assessment session. If he is still considered a client, then a romantic relationship would invoke concerns about a dual relationship, or possibly engaging in sexual relations with a client, should the relationship move in that direction.
If the clinician's profession currently works under a code that states that a former client is always considered a client under these circumstances, then this is a considerable factor in making this ethical decision. For the sake of analysis, however, let us pursue the decision making process with this scenario, and examine it in light of the decision tree.
Is there the potential for harm to come to the client if the clinician accepts a date, based on the evidence presented? It is unlikely. Is there a risk to the integrity of the profession if the clinician accepts a date? Only if the clinician operates outside of the code for her profession, in which case she could be accused of not following the ethical principles agreed to by a consensus of her peers.
Is there a threat to the autonomy of the client if the clinician accepts a date? This issue might require more evaluation. In all likelihood, it would be important for Jessica to clarify the pre-existing professional relationship if she were inclined to accept the date offer.
If this pre-existing relationship were not a concern for Edward, it would actually be more restrictive to his autonomy for Jessica to refuse to even consider dating him.
Will Jessica's acceptance of a date have any impact on whether the client's therapy is promoted? Not at this point in time. There does not appear to be any current therapeutic relationship to be affected by this concern.
Even if the code of ethics for Jessica's profession allowed dating after a specified period of time, it would be extremely important that she conduct a very thorough examination of all the aspects of this situation. To quote the code of ethics for counselors and social workers from the state of Ohio:
"Counselors and social workers who choose to engage in such a relationship ... have the responsibility to thoroughly examine and document that such a relationship does not have an exploitative nature, based upon factors such as duration of therapy, amount of time since therapy, termination circumstances, client's personal history and mental status, adverse impact on the client and actions by the professional suggesting a plan with the client after termination."
This particular issue in counseling is likely to continue to be debated, without complete clarity and resolution for the foreseeable future. Clinicians are advised to proceed judiciously, with careful evaluation of the fine details, and with absolute clarity concerning whether one's judgment is being impaired by emotional considerations.
The clinician is also advised to be very cautious in choosing to abandon the protections offered by a more strict reading of the code of ethics. Ultimately, however, the clinician will need to assume responsibility for his or her own decisions in cases such as these.
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?
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.
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?
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.
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?
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?
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, professional 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.
Janet P. is a licensed clinician who specializes in Christian counseling. She has been seeing Marjorie B. for counseling. Marjorie has been having marital problems. As the counseling progresses, Janet's assessment is that Marjorie's goals for counseling would be better reached if the counseling were to move to couple counseling. Marjorie requests that Janet do the counseling, particularly because one of the primary problems between the couple is the refusal of Marjorie's husband to raise her children in a Christian environment. Is it ethical for Janet to agree to provide Christian based counseling for this couple? Upon what principles related to ethics in counseling do you base your opinion?
This scenario has been introduced in order to ask the question, “who is the client?”, and what principles and interests come into play for multiple clients. The introduction of additional clients adds another level of complexity to the ethical decision making process, as you must look at the stages and the decision tree as they related to both parties in this scenario.
Should Janet elect to include Marjorie's husband in marital counseling, she must now consider whether the course of treatment harms him, promotes his autonomy, promotes his well being, in addition to whether it does the same for Marjorie.
Based upon the information that is contained in the scenario, it is possible that the values held by Marjorie's husband are different than those held by Marjorie.
It appears more likely that Marjorie is attempting to enlist Janet in changing these values. Since Janet shares these values, as is evidenced by her specialization in Christian counseling, she might be viewed by Marjorie as an easy ally.
The difficult issue for Marjorie is that she works under a code of ethics that places autonomy as a higher principle than any single code of ethics contained in religious or cultural ideals. If she chooses to honor her client's request, using her position as a clinician to attempt to persuade Marjorie's husband to become "more Christian", she violates his right to autonomy. Following the decision tree, his right to autonomy supersedes her right to autonomy in choosing to impose her own set of moral values.
Janet is allowed, under her counseling code of ethics, to offer Christian counseling to any client seeking it. In order to respect a client's right to autonomy, however, she may not use her position to attempt religious conversions.
If Janet should elect to see this couple, she is obligated to clarify to Marjorie the limitations on advocacy of Christian values at the expense of the autonomy of Marjorie's husband. If Janet is unable, or unwilling, to see Marjorie's husband unless he autonomously agrees to a Christian based agenda, it is more ethical for her to make a referral to a different clinician. Because of the emotional commitments that each clinician makes to his or her own personal set of religious and cultural values, this can be one of the single most difficult and confusing areas for clinicians in the study and application of ethics.
There are, of course, concerns from various corners of the treatment community that therapy itself is driven by values imposed upon clinicians and clients by the dominant culture. Concepts such as personal growth and individuation, client autonomy, and other core values of treatment could be characterized as indigenous to Western culture. As such, they could also be seen as hostile to the values of a number of other cultures.
While a full examination of this issue is beyond the scope of this introductory course, it bears repeating that each individual clinician must carefully examine his or her values to make sure that they are not being imposed upon a client in ways that are not thought through carefully.
This completes our analysis of the scenarios. How did your answers compare with the responses from our panel of experts?
If there were areas of disagreement, do not be unduly alarmed. Ethical decision making is a difficult and even, at times, a contentious process. The goal of examining these scenarios was not to forge complete agreement on the right solution to each dilemma. These scenarios are not real life, and they leave out a great deal of information that would be available in dealing with ethical dilemmas in the course of a real practice.
The goal was instead to identify a process through which this difficult task might be attempted. The goal was to highlight the principles and interests at stake, and to improve the clarity and understanding about these principles and interests. The goal was to help the clinician enter into this process more prepared and less confused.
This will not protect the clinician from the inherent complexity of making good ethical decisions. In other words, it will not make ethical decision making easy. It will, hopefully, make it easier.
Following our bibliography, we will next turn to the test section which will examine your understanding of the principles learned to this point.