_____________________________________________________________ Managing Professional Boundaries
1. The course of action may not violate any ethical code. In this situation there is no dilemma and no need to apply the decision-making model. 2. The course of action violates an ethical code, and there are no other codes that support the action. This course of action should not be considered. 3. The course of action has codes that simultaneously support the action and some that are violated by the action. This is the most common in clinical practice and is the type of dilemma that a decision-making model is designed to help resolve. • T—Think ahead. Once the dilemma is defined, think ahead to the possible consequences of each potential action. Consider all who are potentially affected by the action. Clinicians have a duty to do no harm and to work to help the client achieve the best possible outcome, so this step aligns with the general principles of beneficence and nonmaleficence. • H—Help. It is important to receive help from others in the form of consultation. Receiving help is different than receiving a decision. Receiving help involves discussion of relevant factors to help determine a course of action, keeping the responsibility for the action with the clinician. Help can be sought from different sources: legal clarification from an attorney, risk-management clarification from a liability company; clinical clarification from a supervisor or colleague. The help received is then applied to each potential action. • I—Information. Information should be sought from all available sources including literature, laws, regulations, and agency policies. The information is then applied to each possible action to highlight pros and cons. • C—Calculate risk. Assess risk to each potential participant in the action. Decreasing risk to one party may increase risk to another. • S—Select an action. The clinician determines the most ethical/least unethical course of action. CASE STUDY Regardless of the specific decision-making model the clinician chooses as a best fit for their practice, all models simplify down to the following steps:
Apply these steps for ethical decision making to the following case study. The case is fictitious but is a situation that would not be uncommon, particularly in more rural areas. Dr. Smith has a private practice in the small town where she lives. Jane has recently moved to the town and has been seeing Dr. Smith for weekly psychotherapy sessions over the past 2 months for symptoms of anxiety with panic episodes. They have a mutually agreed goal of reducing the frequency of panic attacks to one per week. Jane is making good progress in her ability to recognize symptoms and utilize cogni- tive and behavioral strategies, and the frequency of panic attacks has decreased from multiple times daily to an average of three per week. As she has been feeling more in control, she has begun to re-engage in activities that have provided her with support and comfort. One of these activities is church attendance. Dr. Smith was surprised when she saw Jane arrive alone at Dr. Smith’s church one Sunday morning, the only church of that denomination in the town. Jane came up to Dr. Smith and asked to sit next to her during the service. Although somewhat startled, Dr. Smith agreed. At their next therapy session, Jane stated that she has now become a full member of their mutual church and has volunteered to work on the same outreach committee as Dr. Smith but hasn’t attended a meeting yet. How should Dr. Smith proceed? Questions: 1. Is there an ethical dilemma? 2. What about the situation requires decision-making? 3. If a decision is needed, what is the best course of action for resolution? Apply a Decision-Making Model Identify the problem. This may be a multiple relationship. In addition to seeing Jane in therapy, they will also see each other on a consistent basis in social and volunteer situations. Incidental contact outside of therapy is a boundary crossing, but it does not create an ethical dilemma. In this situation, however, the counselor and client will have ongoing close contact in a nontherapy setting. All professional codes of ethics state that the clinician should not engage in a multiple relationship if it could reasonably be expected to impair the counselor’s objectivity and effectiveness. Can objectivity in therapy be maintained in this situation if there is an ongo- ing nontherapy relationship? Can confidentiality outside of therapy be maintained? Gather information. Review laws, rules, codes of ethics, and get consultation. There are no legislative laws that address this situation, but all of the professional codes of ethics have standards that may apply. • APA Standard 3, NASW Standard 1.06, ACA Standard A.4.a, and NBCC Standard 17 all indicate that Dr. Smith has a primary obligation to Jane as her client over her own interests. She must resolve the situation in Jane’s best interest and in a way that minimizes or does no harm.
1. Identify the problem. 2. Gather information.
3. Consider the potential consequences of all options. 4. Determine a course of action and implement it. 5. Review the outcome.
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