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 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: 3. Consider the potential consequences of all options. 4. Determine a course of action and implement it. 5. Review the outcome. 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 cognitive 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 1. Identify the problem. 2. Gather information. 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 ongoing 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
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. 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. ● APA Standard 4, NASW Standard 1.07, ACA Standard B.1.c, and NBCC Standard 19 state that Dr. Smith has an obligation to protect Jane’s confidentiality. This would be difficult in this situation. Consistent social interaction may prevent her from staying objective in her treatment with Jane. Jane is still an active client, and though she has made progress in therapy, she has not yet reached their agreed upon goal. ● APA Standard 10, NASW Standard 1.06, ACA Standard A.11.c, and NBCC Standard 22 state that therapy should be terminated if the client could be harmed by continued services. Is that the case here? Is this an avoidable multiple relationship? What is the potential for inappropriate therapist transparency and self-disclosure in social settings? Identify potential courses of action. a. Dr. Smith could do nothing and continue as is both professionally and socially. b. Dr. Smith or Jane could find a new church. c. Dr. Smith and/or Jane could resign from the committee but continue church attendance. d. Therapy could be terminated and Jane referred to another therapist. e. Therapy could be terminated without referral. Consider the potential consequences of actions, determine a course of action, and implement it . Dr. Smith discussed the ethical issue and her concerns with Jane at their next therapy session since the client should be actively engaged in the decision-process when a boundary crossing is considered. Would it be possible to continue with therapy and not interact socially? What would be the consequence of terminating therapy? Is it in the client’s best interest to terminate therapy? Did Jane know that Dr. Smith was on that particular committee? If so, what was Jane’s motivation for volunteering on it? ● Dr. Smith voiced her discomfort with the potential self- disclosure and her difficulty remaining objective in therapy if the choice was to do nothing. She felt that the choice to do nothing had too much risk to do harm. ● Neither wanted to find a new church since this was the only one of that denomination within a reasonable distance and both were very comfortable there. However, the risk of accidental disclosure was great if they continued on the same committee. ● If therapy was prematurely terminated, there was the potential for Jane’s panic episodes to increase in frequency and again become debilitating.
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Book Code: SWUS1524B
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