Ethical Dilemas

A review of Ethical Dilemma # 1 presents several issues to consider; the first being the counselor’s initial decision to meet with John, sans Phyllis. Section 3.05 of the American Psychological Association’s (APA) Ethical Standards defines a multiple relationship as one that “occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person . . .” (2002). The mere act of meeting with John independently, in effect, created a multiple relationship. Further, Section 10.02 of the APA’s Ethical Standards, which discusses therapy involving couples or families, mandates that “when psychologists agree to provide services to several persons who have a relationship, they take reasonable steps to clarify at the outset (1) which of the individuals are clients/patients, and (2) the relationship the psychologist will have with each person” (2002). Section A.7 of the American Counseling Association’s (ACA) Code of Ethics also speaks to this issue in mandating that “when a counselor agrees to provide counseling services to two or more persons who have a relationship, the counselor clarifies at the outset which person or persons are clients and the nature of the relationships the counselor will have with each involved person” (2005).

Thus, according to the standards of both the APA and the ACA, the counselor should have discussed the dynamics of the working relationship with both John and Phyllis at the outset of the counseling relationship, and made it clear that meeting with them separately would be inappropriate. Assuming this was the case, the counseling relationship with John and Phyllis would have been defined as a triad, not a dyad; therefore, to meet with John independently is a breech of their initial “contract;” so to speak. Section 10.02 of the APA’s Ethical Standards further states that a psychologist “refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists” (APA, 2002).

This brings the principle of fidelity, which states that counselors must “seek to manage conflicts of interest that could lead to exploitation or harm” (APA, 2002), to the table, as meeting with John independently could leave Phyllis feeling a sense of betrayal when she learns of the dual relationship; thus causing her to lose faith in the therapeutic relationship, and ultimately creating psychological harm. Additionally, Section A.5.e. of the ACA’s Code of Ethics mandates that “when a counselor changes a role from the original or most recent contracted relationship, he or she obtains informed consent from the client and explains the right of the client to refuse services related to the change.” This section specifically addresses a change “from individual to relationship or family counseling; or vice versa,” and further requires that the counselor inform the client of any anticipated consequences of such a change (ACA, 2005); therefore, the counselor was in violation of this code when he or she agreed to meet with John, independent of Phyllis, without obtaining Phyllis’s informed consent, and also in not informing John of the potential consequence a private consultation may have on the therapeutic relationship that had been established between the three of them.

The ethical soundness of the counselor’s decision to meet with John, independent of Phyllis, notwithstanding, there are other ethical dilemmas to contemplate in this situation. Specifically, whether or not the counselor should divulge John’s past abusive behavior to Phyllis. Section B.2.a. of the ACA Code of Ethics speaks to both sides of this issue, stating that counselors are to keep information confidential; however, this does not apply when “disclosure is required to protect clients or identified others from serious and foreseeable harm” (2005). This begs the question of whether or not John’s statement that he has visualized “hitting or even choking her,” constitutes “foreseeable harm” to Phyllis; or if it is merely a verbal expression of his rising frustration; with no chance of escalating to physical manifestation. In considering this dichotomy, the principle of beneficence comes into play, as it requires counselors to be proactive when conflicts arise “among psychologists’ obligations or concerns.”

According to this principle, counselors are compelled to “resolve conflicts in a responsible fashion that avoids or minimizes harm” (APA, 2002). If the counselor deems John’s statement to mean Phyllis is in “foreseeable” danger, he is compelled to take action to protect her by warning her of the potential for harm. Ultimately, if the counselor doubts the validity of the exception to confidentiality, he or she should consult with other professionals prior to taking action. Quite honestly, I’m not certain the counselor’s initial decision in this situation is defensible, unless certain assumptions are made; i.e. perhaps John advised the counselor in their telephone contact on the day in question, that he was suicidal or that he was considering hurting Phyllis, and was in need of immediate intervention.

Under such circumstance, I could appreciate the reasoning behind meeting with John independently. In closing, while I do not agree with the counselor’s initial decision to meet with John without Phyllis’s knowledge, that fact remains that the encounter did occur. Considering the reality that nothing that happens within the context of the counseling relationship is benign, consequences, be they positive or negative, are inevitable, and the counselor must be prepared to accept responsibility not only for the decision that was made, but also for the ramifications of that decision. I certainly do not believe that the counselor should continue a separate counseling relationship with John, without informing Phyllis; and truthfully, I believe the best interests of all parties would be more effectively served by the counselor referring John to someone else to deal with his individual issues.

References

American Counseling Association. (2005). Code of Ethics.
http://www.counseling.org/Resources/CodeOfEthics/TP/Home/CT2.aspx American Psychological Association. (2002). Ethical Principles of Psychologists and Code of Conduct. http://www.apa.org/ethics/

Example Response 2 to Ethical Dilemma 1
Dear supervisory board,
A recent case in couples therapy led to some challenging ethical issues. The husband called wanting an emergency private appointment. During the appointment he told of repeated prior partner abuse, an arrest related to his abusive behavior, and visions of hurting his current partner who knew nothing of his past. I wish to share with you my thinking and examination of ethical codes in this case. I have cited each potential ethical dilemma and specific ACA codes of ethics to consider.

1) Should a counselor allow a client to schedule an individual appointment separate from the joint marital counseling sessions? 2) Did the history of repeated abuse history and past arrest play a part in the ethical decisions in this case? 3) Did the wife have a right to know about her husband’s past and about the present statements made by her husband? 4) How important were the frustrations and visualizations expressed by the client to the situation? 5) The client requested confidentiality. How should the therapist respond? 6) The client wanted to continue meeting as an individual client. Was this ethically possible? 2005 ACA Code of Ethics:

A.1.a. Primary Responsibility. When the client called needing an emergency session the counselor sensed immediacy in the situation. The counselor respected the client’s dignity and hoped to promote the welfare of the client. A.4.a. Avoiding harm. The information about the client’s past including repeated offenses and an arrest may have been important when interpreted with current feelings and behaviors. The counselor must act to avoid harm of clients or others in danger. The wife had a right to know information about her husband’s session if she was at risk of being harmed. Growing frustration that led to the emergency meeting implied that the client wanted help. A.5.e. Role Changes in the Professional Relationship. Roles can change from relationship to individual counseling, but the counselor must obtain a new informed consent and explain to the client his rights and any anticipated consequences. After giving a clear explanation, the counselor should have made sure that the client understood all potential consequences intelligently and emotionally.

A.7. Multiple Clients. Because two or more people received counseling and had a relationship with each other, the counselor should have clarified the nature of the relationship with each client. The roles may have needed to be adjusted if the counselor was called on to perform potentially conflicting roles. The change from couples to individual counseling could have put the therapist in a conflicting role. The counselor may or may not have chosen to see the individual separately. B.1.d. Explanation of Limitations. At the beginning and throughout the counseling process the limits of confidentiality should have been explained. There may have been foreseeable situations in the future where confidentiality may have had to been breached. Switching from couples therapy to individual therapy may have been one of those foreseeable times and should have been thoroughly covered during ongoing informed consent. B.2.a. Danger and Legal Requirements.

The general requirement that counselors keep information confidential would not apply when disclosure is required to protect clients from serious harm or when the information must legally be revealed. B.2.d. Minimal Disclosure. If the counselor decided to inform the wife of her husband’s individual counseling session and the potential risk to her, he should have first told the husband of his intension and encouraged the husband to be involved in the disclosure process. Hopefully, the spouse would tell her either on his own or with the help of the counselor. If he still would not tell on his own, the counselor should tell the wife and reveal only the minimal information necessary. C.2.a. Boundaries of Competence. The counselor should only have both group sessions and individual sessions if he felt he is competent to counsel with these parameters. Summary

After reviewing the ACA code of ethics, I feel that the counselor should have seen the husband separately out of respect for the client’s feelings because he felt that there was an emergency situation. However, the counselor needed to cover all items necessary in regard to informed consent as to how the relationship and rules of confidentiality were now different. Based on a risk assessment of the client’s specific plans of hitting or choking his wife, his means and opportunity, and his previous history of violence, I believe the counselor had the ethical obligation to inform the wife. Though the client thought he had no intention of hurting her. In addition there was an identified person at risk and the client was facing an increased stress level at work.

After weighing the risks and costs the counselor must act with beneficence toward the wife. The counselor must uphold fidelity or truthfulness to the counseling profession. The Tarasoff case set the precedent that beneficence overrides confidentiality when there is a duty to warn someone of danger. The client should be consulted as to how best inform the spouse so as to trust the client’s autonomy, empower the client and not betray him. However, if the client will not consent to tell the spouse, the counselor should do so. Future sessions with just the husband should be discussed as an option during couples therapy. The counselor may conduct simultaneous couple and individual counseling if this was within his expertise. As an act of benevolence to the husband, the counselor should have arranged for some type of individual therapy for the husband if he still wanted it. Sincerely,

Example Response 3 to Ethical Dilemma 1
In response to the ethical dilemma provided there are a number of issues that may possibly come up violating the code of ethics. I am not able to identify all the ethical issues that may come up, being a first year Master’s student and new to the code of ethics. The major ethical issues I came across concerned the informed consent, dual relationships, duty to warn and protect, and the responsibility to refer.

The counselor met with the client and his wife in marriage counseling for three sessions and in the first session or pre-session he should have had them sign an informed consent. The informed consent should have lined up a treatment plan for the couple. In the text Counseling Ethics and Decision Making by Cottone and Tarvydas (2007) it is noted that in the informed consent alternative treatments or alternatives to treatment should be addressed (p. 40). If the “alternative treatment” did not state that the couple would meet with the counselor separately to discuss their relationship issues the counselor has entered into a dual relationship. A dual relationship by definition according to Cottone and Tarvydas (2007) is a relationship in addition to the contracted counseling relationship (p. 35).

This particular issue stated that the husband called for an “emergency appointment” showing that this had not been agreed upon. Cottone and Tarvydas (2007) also note in their text that when a counselor changes role from the original or most recent contracted relationship, he or she obtains an informed consent form from the client…it later goes to state that an example of a role change would be changing from an individual to relationship or family counseling or vice versa (p. 39). The fidelity of the wife in the relationship was violated because by entering into a dual relationship with the husband the counselor went against the informed consent, therefore not being loyal, honest, or keeping the promise (Cottone & Tarvydas, 2007, p. 26). During the private session with the client a major ethical dilemma arose.

The client disclosed to the counselor during their private session that in the past he repeatedly and emotionally abused his partner and recently visualized hitting and even choking his wife. In this situation the counselor has a duty to warn and protect the spouse of this client because under the code of ethics he has to inform endangered individuals of an identifiable threat (Cottone & Tarvydas, 2007, p. 31). Even though the client says that he is over his desire to hurt anyone it is prudent that the wife is informed because he did not make a general statement about visualizing hurting her but he made a clear and distinct visualization of exactly what he would do to her. Another ethical dilemma arose when the client was very adamant about his wife not knowing of his past and wanting to meet for additional sessions.

Additional sessions were requested by the client to discuss his personal issues exclusive of his wife. In this case the counselor should not agree to further meet with him and refer out to remain from entering into a harmful dual relationship. Meeting with the client outside of the marriage counseling could harm the relationship between the three because he would be more likely to take a side knowing additional information concerning the husband. In the terms of Cottone and Tarvydas (2007) from the old version of the code of ethics by the American Association of Marriage and Family Therapy (AAMFT), it could “impair professional judgment or increase the risk of exploitation (as cited in AAMFT, 1991, p. 35). Although this statement is outdated the current code still states that a dual relationship should be avoided when possible (Cottone & Tarvydas, 2007, p.35).

In this particular case I feel the counselor should have either referred the client to someone else or made an agreement within the informed consent to meet individually with both clients. I believe that in order to protect the client’s autonomy and confidentiality the counselor should talk to him about disclosing his past to his wife during their joint sessions and refer him to another counselor who is competent in anger management issues. The counselor is seeing the client for relationship problems concerning styles of communications and financial concerns but may not be competent in issues concerning anger management.

Even if the client does not agree to disclose this information to his wife the counselor must inform him that he has a duty to warn his wife. I feel this is a justifiable course of action because the counselor does not want to break confidentiality by talking to the wife about their meeting separate of their sessions and what was discussed. The disclosure of his past will also open up the line of communication and make her aware of any clear and present danger without breaking his confidentiality. Also the counselor needs to refer the client in order to abide by the informed consent agreed upon in the marriage counseling session and to keep himself from entering into a harmful dual relationship. I feel meeting separately with one of the clients would be detrimental to the relationship and skew the counselors feelings toward the other.

Reference

Cottone, R. R., & Tarvydas, V. M. (2007). Counseling Ethics and Decision Making (3rd ed.). Upper Saddle River, NJ: Pearson Education, Inc. Example Response 4 to Ethical Dilemma 1 Before I decided on the course of action, I considered the ACA professional standards and the law. As a counselor, I am ethically and legally responsible for the well-being of John and Phyllis in the therapeutic relationship. This means that I am obligated to maintain fidelity. I have to ensure that I respect the client’s right to privacy and confidentiality. In other words, I am obligated under the ethical standards and law to make sure that the identity of the client and communication remains confidential. However, there are some exceptions in regard to privacy and confidentiality. One of the exceptions is when clients are dangerous. I have the right to breach confidentiality when the client is dangerous to self or others (Cottone & Tarvydas, 2006).

John’s disclosure shows that he may pose a danger to his wife, Phyllis. John disclosed that he has visualized hitting and choking Phyllis. John has a past history of repeated physical and emotional abuse toward an ex-girlfriend. John said that he would not hurt Phyllis; however he is experiencing increasing frustration in his relationship. Phyllis is not aware of the circumstances and she is in close proximity to John.

According to the law, I have the duty to warn and the duty to protect my clients from any “identifiable threat” (Cottone & Tarvydas, 2006). John is confident that he will not hurt Phyllis, but he has a past history of abusing his girlfriend. He also provided details of how he envisioned abusing his wife. The details and past history of abuse cause me to view John’s disclosure as a possible threat. In court cases such as the Mahomes-Vinson v. United States and the Bardoni et al. v. Kim, “the courts considered the expression of violent fantasies to be an indication that the patients were potentially dangerous, particularly in the context of having history of violence or threatening behavior”(Gellerman & Suddath, 2005). As a counselor, I have to view the situation as a possible danger and provide protection to my client. The law states that I have the duty to protect my clients. I am obligated to go beyond warning and/or reporting. I have to ensure that the client receives the needed services in order to protect the client or another party from harm. This means that I have to increase therapy and/or refer John to another therapist in order to decrease the risk to Phyllis. Locating services will not only protect Phyllis, but it will increase John’s effort to cope.

After I considered the ethical standards and law, I concluded that I have to warn Phyllis. During the individual session with John, I will notify him that I am ethically and legally obligated to tell Phyllis. However, I will urge him to disclose his thoughts to Phyllis during therapy. If John agrees, I will set up an emergency therapy session with John and Phyllis. This will provide a safe zone for John to discuss the issue at hand. If John does not agree, I will warn Phyllis. I will also seek consultation from my supervisor in regard to the situation. In addition, I will see that John receives help in order to cope with the frustration that he is experiencing. I will refer John to a therapist who has experience in anger management. If I am unable to refer John to another therapist, I will provide therapy to John under supervision. Then, John can receive individual therapy to deal with his frustration and marriage therapy to assist him with issues in the relationship.

Work Cited

Cottone, R. R. & Tarvydas V. M. (2006). Counseling ethics and decision
making. New
Jersey: Person Education, Inc.
Gellerman, D. M. & Suddath, R. (2005). Violent fantasy, dangerousness, and duty to
warn and protect. The Journal of the American Academy of Psychiatry and the
Law, 33, 484-495, Retrieved January 22, 2007, from the ERIC database.