Case Studies Illuminate Models for Ethical Decision-Making

The first FCP Behavioral Health Workshop of Spring 2021 was presented by Charles Jacob and entitled “Common Ethical Challenges for Psychotherapists: Applying Decision-Making Models to Case Examples.” Dr. Jacob’s expertise and experience as both a behavioral health educator and clinician and his congenial presentation style made this topic interesting and informative. The 3-hour presentation seemed to go by quickly. He appeared very comfortable in the virtual workshop format mandated by Covid-19.

The goals of today’s workshop included the participant’s ability to:

• Discuss current ethical standards as well as relevant decision-making models
• Analyze and describe the efficacy of decision-making models to case examples
• Discuss recent research related to the ethical decision-making of practicing clinicians

In general, all goals were met. As in the past, I felt bad for those seeking “Act 48” credits due to the need to both follow the workshop and, simultaneously synthesize the material to answer the questions on the assessment. To some extent, the flow of the presentation is hindered due to the questions asked. For example, I had trouble focusing on the third bullet point addressing specific research related to ethical decision making of practicing clinicians. Perhaps the workshop goals and questions could be highlighted by the presenter during the presentation.

Dr. Jacob spent a few minutes setting the stage for his presentation on ethics by talking about current trends and recent cases in ethics complaints to insurance companies and sanctions by State Boards. He said that the largest number of complaints to insurance companies was still sexual and romantic relationships with clients and noted that the trend is increasing in recent years. Dr. Jacob said that there are also increasing complaints against female clinicians in recent years. Among other complaints and sanctions included competency, confidentiality, failure to meet continuing education requirements, and inappropriate dual relationships (usually financial). Dr. Jacob also presented a case of fabrication in a research study as an example of an ethical breach. He noted that “Telehealth” is here to stay but ethics consideration for this practice are still being defined.

The Six Principles of Ethics as presented by Dr. Jacob include:

1. Autonomy (Clients right to choose own path)
2. Beneficence (Do no harm)
3. Non-maleficence (Be helpful)
4, Justice (Be fair/nonjudgmental)
5. Veracity (Be truthful and honest)
6. Fidelity (Be loyal to the client)

Dr. Jacob also presented 8 decision making models. Although the elements are similar, each model had a unique theme. These were discussed in no particular order.
The first model presented was the “Forrester-Miller and Davis Ethical Decision -Making Model.” This model uses 7 steps to help identify the problem and the relevant ethics code to analyze the problem, consider consequences, and implement a course of action. Dr. Jacob said that this is a common “general” model used by practitioners.

Dr. Jacob presented “Cottone’s Social Constructivist Model of Ethical Decision Making” as a more interpersonal approach. This model involves for steps and utilizes negotiation and consensus with clients in decision making. Dr. Jacob pointed out that this model represents that there are no absolute truths in ethical decision making.

The “Ling and Hauck’s ETHICS Model” uses the acronym E.T.H.I.C.S:

  • Evaluate the Dilemma
  • Think Ahead
  • Help
  • Information
  • Calculate Risk
  • Select an Action

This model considers morality and the context of the dilemma requiring a decision.

Dr. Jacob presented the “Corey, Corey, Corey, and Callanan Model of Decision Making” as an 8 step model that stresses careful review of ethics codes, laws, and regulations along with consultation as part of the press.

The “Garcia, Cartwright, Winston, and Borzuchoska’s Transcultural Integrative Model” relies on cultural context as a central feature. Dr. Jacob said that this model is somewhat more labor intensive than the others.

An ethical decision-making model that focuses on use of instincts and addresses power gradients between clinicians and clients is the “ Hill, Glaser, & Harden Feminist Model.” This 1998 model has 6 elements that can be used in no particular order and emphasizes the client’s determination of what constitutes success.

The final two models of decision making presented by Dr. Jacob focus on insight and self-evaluation of the clinician.

The “Counselor’s Value Based Conflict Modal Approach” (Kocet & Herihy, 2014) is a 5-step model that encourages the clinician to examine internal conflict as part of the decision-making process.

Finally, Dr. Jacob reviewed “Jacob, Roth, Cilento and Stole’s (2015) Model” which is uses 5 steps for the clinician to be aware of ”bias hotspots” and “ripping points” when making ethical decisions.

Much of the remaining time during Dr. Jacob’s presentation included case presentations on a variety of topics. Each case example was specific to a topic, with a discussion of general considerations and brief application of a particular decision-making model. A few of these are mentioned below.

The first case-study focused on the counseling relationship. This example highlighted a dilemma faced by a counselor who had a personal bias that differed from the values of the institution where employed and a client contemplating a difficult life decision contrary to the facility values. Dr. Jacob’s discussed this case applying the “Forrster-Miller and Davis’ Ethical Decision -Making Model.” He emphasized the need for the clinician to apply the relevant code of ethics and consider all potential consequences to resolve the conflict of values before implementing any course of action. Dr. Jacob also raised the question of the clinician working at a facility where a strong conflict of values occurred, and the need to focus on the client. The clinician must avoid intentionally or inadvertently imposing personal values on the client.

Using the same decision-making model, Dr. Jacob presented a case where a clinician was faced with a revelation by a long-term client that conflicted with personal values to the point where termination was considered. In this case study, two possible courses of action were determined through application of the model, based on the clinician’s professional identification. The ethical choices were referring the client to another clinician or seeking supervision and training to continue with the client. Dr. Jacob pointed out that since 2014, The American Counseling Association code of ethics does not allow termination of a clinical relationship due to discomfort with a topic presented by a client. The licensed counselor would be advised to seek supervision and training rather than terminate the client for this reason alone. On the other hand, the American Psychological Association Code of Ethics would permit a licensed psychologist to help the client find a more compatible clinician if personal conflict warranted termination. Either professional association code of ethics would permit termination and referral if the clinician did not feel competent to provide therapy due to the nature of the topic if training and supervision was not a practical solution.

Another case study presented by Dr. Jacob addressed a request for information from parents for a minor child. This was complicated by the child turning 14 during therapy and the request included records of sessions before then. Dr. Jacob pointed out that the State regulations allowed the 14-year-old child to have control of confidentiality even with a parent request. Using Cottone’s Social Constructivist Model, Dr. Jacob emphasized the need to understand the parent as a person. Empathy should be considered to find out what the mother hopes to gain by obtaining the records. Dr. Jacob mentioned that this model encourages interpersonal interaction and negotiation in ethical decision making. He suggested having the child invite his mother to a session to discuss her concerns and striving for consensus for resolution.

Among the remaining case studies presented by Dr. Jacob was the use of public social media by clinicians. Using the “Counselor’s Value Based Conflict Model Approach,” Dr. Jacob discussed a clinician who was mentioned with his family in a friend’s social media post. One of his clients made mention of following this person’s social media posts and referenced the page to the clinician. Aside from the possible need to discuss this issue in therapy with the client, the nature of the conflict was addressed using the ethical decision-making model. There was no ethical code violated but the clinician felt that personal privacy was violated as the core issue. In this model the clinician is encouraged to process the feelings in supervision. Violation of the client’s rights or offending the friend were to be considered. The clinician’s best choice was to ask the friend to remove personal references and information from the posts to protect personal privacy.

Throughout the presentation, Dr. Jacob mentioned specific research studies that supported use and development of decision-making models for ethical decisions. There was not a specific section for research as part of this workshop.

Overall, Dr. Jacob’s workshop was satisfying despite the virtual format required by the pandemic. I look forward to the future when he can present to an in-person audience to allow a lively discussion of the cases presented.

I can usually tell a good ‘ethics” workshop by how guilty I feel afterwards, because I am not using all the elements in my practice that were discussed. I know that Dr. Jacob’s presentation was thorough because of all the work I need to do. Perhaps that why we need frequent trainings as reminders to stay on task. Dr. Jacob is welcome to return as an “ethics” reminder for future FCP workshops.

What did you think about today’s workshop?

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