counselling ethical dilemma case study

Counseling Ethics Code: 10 Common Ethical Issues & Studies

Despite their potentially serious consequences, ethical issues are common, and without preparation and reflection, many might be violated unwittingly and with good intentions.

In this article, you’ll learn how to identify and approach a variety of frequently encountered counseling ethical issues, and how a counseling ethics code can be your moral compass.

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This Article Contains:

Counseling & psychotherapy ethics code explained, 7 interesting case studies, 3 common ethical issues & how to resolve them, ethical considerations for group counseling, a take-home message.

Most of us live by a certain set of values that guide our behavior and mark the difference between right and wrong. These values almost certainly influence how you approach your work as a counselor .

Following these values might feel natural and even intuitive, and it might feel as though they don’t warrant closer examination. However, when practicing counseling or psychotherapy, working without a defined counseling code of ethics is a bit like sailing a ship without using a compass. You might trust your intuitive sense of direction, but more often than not, you’ll end up miles off course.

Fortunately, there are a variety of professional organizations that have published frameworks to help counselors navigate the challenging and disorienting landscape of ethics.

Members of these organizations are often recommended or required to adhere to a framework, so if you belong to one of them and you’re not familiar with their respective code of ethics, this should be your first port of call. However, these ethical frameworks are also often available online for anyone to read, and so you don’t need to join an organization to adhere to its principles.

Each organization takes a slightly different approach to their code of ethics, so you may find it useful to view several to find one that resonates best with your practice. As an example, the British Association of Counselling and Psychotherapy (2018) has a framework that emphasizes aspiring to a variety of different values and personal moral qualities.

Those values include protecting clients, improving the wellbeing and relationships of others, appreciating the diversity of perspectives, and honoring personal integrity. Personal moral qualities include courage, empathy , humility, and respect.

These values and qualities are not meant to be strict criteria, and there is no wholly objective way to interpret them. For example, two counselors might display the same legitimate values and qualities while arriving at different conclusions to an ethical problem. Instead, they reflect a general approach to how a counselor should think about ethics.

Nevertheless, this approach to ethics may be overly prescriptive for you, in which case a looser and more general framework may be better suited to the nature of your practice. Most professional organizations recognize this, and there is a set of foundational principles that feature widely across different frameworks and refine the collection of different values and qualities described above into simpler terms.

These principles are autonomy , beneficence, non-maleficence, fidelity, justice, veracity, and self-respect (American Counseling Association, 2014; British Association for Counselling and Psychotherapy, 2018). They are largely consistent across frameworks aside from some minor variations.

• Autonomy is the respect for a client’s free will.
• Beneficence and non-maleficence are the commitment to improve a client’s wellbeing and avoid harming them, respectively.
• Fidelity is honoring professional commitments.
• Veracity is a commitment to the truth.
• Justice is a professional commitment to fair and egalitarian treatment of clients.
• Self-respect is fostering a sense that the counselor is also entitled to self-care and respect.

Putting these principles into practice doesn’t require a detailed framework. Instead, as the British Association for Counselling and Psychotherapy (2018) recommends, you can simply ask yourself, “ Is this decision supported by these principles without contradiction? ” If so, the decision is ethically sound. If not, there may be a potential ethical issue that warrants closer examination.

Regardless of whether you navigate using values, qualities, or principles, it’s important to be prepared for how they might be challenged in practice. As explained above, these are not intended to be strict criteria, and it’s good to foster a healthy amount of flexibility and intuition when applying your ethical framework to real-life situations.

You might also interpret challenges to other principles. There is no correct or incorrect interpretation to any of these cases (Cottone & Tarvydas, 2016; Zur, 2008).

For each, consider where you think the problem lies and how you would respond.

A counselor has been seeing their client for several months to work through substance use issues. A good rapport has been formed, but the client has not complied with meeting goals set during therapy and has not reduced their substance use.

The counselor feels they may benefit from referring the client to a trusted colleague who specializes in helping individuals with substance use issues who are struggling to engage with therapy. The counselor contacts the colleague and arranges an appointment within their client’s schedule.

When the client is informed, the client is upset and does not wish to be seen by the colleague. The counselor replies that rescheduling is not possible, and they should consider the appointment a necessary part of therapy.

Beneficence

A counselor working as part of a university service is assigned a client expressing issues with their body image. The counselor lacks any knowledge in working with these issues, but feels as though they may help the client, given the extent of their experience with other issues.

On reflection, the counselor decides to contact a colleague outside the university service who specializes in body image issues and asks for supervision and advice.

Non-maleficence

A counselor developing a new exposure-based form of anxiety therapy is working with a client with severe post-traumatic stress. There is promising evidence suggesting the therapy is effective for reducing mild anxiety, but it is unknown whether the therapy is effective in more extreme cases.

As a result, the counselor recognizes that this client in particular would provide a particularly valuable case study for developing the therapy. The counselor recommends this therapy to the client.

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A client with a history of depression and suicidal ideation has been engaging successfully with therapy for the last year. However, recently they have experienced an unfortunate coincidence of extremely challenging life events because of their unstable living arrangement.

The counselor has noticed problematic behaviors and thought patterns emerging, and is seriously concerned about the client’s mental health given the history.

In order to have the client moved from their challenging living environment, they decide to recommend that the client be hospitalized for suicidal ideation, despite there being no actual sign of suicidal ideation and their client previously expressing the desire to avoid hospitalization.

A school counselor sees two students who are experiencing stress regarding their final exams. The first is a high-achieving and popular student who is likable, whereas the second is a student with a history of poor attendance and engagement with their education.

The counselor agrees that counseling is appropriate for the first student, but recommends the second student does not attend counseling, instead addressing the “transient” exam stress by directing their energy into “working harder.”

A counselor is assigned a teenage client after both the client and their family consent to therapy for issues with low mood. After the first session together, it is apparent that the client has been withholding information about their mental health from their family and is showing symptoms typical of clinical depression.

The counselor knows that their client is a high-performing student about to enter a prestigious school and that the client’s family has high hopes for the future. The counselor reassures the family that there is no cause for serious concern in order to protect them from facing the negative implications of the client’s condition.

Self-interest

A counselor is working with a client who is a professional massage therapist. The client offers a free massage therapy session to the counselor as a gesture of gratitude. The client explains that this is a completely platonic and professional gesture.

The counselor has issues with close contact and also feels as though the client’s gesture may not be entirely platonic. The counselor respectfully declines the offer and suggests they continue their relationship as usual. However, the client discontinues therapy abruptly in response.

Ethics in counseling

Ethical issues do not occur randomly in a vacuum, but in particular situations where various factors make them more likely. As a result, although ethical issues can be challenging to navigate, they are not necessarily difficult to anticipate.

Learning to recognize and foresee common ethical issues may help you remain vigilant and not be taken unaware when encountering them.

Informed consent

Issues of consent are common in therapeutic contexts. The right to informed consent – to know all the pertinent information about a decision before it is made – is a foundational element of the relationship between a counselor and their client  that allows the client to engage in their therapy with a sense of autonomy and trust.

In many ways, consent is not difficult at all. Ultimately, your client either does or does not consent. But informed consent can be deceptively difficult.

As a brief exercise, consider what “informed” means to you. What is the threshold for being informed? Is there a threshold? Is it more important to be informed about some aspects of a choice than others? These questions do not necessarily have a clearcut answer, but nevertheless it is important to consider them carefully. They may determine whether or not your client has given sufficient consent (West, 2002).

A related but distinct challenge to informed consent is that it is inherently subjective. For example, your client may have as much knowledge about a decision as you do and feel as though they fully understand what a decision entails. However, while you have both experience and knowledge of the decision, they only have knowledge.

That is to say, to some extent, it is not possible for your client to be informed about something they have not actually experienced, as their anticipated experience based on their knowledge may be wholly different from their actual experience.

The best resolution to these issues is to avoid treating informed consent like a checkbox that needs to be satisfied, where the client is required to ingest information and then give their consent.

Instead, encourage your client to appreciate the importance of their consent, reflect on their decision, and consider the limitations of their experience. In doing so, while they may not be able to become fully informed in an objective sense, they will achieve the nearest approximation.

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Termination of therapy

Another time of friction when ethical issues can surface is at the conclusion of therapy , when the counselor and client go their separate ways. When this termination is premature or happens without a successful resolution of the client’s goals, it is understandable why this time is difficult.

This can be a challenging transition even when therapy is concluded after a successful result. Like any relationship, the one between a counselor and client can become strained when the time comes for it to end.

Your client may feel uncertain about their ability to continue independently or may feel rejected when reminded of the ultimately professional and transactional nature of the relationship (Etherington & Bridges, 2011).

A basic preemptive action that can be taken to reduce the friction between you and your client during this time is ‘pre-termination counseling,’ in which the topic of termination is explicitly addressed and discussed.

This can be anything from a brief conversation during one of the concluding appointments, to a more formal exploration of termination as a concept. Regardless, this can give your client the opportunity to acclimatize and highlight any challenges related to termination that may be important to explore before the conclusion of therapy.

These challenges may involve features of your client’s background such as their attachment history, which may predispose them toward feelings of abandonment, or their experience of anxiety, which may influence their perceived ability to cope independently after therapy.

If you already have knowledge of these features of your client’s background, it may be worth considering these potential challenges well in advance of the termination of therapy.

Online counseling

Remote forms of therapy are becoming increasingly common. This has many obvious benefits for clients and counselors alike; counseling is more accessible than ever, and counselors can offer their services to a broad and diverse audience. However, online counseling is also fraught with commonly encountered ethical issues (Finn & Barak, 2010).

As remote practice frequently takes place outside the structured contexts more typical of traditional counseling, ethical issues commonly encountered in online counseling are rooted in this relative informality.

Online counseling lacks the type of dedicated ethical frameworks described above, which means e-counselors may have no choice but to operate using their own ethical compass or apply ethical frameworks used in traditional counseling that may be less appropriate for remote practice.

Research suggests that some online counselors may not consider the unique challenges of working online (Finn & Barak, 2010). For example, online counselors may feel as though they do not have the same responsibility for mandatory reporting, as their relationship with their clients may not be as directly involved as in traditional counseling.

For online counselors who are aware of their duty to report safeguarding concerns, the inherent anonymity of online clients may present a barrier. Anonymity certainly has the benefit of improved discretion, but it also means a counselor may be unable to identify their client if they feel they are threatened or otherwise endangered.

Online counselors may also be unclear regarding the limits of their jurisdiction, as qualifications or professional memberships attained in one region may not be applicable in others. It can often seem like borders do not exist online, and while to some extent this is true, it is important to respect that jurisdictions exist for a reason, and it may be unethical to take on a client who you are not licensed to work with.

If you work as an e-counselor, the best way to resolve or preemptively prepare for these issues is to acknowledge they exist and engage with them. A good place to start may be to develop a personal framework for your practice that has a plan for issues of anonymity and confidentiality, and includes an indication of how you will report safeguarding concerns.

In a group setting, clients may no longer feel estranged from society or alone in their challenges, and instead view themselves as part of a community of people with shared experiences.

Clients may benefit from insights generated by other group members, and for some individuals, group counseling may literally amplify the benefits of a one-to-one approach.

However, group settings can also bring unique ethical issues. Just as some groups can bring out the best in us, and a therapeutic context can foster shared insights, other groups can become toxic and create a space in which counter-therapeutic behaviors are enabled by the implicit or explicit encouragement of other group members.

Similarly, just as some group leaders can inspire others and foster a productive community, it is also all too easy for group leaders to become victims of their status.

This is true for any relationship in which there is an inherent imbalance of power, such as traditional one-to-one practice, but in a group context, the counselor is naturally invested with a greater magnitude of influence and responsibility. This can lead to the judgment of the counselor becoming warped and increase the risk of overstepping ethical boundaries (Mashinter, 2020).

As a group counselor, first and foremost, you should foster a diligent practice of self-reflection to ensure you are mindful of the actions you take and remain alert to any blind spots in your judgment.

If possible, it may also be useful to examine ethical issues related to your authority by referring to another authority, in the form of supervision with one of your colleagues.

Finally, to prevent counter-therapeutic dynamics from developing within your group of clients, it may be useful to develop a clear code of conduct that emphasizes a commitment to group beneficence through mutual respect (Marson & McKinney, 2019).

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Take a structured approach to preparing for and dealing with ethical issues, whether this is referring to a framework published by a professional organization or simply navigating by a set of core values.

Prepare for the most common types of ethical issues, while also keeping an open mind to the often complex nature of ethics in practice, as well as the specific ethical issues that may be unique to your practice. Case studies can be a useful tool for doing this.

If in doubt, refer to these five steps from Dhai and McQuiod-Mason (2010):

• Formulate the problem.
• Gather information.
• Consult authoritative sources.
• Consider the alternatives.
• Make an ethical assessment.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

• American Counseling Association. (2014). Ethical & professional standards . Retrieved July 22, 2021, from https://www.counseling.org/knowledge-center/ethics
• British Association for Counselling and Psychotherapy. (2018). BACP ethical framework for the counselling professions . Retrieved from https://www.bacp.co.uk/events-and-resources/ethics-and-standards/ethical-framework-for-the-counselling-professions/
• Cottone, R., & Tarvydas, V. (2016). Ethics and decision making in counseling and psychotherapy . Springer.
• Dhai, A., & McQuoid-Mason, D. J. (2010). Bioethics, human rights and health law: Principles and practice . Juta and Company.
• Etherington, K., & Bridges, N. (2011). Narrative case study research: On endings and six session reviews. Counseling and Psychotherapy Research , 11 (1), 11–22.
• Finn, J., & Barak, A. (2010). A descriptive study of e-counselor attitudes, ethics, and practice. Counseling and Psychotherapy Research , 10 (4), 268–277.
• Marson, S. M., & McKinney, R. E. (2019). The Routledge handbook of social work ethics and values . Routledge.
• Mashinter, P. (2020). Is group therapy effective? BU Journal of Graduate Studies in Education , 12 (2), 33–36.
• West, W. (2002). Some ethical dilemmas in counseling and counseling research. British Journal of Guidance & Counselling , 30 (3), 261–268.
• Zur, O. (2008). Bartering in psychotherapy & counseling: Complexities, case studies and guidelines. New Therapist , 58 , 18–26.

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I appreciated your insight on the autonomy of the client, and this article was a great help for me in my master’s program and things to consider as I choose the right path for practice.

I enjoyed the lessons

I was recently at a social gathering where a former chemical dependency group counselor also attended. I tried to be polite, however I felt stalked. I was speaking with another person at the event, and he was within earshot of the conversation and hijacked my intent and the conversation. I had to literally seek an escape route. Before the event was over, he knocked my food from my plate and then ran to take the seat intended for me. This person knew that I am a retired professional and had access to my mental and physical health files. To say I was triggered is an understatement. What else could I have done in the moment to protect my psyche from the collateral damage that his inappropriate behaviors caused me? Is there any recourse? Do I now have to avoid the venue for fear he may show up there again and harass me further? Thank you in advance for your prompt attention.

I’m truly sorry to hear about your distressing experience. No one should ever feel cornered or unsafe, especially in social settings. In the moment, prioritizing your safety and well-being is paramount. If you ever find yourself in a similar situation, consider:

– Seeking Support : Approach a trusted friend or event organizer to stay with you, making it less likely for the individual to approach. – Setting Boundaries : Politely yet firmly assert your boundaries if you feel safe to do so. Let the person know their behavior is unwelcome. – Seeking Professional Advice : Consider discussing the situation with a legal professional or counselor to understand potential recourse.

Remember, you have every right to attend venues without fear. If you’re concerned about future encounters, perhaps inform the venue’s management about your experience.

Warm regards, Julia | Community Manager

Thanks for the reminder that group counseling is also a whole different thing compared to a more typical counseling session. I’d like to look for professional counseling services soon because I might need help in processing my grief. After my dog died a month ago, it’s still difficult for me to get on with my life and get on with life normally.

https://www.barbarasabanlcsw.net/therapy-with-me

Thanks the topic is well explained have learnt alot from it

Very informative article. I particularly enjoyed the case studies on the ethical principles

Thanks a lot

Ngini Nairobi, Kenya

very useful article .thank u very much. from… Sri Lanka

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Embodied Ethical Decision-Making: A Clinical Case Study of Respect for Culturally Based Meaning Making in Mental Healthcare

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• Published: 15 January 2021
• Volume 43 , pages 36–63, ( 2021 )

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How does embodied ethical decision-making influence treatment in a clinical setting when cultural differences conflict? Ethical decision-making is usually a disembodied and rationalized procedure based on ethical codes (American Counseling Association, 2014; American Dance Therapy Association, 2015; American Mental Health Counseling Association, 2015) and a collective understanding of right and wrong. However, these codes and collective styles of meaning making were shaped mostly by White theorists and clinicians. These mono-cultural lenses lead to ineffective mental health treatment for persons of color. Hervey’s (2007) EEDM steps encourage therapists to return to their bodies when navigating ethical dilemmas as it is an impetus for bridging cultural differences in healthcare. Hervey’s (2007) nonverbal approach to Welfel’s (2001) ethical decision steps was explored in a unique case that involved the ethical decision-making process of an African-American dance/movement therapy intern, while providing treatment in a westernized hospital setting to a spiritual Mexican–American patient diagnosed with PTSD and generalized anxiety disorder. This patient had formed a relationship with a spirit attached to his body that he could see, feel, and talk to, but refused to share this experience with his White identifying psychiatric nurse due to different cultural beliefs. Information gathered throughout the clinical case study by way of chronological loose and semi-structured journaling, uncovered an ethical dilemma of respect for culturally based meanings in treatment and how we identify pathology in hospital settings. The application of the EEDM steps in this article is focused on race/ethnicity and spiritual associations during mental health treatment at an outpatient hospital setting. Readers are encouraged to explore ways in which this article can influence them to apply EEDM in other forms of cultural considerations (i.e. age) and mental health facilities. The discussion section of this thesis includes a proposed model for progressing towards active multicultural diversity in mental healthcare settings by way of the three M’s from the relational-cultural theory: movement towards mutuality, mutual empathy, and mutual empowerment (Hartling & Miller, 2004).

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Embodied ethical decision-making (EEDM) can effectively influence treatment in a clinical setting when cultural differences conflict. Professional ethics are the standards of care and rules that govern the expectations for professionals, protect patients from harm, and guide ethical decision-making when faced with an ethical dilemma (Welfel, 2016 ). The two determinants of ethical decision-making are biological make-up and cultural norms (Ayala, 2010 ). Biological make-up includes our capacity to 1. Anticipate consequences of actions taken; 2. Make valuable judgments; and 3. Possess the ability to choose between courses of action (Ayala, 2010 ). Cultural norms are learned standards based on our shared experiences with family, friends, school systems, and other social environments (Sieck, 2019 ). Typically cultural norms of dominant cultures and are used to assist therapists with decision-making when faced with ethical dilemmas (Laws & Chilton, 2013 ).

Ethical decision-making is usually a disembodied and rationalized procedure based on ethical codes and a collective understanding of right and wrong. Trahan and Lemberger ( 2014 ) recognized that professional ethics codes are incomplete when considering underrepresented populations. Many studies have provided examples that point to insufficient measures taken in academic settings to address cultural competency, therefore producing counselors, psychologists, doctors, and nurses who are inadequately culturally sensitive and ignore cultural complexities (Alqahtani & Altamimi, 2015 ; Carmichael, 2012 ; Harris, 2016 ; Hebenstreit, 2017 ; Laws & Chilton, 2013 ; McEldowney & Connor, 2011 ; Dominguez, 2017; Wadley, 2016 ). The underlying somatic and intuitive constructs of our cultural norms, morals, and values are what guide our ethical decisions (Robson, Cook, Hunt & Alred, 2000 ). Hervey ( 2007 ) positioned that we can enhance the ethical decision making process by shifting from a rule-based approach to an embodied approach to address dilemmas in a more effective manner.

The purpose of this clinical case study was to explore how Hervey’s ( 2007 ) EEDM steps influenced ethical decision-making when cultural differences conflicted during treatment for a spiritual Mexican–American patient. My intersectional identities as an African-American, non-heterosexual woman have inspired my ambition towards creating change within healthcare systems. Healthcare systems have a long history of creating unsafe environments for people with diverse cultural identities; consequently the construct of cultural safety was established in the 1980′s in an effort to protect people of color from these harmful practices (McEldowney & Connor, 2011 ).

Embodied Ethical Decision-Making

As movers and body-based practitioners, it is difficult to ignore the intelligence held within the body. To explore knowledge surfacing from the body during an ethical dilemma grants vital data and, “using the body as a teacher puts the mover in charge of the process” (Goldman, 2004 , p. 131). It further allows us to use our body for inter-affectivity and empathetic understanding (Schmidsberger & Loffler-Stastka, 2018 ), thereby experiencing and sensing the perspectives of other individuals. Hervey outlined Welfel’s ( 2001 ) nine ethical decision-making steps and paired them with corresponding embodiment suggestions collected from roughly 80 dance/movement therapists and student participants (Table 1 ). These participants attended Hervey’s EEDM workshops, and from there, she analyzed the records of their movement responses and rationales to hypothesized ethical dilemmas (Hervey, 2007 ). I included these movement suggestions from the participants for each step in this article to provide readers with movement stimulating recommendations that may be helpful while engaging in the ethical steps as they were for me. At the time of Hervey’s ( 2007 ) article, Welfel ( 2001 ) identified nine ethical decision-making steps to thoroughly guide counselors in the process of making ethical decisions. In 2012, Welfel added an extra step that includes clarifying socio-cultural contexts of the dilemma. However, since this article is embedded with cultural context, I encourage readers to consider socio-cultural contexts for their patient, the situation, and themselves throughout the entire ethical decision-making process, and how one’s cultural lens can further deepen the movement suggestions presented by Hervey ( 2007 ).

Clinical Case

The case where the ethical dilemma arose involved a Mexican–American male patient, Juan. (Juan is a pseudonym used to protect this patient’s privacy.) Juan hesitantly disclosed having a spirit attached to his right shoulder that he could regularly see, feel, and talk to. Juan was being treated in an urban outpatient hospital facility for generalized anxiety disorder and post-traumatic stress disorder (PTSD), which involved individual therapy and medication management. Neighboring communities that the hospital served were made up of majority Latino and African American identifying populations. As reported by the Chicago Community Trust ( 2018 ), social and economic resources are historically and unjustly distributed in this area, and have resulted in health inequities that nearly three times the well-being concerns of the U.S. on average.

Juan mentioned in the beginning of our work together that he did not trust hospital systems, specifically, employees who identified as White. Therefore, the patient did not disclose important information regarding his mental health to the hospital and me, as his therapist. I reflected on my own mistrust of the medical system and assured Juan that his apprehension was valid and accepted in our therapeutic space. We met once a week for two months to assist Juan with developing coping skills to manage his anxiety and to support his recovery from traumatic experiences. Our sessions included movement experientials that drew from Laban Movement Analysis (LMA) techniques, improvisational movement, and mindfulness-based activities, and were supplemented with verbal processing. Many of our sessions involved evocative verbal exploration into Juan’s interpretation of his life experiences; this helped to strengthen our therapeutic relationship and build trust. During our seventh individual session, one of his deepest secrets was revealed. He stared me in the eyes and stated, “I have a spirit attached to my right shoulder. I can see him and feel him. He’s talking to you. Can you hear him?” I was thunderstruck and became curious about his unexpected disclosure. The spirit had attached to Juan two months prior after he prayed to his God for companionship and guidance. What started out as a positive human-spirit friendship turned into daily negative comments from the spirit, which led the patient to share his experience with me, but not without hesitation.

Juan communicated that he would not return to treatment if the divulgence of his private information had to be revealed as he had his own codes that he lived by. Identified as street codes, or rules regulating interpersonal public behavior (Anderson, 1994 ), these rules evolved from street culture as an adaptation to the lack of faith and trust in America’s oppressive systems. Street codes recognize that toughness is a virtue and that vulnerability equaled death; thus, privacy is a necessary survival skill amongst cultures that are dependent upon street living (Anderson, 1994 ). Additionally, Juan closely identified with being spiritually gifted since childhood. He talked about seeing people’s auras (even mine) and sightings of spiritual entities throughout his upbringing and adulthood. This was the first time Juan had confided in anyone, aside from his mother, about seeing spirits.

Culture Interfaces in Ethical Decision Making

Spirituality, religion, and culture have been omitted from psychology for many decades. Current mental health models are built upon, and view patients through, a mono-cultural lens (Dominguez, 2017) and this miscommunication results in increased and worsened health disparities for populations who identify as non-White. Ethical decisions become harmful when they disempower the cultural identity of a patient and insensitively discount individual and cultural views of treatment (McEldowney & Connor, 2011 ). Although my dance/movement therapy program often brought awareness to culture, I still did not feel prepared or adequately trained to know what to do with Juan’s disclosure.

While the support and involvement of practitioners who identify as persons of color are insufficient, there are new efforts being made to reduce these deficits in mental health programs (Dominguez, 2017; Walker, Burman & Gowrisunkur, 2002 ). For example, Frame and Williams ( 2005 ) introduced an ethical decision-making model from a multicultural perspective that helps therapists view differently the Eurocentric, one-dimensional, and ruled-based way of approaching ethics. The counseling profession has begun to support the idea of spiritual needs in counseling for patients and has shown an increase in therapy effectiveness, both spiritually and psychologically (Giordano & Cashwell, 2014 ).

Theoretical Orientation

Informed by a humanistic/existential paradigm and a relational-cultural theory (RCT) and positive psychology clinical approach, my spirituality, intersectional identities, and familial experiences motivated me to fully engage in this clinical case study and to advocate for increased multicultural competency amongst healthcare practitioners. From a relational-cultural perspective, our goal when Juan and I worked together was to build our relationship, so as to increase the patient’s sense of safety and trust within the treatment facility and me. My positive psychology approach served to foster the patient’s happiness and well-being in addressing his adverse life experiences. Both approaches led to a strong therapeutic relationship between Juan and me, and helped to increase his ability to open up and share with me his circumstance with the spirit.

Exploration of Ethical Decision-Making with Juan

It was clear that further culturally based ethical decisions needed to be made in order to provide ethical, safe and cultural focused care to Juan. This article identifies and evaluates the EEDM process by working through the case using the embodied ethical steps as outlined by Hervey ( 2007 ). Along with the movement recommendations from Hervey ( 2007 ), I also explored my own movement experiences as I embodied each step in response to my ethical dilemma during the process of writing this article.

Step One: Become Familiar

Given how violently ethical conflicts can be experienced in the body, (Hervey, 2007 ), clinicians are drawn away from their embodied experience and shift towards more cognitive approaches to solve ethical dilemmas. Instead of allowing this mind/body disconnect to happen, dance/movement therapists are able to embrace the body using EEDM steps. Hervey ( 2007 ) reminds readers that true ethics started as a body-based experience of wrong and right, and in order to find appropriate solutions for ethical dilemmas, one must return to the body for guidance. Embodiment permits us to move past the rational thinking brain (prefrontal cortex) and enter the body. This allows us to develop ethical sensitivity and recognize that there is an ethical dilemma in existence (Hervey, 2007 ). Step one involves attending to our body’s experience (Csrodas, 1993) by being present and engaged with its perceptual experience. This takes place in the form of movement.

Analytic and somatic movements are two avenues to consider when analyzing bodily movements (Moore, 2014 ). Moore ( 2014 ) introduces analytics as the observation of body movement from an external perspective and somatics as the first-person perspective of internal movement. Csordas ( 1993 ) adds that the somatic dimension of movement not only includes attending to one’s internal bodily experiences but also involves attending to the bodies of others, called the somatic modes of attention. Humans are gifted with the ability to interpersonally connect in a way that allows us to feel what others feel when we exercise our use of mirror neurons. Analytic and somatic movement shifts from one’s self and their environment provide evidence that deepens the collection of information and tell us when we have an ethical dilemma on our hands. Again, in this first step of EEDM, it is suggested to postpone any type of action, only to recognize the existence of an ethical dilemma in order to prevent premature and inappropriate action (Hervey, 2007 ). Instead, Hervey ( 2007 ) positions that “vertical containment” of just attending to the body signals and exploring movement in the horizontal plane is ideal for the initial development of an ethical dilemma.

Embodiment of Step One

In the initial stage of the ethical dilemma presented in this article, my movements became accelerated in the sagittal plane, specifically in my upper limbs, torso, and core. There was a sense of urgency I felt to confide in someone about Juan’s release of private information regarding the spirit attached to his shoulder. I was fascinated by my in-session encounter and wrote in my journals about feelings of excitement and tingling surges running through my body. I also recorded my impression of shaky sensations in my arms, knots in my throat and core, and decreasing pressure in my lower body. Tortora ( 2006 ) explains that weight assumes the physical intention of executing an action; the decreasing pressure I experienced in my legs indicated how careful I was to move forward in the dilemma. The vibratory action in my arms implied feelings of anxiousness, and the knots in my throat and core signified some sort of blockage. In my journal I reported feeling a sense of imprisonment; my body felt the restraint of navigating such a cultural dilemma in a hospital setting embedded with Eurocentric forms of healthcare. Though I was excited to learn more about Juan’s experience with the spirit, my movement observations for my core, arms, and legs suggested and confirmed a hesitancy to approach and navigate the disclosure about the spirit. I was motivated and empowered to advocate for him, but I also felt sad and angered by my thoughts of foreseeable outcomes that would be adverse to our therapeutic relationship. Given the cultural context of the dilemma and its tendency to be overlooked in westernized hospital settings, my thoughts held weight. I avoided making any decisions to address Juan’s case, except to obtain support in supervision.

Step Two: Define the Dilemma

After identifying that an ethical dilemma exists, we are encouraged to define the dilemma and identify potential problem solving opportunities. For this case, the ethical dilemma was respect for culturally based meanings in treatment and how mental health clinicians identify pathology. Juan believed his seeing the spirit was a gift given to him by God; he refused to accept any diagnosis that labeled it otherwise. What Juan described as a spiritual experience is usually understood as a form of psychosis in hospital systems that rely on symptom identification and diagnosis for the treatment of symptoms. Despite encouragement from me, he opposed the idea of talking to his psychiatric nurse about his spiritual experience. I felt stalled between my own spiritual and cultural awareness, Juan’s spirituality, his safety, and having to uphold the policies and procedures of the hospital where I was interning. I understood Juan’s story as a spiritual person, as a clinician, and as a Black woman from the inner city of Chicago; but I wondered if I resonated with his story all too well because we shared the people of color in the American healthcare system narrative. I wanted to make sure he felt heard and included in his treatment. On the other hand, I wanted to avoid compromising his safety in an effort to advocate for him and for increasing cultural awareness at my site. This case with Juan was a culturally embedded ethical dilemma that required my full participation with the embodied ethical steps.

Embodiment of Step Two

My body and my mind felt uneasy about making a decision; there was a fight between my cultural background and my emergence as a clinician. The idea of both weighed heavy on my shoulders and drained my energy. My upper torso gradually sank downward along the vertical dimension and my entire body wanted to enclose itself and curl like a ball. I encountered feelings of isolation as one of few Black clinicians at my internship site as well as in the academic program at my college. I felt lonely in my ethical dilemma. There are very few articles that talk about a Black clinician’s experience of loneliness during a culturally situated ethical dilemma. Smith ( 2012 ), communicated in her thesis about a similar struggle she felt during an ethical dilemma when battling between holding on to her cultural identity as an African American woman versus choosing an identity as a clinician and abiding by ethical codes. I thought with frustration: Why does there have to be a choice? Why cannot my cultural background and my developing identity as a clinician co-exist? Hervey ( 2007 ) acknowledged the need to cope with one’s bodily felt experiences when managing complex cases. She concluded that dance/movement therapist found value in moving out the dilemma with full embodiment to support determining the next direction to take. In my attempt to release my body from the enclosed ball and fully embody the dilemma, I encountered hesitation and emotional discomfort. I felt my anger and frustration expand with my movement in the form of increased pressure and restricted affect. My body was reluctant to engage in an emotionally overwhelming, cultural dilemma, but there was a sense of freedom in knowing that I was not giving up.

Step two further required the embodiment of my patient as well as my supervisors and the treatment team to provide an empathic approach to decision-making and deciding the best course of action. In her workshops, Hervey ( 2007 ) noted that in this step participants commonly collaborated with one another using creative movement to unlock alternatives to ethical dilemmas. I recall deliberating about the advice of my supervisors, unsure if they realized the substance of my patient’s fear and request for confidentiality given that they did not identify as people of color. For them, it appeared simple: make sure he’s not homicidal or suicidal and inform the nurse practitioner. Juan denied suicidal (SI) and homicidal ideation (HI). But again, one of my supervisors informed me that regardless of his denial of SI and HI, it was imperative that I report his spiritual experience to his nurse due to the fact that she prescribed him medication and that operating as a team in our department was a requirement.

Embodying Juan, my supervisors, and others who played part in the dilemma, such as the psychiatric nurse, helped to increase my understanding of their positioning in the case. My movement consisted of taking on each person’s postures and gestures, and verbalizing notable statements from our encounters. My kinesthetic empathy allowed me to view the case from their perspective. I felt each person’s concern for safety: safety for the patient, the hospital, the college, and each person involved in the dilemma, including myself. To consider safety for everyone and everything taking part in the ethical dilemma, it required diverse methods of examination, risk management, and knowledge. My movement responded with openness to the varying perspectives of stakeholders.

Identifying the Options

Lastly in step two, Hervey found it helpful to encourage participants to imagine the most ludicrous option and move it (Hervey, 2007 , p. 103). In this way, options disregarded due to fear and being premeditated as unethical decisions become spontaneous possibilities to solving one’s ethical dilemma (Hervey, 2007 ). Identifying options will help counselors focus their energy during complex ethical dilemmas. In Table 2 , I present options considered for Juan’s case. Ultimately, I wanted to avoid causing harm to him and his beliefs by providing space for autonomy and cultural advocacy. Conversely, I was thoughtful about improperly treating a patient who may in fact benefit from receiving a diagnosis in alignment with his symptoms.

Step Three and Four: Search, Evaluate, and Determine

Hervey ( 2007 ) joins steps three and four of Welfel’s ( 2001 ) ethical decision-making model into one complete phase to evaluate options and to determine the best solution. It requires dance/movement therapists to utilize professional literature, ethical codes and regulations, and agency policies to provide structure for later deliberating processes (Hervey, 2007 ). Referencing codes, regulations and policies, as implied by Constable, Kreider, Smith & Taylor (2011), helps novice therapists navigate the uncertainties associated with ethical decision-making. Even for experienced counselors, this step remains a priority for continued growth and development and enhanced ethical judgment (Oramas, 2017 ). Ethical standards are designed to protect professionals and patients; yet, these standards usually result in more reactive than proactive ethical decision-making (Trahan & Lemberger, 2014 ). So in addition, seeking guidance from ethics scholarship enables counselors to vicariously learn by trial and error from practiced professionals. Aside from providing clarity, focus, and structure, this step also increases confidence through skill building and acquisition of ethical knowledge, and further limits risky decision-making. Once all relevant information has been obtained regarding options identified in step two, dance/movement therapists are to move out those possibilities. It is essential to utilize this step as an explorative measure with movement to create more available options than to rely on rules to quickly resolve the dilemma (Hervey, 2007 ).

Codes and Scholarship

The ethical dilemma of respect for culturally based meanings in treatment and how mental health clinicians identify pathology is related to the American Dance Therapy Association’s (ADTA, 2015) ethical standard of display of integrity within the therapeutic relationship. It states, “Dance/movement therapists encourage the patient’s voice in treatment and respect the patient’s right to make decisions based on personal values” (ADTA, 2015 , p. 3). The ADTA ( 2015 ) Code of Ethics additionally encourages dance/movement therapists to continuously reexamine their own biases and worldviews to avoid imposing them onto patients, and to consider the impact of oppressive systems on individual patient experiences. According to these ethical codes, Juan had every right to name his spiritual experience as he saw most fitting with his beliefs. Providing space for Juan to do that directly aligned with my obligations as an intern dance/movement therapist. However, the hospital did not ascribe to these standards. Though Juan experienced a sense of safety in my office space, we were a part of a larger operating system that he relied on for treatment.

The American Counseling Association’s (ACA, 2014 ) ethical code Avoiding Harm and Imposing Values states that counselors work to avoid harm and minimize potential harm to patients. I perceived there could be potential harm in revealing Juan’s undisclosed information to the treatment team. Counselors are trusted with the safety of each patient as they enter our therapeutic spaces, and as humans who have accepted the responsibilities of a counselor as a life calling, we feel competent enough to complete this task. Avoiding harm requires more than providing evidence-based interventions, private and clean spaces for therapy, judgment-free zones, and upholding ethical standards. It requires constant self-awareness and reflection, and honoring cultural differences.

The ADTA ( 2015 ) Codes of Ethics are informed by and parallel the ACA ( 2014 ) Code of Ethics. It is acknowledged that the ACA Code of Ethics was constructed and shaped by an individualistic, Western society (Birrell & Bruns, 2016 ) and remains firmly established in a modern society that accordingly places emphasis on rules, independence, and power-over rather than relational engagement and power-with patients in treatment. Ergo, complex situations in treatment settings become central when persons in power are compelled to make ethical decisions regarding the well-being of a patient, even when cultural beliefs conflict (Laws & Chilton, 2013 ). The patient in this case had a different cultural meaning of issues regarding his psyche than that of the hospital setting where he received treatment.

The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA) is a manual of classified mental disorders that serves as a guide for interventions and treatment recommendations. In the DSM-5 (APA, 2013 ), a practical diagnosis for Juan’s case would fall under schizophrenia spectrum and psychotic disorders given his presentation of what the mental health field considers visual, auditory, and somatic hallucinations. Overtime, the DSM-5 has integrated cultural factors into disorders in the form of V-codes, described as supplementary conditions influencing a disorder. V-code 62.89, “Religious or Spiritual Problem”, accounts for loss or questioning of religion or spirituality (APA, 2013 , p. 725), however, this code does not encompass religious or spiritual factors as it pertains to this case. The option of diagnosing Juan carried the risk of deterring him from seeking therapy and decreasing his overall well-being. A diagnosis would suggest that his cultural interpretation of his spiritual experience was either false or meaningless. Timimi ( 2014 ) and Allmon ( 2013 ) are clear that these types of interpretations of culturally based beliefs disempower the patient and could increase negative symptoms.

The second professional value listed in the ACA’s ( 2014 ) code of ethics honors and supports, “the worth, dignity, potential, and uniqueness of people within their social and cultural contexts” (p. 3). Since values are the cornerstone of which ethical decisions are carried out, counselors are to refrain from submitting a diagnosis if they know that it will cause harm to the patient in some way (ACA, 2014 ). It is rational to consider how the stigmatization of an oppressive label from the western culture will cause individual, cultural, and societal adverse consequences for some patients (Ratts & Hutchins, 2009 ).

Social consequences for the patient must be taken into consideration when making ethical decisions (Zheng, Gray, Zhu & Jiang, 2014). Usually in the decision-making process, the counselor identifies the ethical dilemma, takes the necessary steps to problem-solve outside of the therapy room, and decides on a resolution to the dilemma absent the patient’s voice (Birrell & Bruns, 2016 ). Yet, the ACA’s ( 2014 ) code of ethics states that counselors work collaboratively with patients to promote growth and development during an ethical decision-making process. Shared decision-making (SDM) is a model that was first developed in the 1980′s to improve the experience of patients in treatment settings by encouraging a collaborative process between the patient and health professional (Bradley & Green, 2018 ). This comes with controversy regarding the risks of granting access to a patient, which allows them to collaborate with doctors regarding their treatment, given their level of competency of medical knowledge may be limited (Christine & Kaldjian, 2013 ; Herlitz, Munthe, Torner & Forsander, 2016). The same is true to consider when patients are invited to autonomously collaborate in counseling settings.

Embodiment of Steps Three and Four

As I embodied the Effort weight, for this ethical dilemma, I found strong feelings surfacing about my cultural identity and the desire to advocate for marginalized groups. There was increasing pressure in my upper body and I associated this with the idea of fighting oppressive systems at my site, as well as healthcare systems in general. I let that increasing pressure sink downward into my lower body and invited decreasing pressure to my upper body. The anger and frustration of having to engage with such a system did not disappear, however, awareness of my embodied experience encouraged me to take a gentler approach to ethical decision-making.

I had a lot mixed feelings that were reflected in my movement while searching the ethics codes and gathering information. I felt confused and surrounded by information as I turned in circles reaching and pulling. The information seemed full of loose ends and, to a great extent, required interpretation. There was increased tension in my shoulders, and I eventually distanced myself from the imaginary visual of the ethics codes and scholarship. I entered into a remote state of increased bound flow and directing as I gazed at the information from a far. I began to move in my preferred style of popping and locking while visualizing the information regarding the clinical case. I was able to bring in my culture when understanding and interpreting the codes. Although complete clarity of the codes was not realized, I experienced increased confidence and intention for working through the dilemma with this new knowledge.

Step Five: Ethical Principles

Step five requires reference to the five ethical principles identified by Kitchener ( 1984 ). They are: autonomy, nonmaleficence, beneficence, justice, and fidelity, along with the added principle: veracity. Ethics involves cultural norms, personal morals, and values during the decision-making process, and these will serve counselors in the self-exploration process of relating to the guiding principles (Evans et al., 2012 ). Ethical principles were conceptualized to provide a foundation of morals to help interpret ethical codes and adjust routine responses to unconventional ethical dilemmas (Chmielewski, 2004 ).

Each ethical principle has been layed out with common movement qualities that were found by dance/movement therapists when they moved out the principles separately (Table 1 ; Hervey, 2007 ). A key part of step five is to be attentive to any embodied responses that are experienced while moving each principle. Principles have the potential to draw out essential details to help us strengthen our understanding of the dilemma and where the conflict is coming from, externally, and internally within ourselves in the form of values (Miller & Davis, 2016 ).

Another key factor is to acknowledge that these principles were created as a guide to culture-specific standards of behavior, and that ethical principles will be prioritized differently within varying cultures (Gauthier, Pettifor, & Ferrero, 2010 ). The new age invites new rules of behaviors, and these rules are changing rapidly (Hoose, 1986 ). It is important to be aware of the cultural body’s response to each principle and how it shapes our experience with them.

Autonomy describes mutual respect in a relationship, where both individuals honor one another’s ability to make autonomous decisions (Kitchener, 1984 ). During complex ethical dilemmas, counselors may feel an urgency to act on impulses, yet feel the tension of respecting the autonomy of the patients, others involved, and that of themselves (Hervey, 2007 ). Indeed, the act of yielding and pushing through movement, which can be realized in dance/movement therapy, informs our boundaries and asserts greater independence (Schwartz, 2018 ).

There was constant pushing in my movement to create boundaries while embodying autonomy. I used my arms to separate and push back on the healthcare system to provide space for Juan and myself. It felt like I was taking on the role of advocate: working to gain autonomy for two people of color in a Eurocentric hospital setting. While moving I wondered how much autonomy could I actually encourage Juan to have given his presentation of symptoms and possible limitations of mental health information. Juan had previously omitted important details regarding his symptoms because he did not feel safe. I cautioned myself against allowing too much space as I thought about what other information might be unknown about him. As I moved and created space for myself, I realized I needed separation from both Juan and my internship site to be free in my own autonomy. In a cultural sense, autonomy for me meant expressing and standing strong with my own beliefs. I had responsibilities as an intern clinician to uphold the policies at the hospital, policies that I understood to be Eurocentric cultural norms and did not fully agree with. However, as a novice clinician, how much autonomy could I possess given my own limitation concerning the knowledge of policies and procedures regarding the clinical case? I engaged in a back and forth movement, suggesting the tug between inviting space for autonomy and enclosing space where autonomy may have been less beneficial to resolving the dilemma.

Nonmaleficence

Nonmaleficence means not causing harm to patients, including intentional actions to harm or carrying out risky actions that have the potential to harm them (Kitchener, 1984 ). This ethical principle corresponded with careful, cautious, and tentative movement responses (Hervey, 2007 ).

I attuned to my visceral experience of decreasing pressure and binding flow, as suggested by Hervey ( 2007 ), as I moved carefully. There were multiple pieces to consider to avoid harm. I wanted to culturally empower Juan and I wanted to keep him safe; however, safety could have looked like many things from the different perspectives of everyone involved in the dilemma. Safety could look like Juan feeling empowered and gaining trust in the healthcare system because he felt heard and believed by his treatment team. Safety could look like diagnosing Juan and giving him medication from the nurse’s perspective. Safety could look like informing Juan’s treatment team and engaging in ongoing investigation of his symptoms from my supervisors’ perspective. Safety could also look like keeping the information to myself and linking Juan to spiritual healers in nearby communities. I engaged in movements that looked like dipping and dodging as I moved, carefully considering all of these pieces that surfaced. I further examined my own safety in relationship to nonmaleficence. A decision to inform Juan’s treatment team would potentially cause harm to my cultural identity; I would feel like I betrayed my values and my community by going against street codes and abiding by rules of a mistrusted healthcare system. On the other hand, a decision to not inform the treatment team would leave me feeling disconnected as a team member at the hospital and also feeling like I am not doing my job correctly as a clinician; both would cause harm to my professional identity.

Beneficence

Beneficence is the act of reducing human suffering by supporting the welfare of others and enhancing their sense of empowerment (Jennings et al, 2005 ). This was a principle that I found myself sitting on during the time of my ethical dilemma. There is a two-sided impression of what doing good actually looks like; it could be the literal act of taking action to do good, or it could involve being good in a time of complexity and chaos (Hervey, 2007 ). Naturally I wanted to advocate for Juan by taking action, and I deemed it necessary for a culturally embedded case. Robson et al., ( 2000 ) argues that beneficence carries the obligation for counselors to seek substantial knowledge and perform in the best interest of the patient’s welfare. On the other hand, I felt that beneficence was just being good for my patient by offering a therapeutic space where his cultural interpretation of his experience was true, regardless whether the site was willing to change its process of labeling pathology. My upper torso instantly advanced forward in the sagittal plane without hesitation, my head shook side to side suggesting the word no, my limbs supported me with increased weight. My body gladly considered no other option but to actively engage in this clinical case by advocating for Juan and other underserved people who could benefit from a change in the healthcare system.

Justice, as an ethical principle, means fairness, treating others as equals, and promoting equality counseling. This ethical principle was most challenging for me to embody. In my body I felt stuck with increased bound flow at thoughts of how inequalities in healthcare systems continue to persist. In my exploration of balancing movements for justice, my body maintained its bound flow in every part except my arms. My bound flow was accompanied by rage and sadness. I attempted to take on the posture of the scales of justice with my hands held outward to the side; they felt empty and light. I brought my hands in front of me, side-by-side, and gazed at the emptiness for a moment. The ethical codes themselves require revamping to address the inequalities that exist within them (Kitchener, 1984 ; Robson, et al., 2000 ; Trahan & Lemberger, 2013). ‘It started to become clear that Juan’s case was a step forward in advocating for others like him who want and deserve fair and culturally sensitive treatment. This clinical case study was a component of seeking justice in itself.

Fidelity is an act of faithfulness; it is about remaining loyal and keeping promises to patients (Kitchener, 1986). This was another challenging principle to embody. The moment a counseling relationship is established, there is an obligation on the part of the therapist to honor commitments and promises, and to fulfill the responsibility of trust and accountability (Wade, 2015 ). While some dance/movement therapists affiliated fidelity with commitment, honesty, and integrity, others associated it with retaining secrets. I considered how this principle could relate to one of my options: doing nothing and disregarding my patient’s spiritual experience in an effort to protect Juan from harm. During my embodied experience, I felt the sensation of being pulled in different directions with an uncomfortable tingling sensation in my stomach. I was confounded, caught in the middle of both my developed and emerging identities. On one end, I felt a pull from my patient to be with him in our marginalized identities. On another end, I felt pulling from my internship site and the counseling field to be an ethical therapist. Lastly, I saw an image of me pulling myself to just be me and to separate from both. I resorted back to autonomy and engaged in boundary setting movements, realizing that being faithful and honest to myself was my first responsibility.

Healthy disconnections are a key factor in the RCT framework. I refused the idea of becoming enmeshed with either the hospital or my patient during process of navigating the dilemma. I desired a healthy balance of connecting and disconnecting, which meant standing in my own identity while engaging with the clinical case. I reflected back to autonomy while moving this dilemma; fidelity helped me see where multiple truths encountered and overlapped one another. The nurse practitioner’s truth may be helping others in an informed way by assigning diagnostic labels in order to effectively treat multiple patients and prescribe medication. The nurse’s truth overlapped Juan’s truth of seeing his mental concerns as something spiritual, but not having many resources to turn to for support. I understood fidelity as a principle to encourage all involved in the case to be true to themselves and not place rules and labels above being human.

Veracity was added to the most recent addition of the ACA’s ( 2014 ) Code of Ethics and is defined as dealing truthfully with individuals during professional interactions. In my embodiment of veracity, I discovered a vertical stance that turned into spiraling movements of my spine with free flow and lightness. I felt authentic and vulnerable in my movement, and I also felt the willingness to share myself and connect with others involved in the ethical dilemma. True veracity requires authenticity to be effective; vulnerability is a bonus. It goes back to fidelity and being aware of placing rules above respect for human differences. The dilemma in this clinical case rose from a lack of acknowledgement of cultural differences and viewing ethical dilemmas through intellectualized codes instead of the truth within the human body.

Step Six: Consult and Share

When does spirituality become pathology? How do we ethically honor a patient’s cultural meaning of spirituality in a westernized medical system? These were the questions that had surfaced for me in supervision. Interestingly, I had three White identifying supervisors, and I was one of very few Black clinicians in training at my academic setting and the only Black supervisee at my site. There is an established power differential that comes with a supervisee-supervisor relationship which was compounded by Black-White dyads that constituted each of my supervisory relationships. Clinicians of color in training commonly experience their voices being silenced in clinical and academic settings, especially when topics of culture and race need to be addressed (Estrada, 2005 ; Hardy, 2015 ; Hernández, 2003 ; Jernigan, Green, Helms, & Perez-Gualdron, 2016 ). This is likely a consequence of practiced cultural conditioning in Western societies as well as a lack of cultural awareness and training that has persisted throughout the counseling field, thus continuing the cycle of supervisors overlooking cultural issues (Estrada, 2005 ; Vereen, Hill, & McNeal, 2008 ; Jernigan, et al., 2016 ; Ivers, Rogers, Borders, & Turner, 2017). As a result of being a therapist in training, a therapist of color, and dealing with an ethical dilemma involving a cultural conflict, I was very hesitant to confide in my supervisors due to our cultural differences.

I struggled with feelings of discomfort when it came time to discuss the dilemma with my supervisors. Supervision felt like an unsafe setting to express my anger and frustrations of being a Black woman working to resolve an ethical situation deeply embedded with cultural conflict. My experience was not normalized. When I brought up the cultural factors of the case, the room seemed to either become silently heavy or the conversation deflected to an idea outside of culture. That only led to more frustration. I wanted to avoid the angry Black woman stereotype that accompanied my skin tone and aesthetic appearance and affected the way others perceived me interpersonally. I knew it would only hurt my professional career if my expressions were perceived outside of professional behavior, whatever professional behavior is according to Eurocentric standards. Consequently, I eventually suppressed my feelings and operated from a place of numbness whenever I had to discuss the clinical case further. I thought it was pointless to continue to take my body through a wave of unheard, misunderstood emotions. Suppressing my feelings and emotions was not the best coping strategy, but it was healthier and less exhausting than continuing to feel shut down or deflected. I objectively shared all the facts about the case with Juan. I did not share my subjective experiences, at least not nearly to the extent of how they lived in my body during supervision.

Embodiment of Step Six

Hervey ( 2007 ) recommends that dance/movement therapists share their ethical dilemma with trusted colleagues or supervisors through authentic movement, verbal communication, or by designing their own way of sharing. Step six aims to increase the mover’s confidence for consultation.

While engaging in this step during my journey of writing this article, I experienced step six to be helpful with extracting the dilemma from my body and putting into movement. I shared the dilemma alone first, and then I shared my movement with a peer. By first moving the dilemma alone, I was able to see what I wanted to share and how I wanted to share it, absent the influence of another body in the room. When I offered my movement to my confidant, I was again nervous, worried about their criticism of my choice of movement, as they were unfamiliar with embodiment practices. The art of moving past internal and external criticism of who I am as a dance/movement therapist allowed me to connect deeper to how the dilemma lived in my body. I could extract it and put it into an art form in which I have always experienced healing. It allowed me to gain control over what was suppressed inside of my Black body.

Step Seven and Eight: Deliberate, Decide, and Rehearse

Steps seven and eight of Welfel’s ( 2001 ) ethical model prompt therapists to deliberate and decide the best plan of action, and Hervey ( 2007 ) puts emphasis on taking responsibility of the final decision. Ethical thinking is a complicated process and we must consider the impact of our decisions on individuals and the institution we serve (Chmielewski, 2004 ). Without careful acknowledgement of the responsibility we hold in these types of situations, counselors run the risk of creating unsafe environments for current and future patients, and further risk producing adverse consequences for institutions. (Chmielewski, 2004 ). This step precedes any action to promote clarifying our intentions while solidifying our final decision.

Decision Made for the Case with Juan

I decided to inform Juan’s nurse practitioner of his spiritual experiences. Ultimately, it felt like I was without much choice as I had already informed my internship site supervisor before I was aware this clinical case was an ethical dilemma, and one that would affect me deeply from a cultural perspective. I abided by the rules of the hospital and complied with directions given to me regarding the next steps to take. Before disclosing Juan’s information, I talked with him in one of our sessions about my obligation as an interning clinician to inform his nurse. Again, I provided the option for him to tell his nurse, alone or accompanied by me; however he refused both. Juan stated he understood and respected my responsibilities, but he would not return to therapy. I informed him of the sadness that his decision brought me and expressed that I also understood his responsibility to protect himself. In the end, Juan ended up coming back to therapy. The relationship we built in our therapeutic space of allowing our cultural identities to exist freely without judgment surmounted the undesired ethical decision that was executed, and led to Juan’s return.

Honestly, if I could go back and engage in this ethical decision-making process and change something, I would not. The process has taught me so much about who I am as a clinician and an advocate of cultural needs in healthcare systems. I also believe that Juan benefitted greatly from our therapeutic relationship that involved increased sensitivity to and active inclusion of cultural differences. Though he felt our trust was broken, we were able to rebuild it in our proceeding sessions by repairing the rupture that had taken place. Repairing our rupture contributed to strengthening our therapeutic alliance even further. From an RCT perspective, the therapeutic relationship was the healing factor to the decision made in this culturally situated ethical dilemma.

Embodiment of Steps Seven and Eight

In order to clarify intentions and solidify a plan, dance/movement therapists are directed to move alone, journal, or do both while deliberating (Hervey, 2007 ). This is a resourceful point in the ethical decision-making process to connect all of the important pieces of the case and evaluate the risks involved for one’s self, the patient, and treatment team. The deliberation process can create feelings of reconnection and groundedness as we reach for clarity. Once deliberation has been finalized and intention clarified, the next measure is to commit to a plan of action (Hervey, 2007 ). It is recommended to rehearse acting out the final decision through movement or imagination to increase one’s confidence before implementing the plan (Hervey, 2007 ). After the decision has been carried out, counselors are to head into the final step of the EEDM process for reflection. In an effort to support a reconnection to my own intentions, it was helpful for me to ask myself questions as a way to facilitate my movement. For instance: What motivated me to engage in this ethical decision-making process? Why and how will this benefit my patient? How will my decision support future patients and therapists who encounter a similar ethical dilemma? It was interesting to notice my arms reaching outward in all directions of the dimensional scale, and then carving their way back to my core, as if they were bringing me something back. I experienced a sense of clarity, and moreover, I experienced a sense of knowing who I am in this dilemma, and on a spiritual plane, what purpose this dilemma has brought to my career as a dance/movement therapist.

Step Nine: Reflect and Evaluate

Though Hervey ( 2007 ) excluded this final step from her workshops, it is important to engage in this reflective step to evaluate how effective the entire EEDM process has been, and doing so in an embodied fashion (Hervey, 2007 ). While understanding what parts of the process were effective, it is also possible to learn what steps can be done differently for future dilemmas (Hervey, 2007 ; Constable et al., 2011 ). Cottone ( 2001 ) agrees that the reflection process is not one of the mind, but an appraisal process of actions and a continued process of seeking alternative perspectives. Cottone ( 2001 ) encourages clinicians to go beyond the perspectives of supervisors, peers, and respected colleagues, and consider the cultural context in which the decision was implemented and how it affects the community at large.

For one, extending an open conversation to the patient in an effort to understand how the final decision affected them can increase feelings of safety and empathy for both the patient and counselor, especially if the ethical decision was contrary to the stated desire of that patient. Furthermore, I also suggest reaching out to community members and persons who identify within that associated culture. Shah (2011), described inviting pushback, where a group of people express resistance or redirection, as a way to show care and feelings of importance to the perspectives of underserved communities that may otherwise go unnoticed. Shah (2011) also brings attention to the fact that mistakes are inevitable during ethical decision-making, and it is essential that counselors prepare themselves for this kind of feedback. If not, the fear of criticism will keep counselors oblivious to the needs of patients, community members, and different cultures, therefore creating greater barriers that could potentially aid in the progression of mental healthcare for those in need.

Embodiment of Step Nine

In my movement reflection, I discovered that I was able to remove the heaviness of my culture from my back and place it in my hands in front of me. I now saw it as a tangible construct, something I could work with and move through. My body felt mobile with free flow as I integrated movements from the previous steps as a way to reflect on my experiences. There was a sense of gained knowledge and tools to assist me with navigating future complex ethical dilemmas in a culturally informed and embodied way.

By engaging in this in-depth exploration with the EEDM steps, I learned how meaningful this case was to me and possibly to underserved populations who engage in healthcare services. As opposed to intellectually escaping my bodily felt responses to the dilemma, these steps encouraged me to listen to and engage with them. Without doing so, I would not have reached the conclusions I have presented in this article. My connection to this clinical case was a deep visceral experience that had been silenced by an oppressive healthcare system and me, but illuminated through an embodied process. Current healthcare practices disempower and affect the long-term health of people of color because they are expected to comply with mono-cultural views of mental health and treatment. I made a decision to share Juan’s spiritual experiences with his nurse against his will. My therapeutic approach of displaying respect and giving prominence to Juan’s culturally based meaning-making of his spiritual experience was what encouraged Juan to return to treatment. Still, it is essential to examine potential harmful outcomes and how they can be prevented or diminished until healthcare systems modify their operations.

Throughout the ethical dilemma, I was the intermediary between my patient, the psychiatric nurse, and my site supervisor. ACA’s ( 2014 ) Code of Ethics assert a collaborative process between counselors and patients, yet, in most ethical dilemmas, the counselor makes decisions in isolation (Birrell & Bruns, 2016 ). Most clinical guidelines similarly recommend involving patients in decisions regarding assessment and treatment thus supporting collaborative and informed goals (Elwyn et al., 2006 ). This type of patient-centered care has been increasingly adopted as interdisciplinary teams realize how valuable shared decision-making (SDM) is for patient success and well-being (Adisso et al., 2018 ; Chewning et al., 2012 ; Elwyn, Edwards, Kinnersley, 1999; Elwyn, Edwards, Kinnersley, Grol, 2000; Légaré et al., 2011 ). Persons directly involved in an ethical dilemma have great potential to effectively influence the decision-making process, and no one voice should be given exclusive privilege over another (Birrell & Bruns, 2016 ). From an RCT perspective, interconnection during ethical decision-making processes can invite real change in a positive direction for not only the patient, but for the counselor and institution as well.

RCT acknowledges that growth-fostering relationships, relationships that include increased understanding and empathy for one another’s thoughts and feelings, display respect for the multitude of sociocultural aspects that each individual brings to the experience (Duffey & Somody, 2011 ). As humans, we are wired to move through and toward connection with others, and it is the connection and relational experience that contributes to healthy functioning and flourishing (McCauley, 2013 ).

What I desired most during my ethical decision-making process was to have all the people involved in the dilemma to be in one room listening to each other with openness, curiosity, and empathy. I was the intermediary of all communication amongst my supervisors, Juan, and the nurse. It was exhausting relaying information, and a lot of the time I was repeating the same information to a different person. So much of my time and energy was expelled in this back and forth communication, only to implement the decision alone. As the intermediary, I additionally witnessed statements from my encounters with each of them that made me feel uncomfortable or suggested a lack of empathy for one another. I wished they were able to learn of one another’s circumstances to create more understanding and empathy within the case. I understood that our workloads prevented a collaborative decision-making meeting that would have included my site supervisor, the nurse, Juan, and myself in one room discussing the details of the case and all the possible solutions to working with Juan’s spiritual experience. I further understood that such a meeting would have been quite frightening for Juan who wanted to keep his experience a secret. I wondered how that might have been different if Juan discovered the hospital altered their policies to accept and consider his meaning making of his spiritual experience? A joint meeting could have saved me much time, energy, and stress over a dilemma that affected others and me deeply.

Based on my experiences with this ethical dilemma, I developed a model for active multicultural diversity (AMD), a term credited to Carmichael ( 2012 ), as a guide for ethical decision-making aimed at increasing effective outcomes for patients by taking culture from a concept that exists in one’s awareness to a concept acted upon (Fig.  1 ). It incorporates the EEDM steps with SDM and the three M’s of RCT: movement to mutuality, mutual empathy, and mutual empowerment. With the embodied ethical decision making steps at the center of decision-making, I encourage the patient, therapist, and treatment team to equally collaborate when making ethical decisions. In this way, the burden of resolving the ethical dilemma is not placed in the hands of one person, but instead, all are responsible for reaching a conclusion, therefore increasing the vitality of each person through involvement and interconnectedness.

Active multicultural diversity in ethical decision-making

Movement Towards Mutuality

Hartling and Miller (2004) describe non-mutual relationships as dominate/subordinate or power-over relationships, which the more powerful or dominant participant in the relationship receives greater benefit. Instead, movement towards mutuality calls for all participants of the relationship to engage in, and take emotional and cognitive action towards change (Hartling & Miller, 2004). This movement towards mutuality benefits people by preventing humiliation while supporting growth, healing, and human rights. All participants in the ethical dilemma must be willing to change where possible and appropriate in order to see each other as equal individuals while collaborating to resolve the ethical dilemma.

Mutual Empathy

Mutual empathy is the ability to be impactful and to be impacted in the relationship through seeing and feeling within the experience (Duffey & Somody, 2011 ). It is through acceptance and validation that an authentic relationship can be built and become a priority (Duffey & Somody, 2011 ; Hartling & Miller, 2004). This is an essential piece to navigating complex ethical dilemmas.

Mutual Empowerment

Empowerment is the feeling of having control and understanding over one’s life (World Health Organization, 2010 ). The World Health Organization ( 2010 ) realizes that institutions have a responsibility of operating in ways that empower the people and communities they serve to encourage vitality, health and well-being. Empowerment in relationships must be mutual so that all parties feel competent, heard, seen and respected as they collectively shape and develop the experience (Hartling & Miller 2004). Decision-making is best done when those engaging in the collaborative process do so feeling confident and empowered.

I envision healthcare facilities employing a designated ethical dilemma consultant, to mediate the collaboration process. Clinicians, nurses, doctors, and even patients could send the consultant a notification that a potential ethical dilemma arose. From there, the consultant would initiate communication for all involved in the dilemma to decide on a date and time to meet and work through the AMD model to resolve the case. The consultation session could be structured according to the persons participating in the meeting. A session may involve a lot of movement or minimal movement with mostly postures and gestures. A simplified version might employ mindfulness techniques to identify body-felt sensations to each embodied step. The three M’s should be illustrated at the beginning of each consultation to help clarify the intent and goal of engaging in the EEDM process. The three M’s, movement to mutuality, mutual empathy, and mutual empowerment, effectively work to create an open and safe atmosphere that encourages full participation in the EEDM steps.

Active Multicultural Diversity for Juan’s Case

In order for AMD to work in this clinical case with Juan, increased funding for mental health programs leading to less overworked professionals is a definite necessity. Professionals at the hospital were consistently double booked with patients for the majority of the workday. The oppressive system in which the hospital was situated, affected patients and employees alike. The hospital consistently treated people of color with limited support service options. It is feasible that if the hospital had sufficient funding for mental health services, increasing staff and office space, the AMD model could have been implemented in this clinical case. Further, to participate in a collaborative process, the patient, nurse, and clinical supervisor would have to be willing to engage with one another with an increased open mind and non-judgmental attitude. This would help cultivate a collaborative process insofar as Juan would have been able to communicate his desires to resolving the dilemma in a way that would also increase his trust for the hospital setting through our relational experience.

Limitations and Possibilities

Active multicultural diversity in ethical decision-making does not come without its challenges and limitations when considering the integral components of how westernized healthcare systems have been operating for decades. For one, SDM requires more time for collective consultations between healthcare professionals and patients (Elwyn et al., 1999 ). Most healthcare professionals are occupied with required treatment planning, writing notes, other consultations, case management, and other daily tasks. Counselors may also experience the obligation to educate patients on mental health to increase competency levels for ethical decision-making, which also requires more time (Elwyn et al., 1999 ). In light of this, patient decision aids, new technologies designed to prepare patients and to increase their knowledge of information related to treatment, are used to assist in making informed choices when collaborating with healthcare providers (Elwyn et al., 2006 ; Adisso et al., 2018 ). In an effort to increase active multicultural diversity in healthcare settings, patient decision aids should be made accessible to all communities, all populations, and in all forms of healthcare. Another limitation of active multicultural diversity is the perceived threat to power in professional-patient relationships (Elwyn et al., 1999 ). This is associated with a lack of cultural competence, caring knowledge, mono-cultural embedded lenses, and power-over preferences from health professionals and institutions. Moreover, just like cultural competency training is deficient in mental health programs, SDM is also deficient in programs and skill building workshops, and is further absent in modeling from older, more experienced clinicians (Elwyn et al., 1999 ). It is possible that with an ethical decision-making consultant on site, regular trainings could be provided to keep professionals and patients informed on ethical decision-making and cultural competency.

Finally, embodiment is a skill that dance/movement therapists and other body-based practitioners are accustomed to, and it could be a challenging to engage non-body-based practitioners and patients in movement during an ethical decision-making process without significant willingness or training. This could reshape healthcare systems requiring leadership figures to provide more resources, education/training, and time to healthcare professionals so they are prepared and available to engage patients and team members in active multicultural diversity for ethical decision-making.

I can embrace the AMD model moving forward by including my patients in the EEDM process as a part of our therapy sessions, if a dilemma happens to emerge during our work together. We could collaborate to identify options to resolve the dilemma. I would then present those options in consultations with the treatment team to include and discuss their viewpoints. Another possibility is having someone from the treatment team join one of the therapy sessions with my patient and have them witness our movement, as identified in step six of sharing the dilemma. After, we might engage in a discussion to decide on an action to take, invite the team member to join the movement, or both. In this manner, there is an inclusion of multiple voices to collectively resolve a dilemma in an embodied way. Inviting a treatment team member into a session also indicates movement towards mutuality as each person shows initiative by taking time out of their day to dedicate to the safety and care of the patient. Mutual empathy happens in the process of moving and witnessing movement; illuminating how the movement affected each person in the room can deepen the process. Mutual empowerment is experienced in the feelings of inclusion, displaying respect and interest in one another’s opinion.

The purpose of this clinical case study was to illustrate how the EEDM steps influenced ethical decision-making when cultural differences conflicted. I found that by engaging in the embodied ethical steps, I was able to deepen the decision-making process by accessing the lived experience of the dilemma in my body. I carried the heaviness of a silenced cultural identity until it was able to speak through movement. The ethical dilemma in this case was respect for culturally based meanings in treatment and how we name pathology. Culture is inadequately considered in healthcare operations, treatment models, and educational programs. We must actively consider how this deficiency affects patient health over time and disempowers underserved populations from engaging in treatment. The EEDM steps provide an effective way for working with diverse populations as we can connect to our bodies to explore new possibilities for complex situations. In this clinical case with Juan, though the decision to inform his nurse practitioner of his spiritual experience was against his will, our relationship encouraged his continued engagement with treatment services. To consider culturally based meanings in treatment, the relational experience is essential in order to receive support from different perspectives. Sharing the embodied decision-making process can be most effective for culturally situated ethical dilemmas. As suggested in the AMD model presented here, engaging in the EEDM steps through a RCT lens benefits silenced and underserved patients, and healthcare professionals with an increased sense of mutuality through a meaningful process.

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Roberts, M. Embodied Ethical Decision-Making: A Clinical Case Study of Respect for Culturally Based Meaning Making in Mental Healthcare. Am J Dance Ther 43 , 36–63 (2021). https://doi.org/10.1007/s10465-020-09338-3

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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
• 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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Ethical Dilemmas in Counseling

Contemplate these 16 conundrums..

Posted February 15, 2019 | Reviewed by Jessica Schrader

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Ethical dilemmas are important puzzles with no easy answers but are fun to contemplate.

Of course, they exist in all forms of counseling, from short-term advising to long-term therapy , from eating disorders counseling to career counseling. Because most of my counseling experience has been as a career counselor, the ethical dilemmas I present here are career-related but most have broader applicability.

In the service of presenting as many dilemmas as possible within this space's confines, I’ll present each dilemma as pertaining to the same client. That way, I needn’t provide a separate client background for each dilemma. I’ll make our ethically challenged client a man but, of course, it could have been a woman.

1. A client was terminated as a fundraiser for an environmental nonprofit. At first, he said it was because “I didn’t make my number” but on probing, he admitted that he lied to prospects, overstating what the nonprofit had previously accomplished. Now, he says he’d like to take a shot at making a living at a long-shot career: hosting a TV, radio, or podcast show on “social change.” “I want to be a liberal Jordan Peterson.” Given his track record, reasoning, and communication skills, it’s clear to you that he’s facing lottery odds. What do you say or ask?

2. You tell them that before he selects a career, it would be wise to spend a session or two plus some homework to explore. He says, "I don't need to pay you for that. I can just use MyNextMove.org. You sense he's not self-efficacious enough to do that well enough on his own but you don't want to unduly pressure him into paying you to work with him on the exploration. What do you say or do?

3. You ask the client questions about his career history, in part to facilitate his making a clear-eyed decision on whether it’s worth the risk of trying to make a sustainable living as “a liberal Jordan Peterson.” The client ascribes his poor job history to a “racist society.” What would you say or ask?

4. The client claims to be 1/4 Hispanic and asks if it’s ethical to claim minority status on his job or graduate school applications. He argues in favor of it because he has applied for many jobs without having stated that and hasn’t landed anything, has three children, a wife who is a stay-at-home mom, and savings have run out and they face eviction for non-payment of rent. You sense he doesn’t really want your opinion. He wants your blessing. What would you say or ask?

5. The client says “I’ve been begging my wife to get a job but she says her skills aren’t great so she’d only get a low-paying job and, when you subtract the child-care and commuting expenses, it’s not financially worth getting a job. Besides, she feels the kids benefit from her staying home. In addition, she argues that before we got married, I agreed to be the sole breadwinner. But I didn’t realize how hard it would be to make it on one income let alone when I keep getting let go from jobs.” What would you say or ask?

6. The client asks you to write his resume and cover letter. You’re aware that employers use resumes and cover letters not just as a recitation of work history but as an index of the person’s ability to reason, communicate, and produce an error-free document. You consider your writing a client’s resume and cover letter to be no more ethical than a parent writing their child’s college application essay. What would you say or ask?

7. That client finally lands a job, at another nonprofit, but after the first week complains that the organization is unethical because he learned that it retains 40% of donations as "administrative expenses," so only 60% is spent on the cause. Plus, the website’s donor page makes no mention of this. What would you say or ask?

8. The client quits that job and decides to start a marijuana delivery service. You’ve read the two most authoritative reviews of the literature, one by the National Institutes of Health and one by the National Academies of Sciences and conclude that marijuana is at least as deleterious as a second alcohol and that millions of people would be greatly harmed by that. So you feel you can’t support the client’s effort to start that business. What would you say or ask?

9. When you ask how the client’s wife feels about his going into that business, he says, “She’s fine with weed but is mad that I’d want to be self-employed. She says we need financial security, that we can't afford the risk of going into business." What would you say or ask?

10. The client reveals that he vapes weed most nights, in front of his kids, who are 15, 17, and 18. It’s clear he’s not open to stopping or moderating his vaping, so you focus on the kids: “Do you think it’s wise to vape in front of your kids?” He responds, “It’s no worse than drinking in front of your kids. Millions of people do that and their kids don’t become addicted. And that way, the kids don’t feel they need to hide weed from you or to vape as a way to rebel. And, in France, wine with dinner is normal; they give it to their kids.” What would you say or ask?

11. The client says, “Paula (his 18-year-old) isn’t a school person and when finishing high school, I’m trying to get her to be in the business with me. All her friends—and she has a lot of older friends in their 20s, so they’re legal. A lot of them are in her spiritual community. She’d be a great salesman.” What would you say or ask?

12. The client returns a few months later saying he wasn’t able to compete with other marijuana delivery services and wants you to help him find a job as a fundraiser for an environmental nonprofit. What would you say or ask?

13. The client decides to discontinue working with you and a month later, phones you: “I saw another career counselor, who recognizes there’s nothing wrong with writing your resume and cover letter, and saying you’re Hispanic even it’s just 1/4 because there’s racism even against 1/4-Hispanic people. He helped me get a fundraising job.” What would you say or ask?

14. Ten years later, the client calls and says he became very successful as a fundraiser and has risen to vice president of fundraising but is sick of it: the people management , the ever-increasing fundraising quotas, and he’s thinking about returning to a simpler job. “Sometimes, I even think I’d be happier working as a $15 budtender. My wife is furious. We bought a house and have a big mortgage and we’re still paying off our kids’ college loans. Again she’s calling me irresponsible even though I’ve worked my butt off to become a VP and afford the house, a nice car, furniture, vacations, everything.” What would you say or ask?

15. As you're reflecting on clients like this person, you're wondering if it's ethical to try to help them get jobs. After all, it's a zero-sum game and if you're successful, you've taught the person tips and tricks that get him the job over more qualified candidates. That's unfair to them, the coworkers, boss, the consumer, and ultimately the larger society. On the other hand, compassion says we should treat everyone equally, especially those with deficits. Your thoughts?

16. He calls to say, "I can't get over all your implying I'm unethical and an overall jerk. You've driven me to think about committing suicide ." What would you say or ask?

The takeaway

As you review your responses to these dilemmas, is there anything you want to keep in mind?

Marty Nemko, Ph.D ., is a career and personal coach based in Oakland, California, and the author of 10 books.

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Ethical Dilemmas in Counselling and Treatment Methods Research Paper

• To find inspiration for your paper and overcome writer’s block
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Introduction: What is an Ethical Dilemma?

An ethical dilemma is an intricate situation that involves an apparent mental conflict. One is unable to choose a result that professionally is right but would transgress another. In counselling, it emanates from conflicting professional approaches that affect ones moral imperativeness therefore leading to a moral paradox. Professionally, either a diagnosis pits a previous diagnosis by a counsellor of psychiatrist in an incompetence situation or legal implications arise after confidential data from a diagnosis are released against a patients will, but with the sole purpose of helping the patient recover. In such an event, to ‘disclose these contexts to aggrieved parties or not disclosing’ becomes a moral paradox. Ethical dilemmas are commonplace in counselling and psychiatry. Professionals in these careers often face these dilemmas especially when referrals are made to them.

An Ethical Dilemma

June and Ward’s son Brett is having a physiological problem. A diagnosis by the school counsellor points out a condition known as ADD, ‘attention deficit hyperactivity disorder (Foreman, 2006).

The case of Brett has become an ethical issue based on the following; questions are revolving around what information can be released to the parents (refraining from diagnosis) and parents request to review the diagnosis since no procedure existed in the school (informed consent in assessment).

The Ideal Decision Making Model in This Case

Counsellors face ethical dilemmas throughout their profession. How to address these dilemmas require one to follow an outlined guideline referred to as an ethical decision making model. Ethical decision-making model helps counsellors resolve and treat diagnosed conditions (Ethical Decision-making Models across the Professions, 2003).

Identifying the problem

Brett’s parents sought a second opinion from a family counsellor. He filed their report. He requested the school counsellor to furbish him with the records of his diagnosis on Brett. This information arms the counsellor with adequate information about the boy, his background, pre-existing conditions and any other relevant information that can be helpful (Kitchener, 1984).

Each detail acquired about the case is put down on paper. This helps the counsellor to outline facts and separate hypothesis, assumptions, suspicions and innuendos. This helps clarify the problem, classify it as fitting, professional, legal, ethical, or clinical approach. This approach helps in establishing a comprehensive resolve for the problem (Miller & Davis, 2006).

Ethical Decision making model

In this case, the perspectives of Van Hoose & Paradise (1979), Kitchener (1984), Stadler (1986), Haas & Malouf (1989), Foster-Miller & Rubenstein (1992), and Sileo & Kopala (1993) form the ideal structure of making a proper ethical decision making model. Their perspectives form a practical 7 steps ethical decision-making model that is ideal for this ethical dilemma. This ethical decision making model is as follows, and it addresses comprehensively this dilemma.

Applying the ACA code of ethics

According to the ACA code of ethics, once you identify the problem, the ACA code of ethics helps you to resolve dilemmas (ACA, 2005). It addresses various issues and if the dilemma you face is addressed here, it is ideal to use the approach underline on the ACA code of ethics. If the ethical dilemma takes the dimension of what you deem as the redress offered by the ACA code of ethics, then you should resolve it promptly, only if you understand the context as per the caps and the implications of taking that route to resolve the issue (Standler, 1986).

• Determine the ethical dimension of the dilemma and its nature.
• Come up with a list of resolve fitting this problem, through analysing all available medical, therapeutic, and even rehabilitative measures.
• Put down all the implications that would emanate from resolves of this problem. This protects the counsellor from making the wrong decision that would jeopardize his career, compromise his patient, infringe his patients rights and confidentiality and his guardians rights.
• Carefully weigh the course of action. Many counsellors fail to identify the correct measures since the ethical dilemma and the appropriate medication to treat the condition interfere with the code of ethics and could result to legal implications.
• Based on your findings, resolve this problem comprehensively, this may include treating the condition through medication and therapeutic approaches.

Bias and influence

Professionally, personal opinion and objectives to address this issue and a reciprocal from both parents is biased. However, what would compel one professional approach is based on ethical considerations. The child’s well being could compel a biased approach since as a counsellor; the patient’s confidentiality is case is paramount. Protecting the kid is important than the interests of the parents. The approach the counsellor takes is influenced by the previous diagnosis, professional ethics and personal opinion (Haas & Malouf, 1989). The parents might feel denied the chance to participate and contribute to their child’s well being by the counsellor’s methods. This is due tot the fact that the counsellor is biased to the child (Exploratory study of common and challenging ethical dilemmas experienced by professional school counsellors, 2009).

I feel it’s my obligation to treat the child without divulging as much information as the parents want. The counsellor in his capacity has to deliver based on acting in an ethically responsible way concerning the patient (Van Hoose, 1980). The counsellor in his capacity maintains honesty and the best interests or the client without prejudice or objective to gain. He should understand comprehensively the implications, that the solution will work, and that the approach was based on professionalism (Van Hoose & Paradise, 1997). In the event of breaching these codes of ethics principles, the counsellor exposes himself to legal prejudices arising from his failure to understand these guidelines properly (Kitchener, 1984).

Pennsylvania State laws on ethical dilemmas involving schoolchildren

If the guardians or a client questions the treatment, physiological, clinical or rehabilitative, legal implications may follow. This will force the counsellor to appear in court and defend his actions. Unfortunately, professional ethics might force a counsellor to use an-unpopular method.

• The law clearly states that, counsellors are required to abide by the ethical standards of their particular professional organizations.
• The law emphasizes that the professional counsellor should strictly abide to the confidentiality perspective (Van Hoose, 1980).
• Disclose to the clients/parents methods of treatment, the risks and benefits of the method and make sure the patient’s welfare and health is maintained.
• Inform the parents about the limitations, goals risks and benefits when counselling is initiated.
• Determine if the client is receiving services from another practitioner, if so; refrain from providing services until the other professional consents alongside the client.
• Recognize conflicts of interest and inform all parties of the nature and directions of loyalties and responsibilities involved.

These laws are stated in the Pennsylvania counselling laws and directly affect this case. Breaking them could have eventual legal implications (Sileo & Kopala 19).

How State laws affect this approach

Balancing Brett’s confidentiality and parental rights is overburdening. Brett is a minor (under 18 years of age), hence he cannot legally provide informed consent for his counselling and treatment, and as such, his parent’s rights supersede the context of confidentiality. Ethically, confidentiality is needed between the counsellor and Brett within to establish a relationship (Kitchener, 1984); however, his parents want more information than the counsellor believes should be divulged to them in this case.

The sensitive nature of the counsellor relationship with the child cannot be prejudiced in favour of the parents. The counsellor is bound by the law to strictly follow a code of ethics. He will have to deliver without prejudice, favour, or objective to gain in any way from his actions.

The previous diagnosis and subsequent recommendations by the school counsellor forces the counsellor to recognize conflicts of interest. This compels him to inform all parties of the nature and directions of loyalties and responsibilities involved.

The counsellor should determine if the client is receiving services from another practitioner, in this case the school counsellor. If so; refrain from providing services until the other professional consents alongside the client. During treatment, a child may reject treatment or to undergo psychiatric examination. This calls for a closer look at the code of ethics and ones professional priorities. If the ACA code of ethics fails to address this, and then a referral is the obvious next step.

Resolution to Ethical Dilemma

Ethical and legal perspectives surrounding ethical dilemmas should be understood, well (Kitchener, 1984).The ethical practices in the treatment of this condition are consistent with the four principles of beneficence, non-maleficence, justice, and respect to confidentiality or autonomy. There are minimal legal implications that would arise from the diagnosis or treatment of ADHD. However, legal implications would arise in the event where the counsellor treating the patient involves other agencies to supply or disseminate crucial material or information that would contribute to the treatment of this disorder (Foreman, 2006).

Resolving the ethical dilemma using the ACA Code of ethics provisions

The questions revolving around what information can be released to the parents. This type of ethical dilemma is renowned refraining from diagnosis while the ethical dilemma emanating from parents request to review the diagnosis since no procedure existed in the school is known as informed consent in assessment (Rosenbaum, 1982)..

The initial steps of resolving this dilemma is to open communication with all parties involved. Dialogue will help the counsellor inform the parents about his findings, recommendations and other core issues necessary to treat the child.

In this case, it is advisable to widely consult with other professionals. Seek their opinion and recommendations, especially the school counsellor.

Use knowledge

Counsellors need to review the counsellor’s ACA code of ethics thoroughly. This will provide him with an insight on treatment and legal implications. Failure to understand the code of ethics is not defence against unethical conduct.

Assess conflicts between ethics and laws

The counsellor’s ethical responsibilities may conflict with the law. The counsellor should make known his commitment to the ACA code of ethics as the way forward to resolve the problem. In the event the dilemma cannot be resolved through the Code of ethics, then the legal way should be used promptly.

Report ethical violations

The report by the school counsellor indicates that he violated the code of ethics. He failed to abide by the ethical standards. Unless reported, the parents will still pursue the same and sue the current counsellor for failing to do so.

Consultation

If uncertain about his actions, the counsellor should consult with other professionals who are knowledgeable about ethics and the ACA code of ethics. Consultations provide resolves to the dilemma easily (Sileo & Kopala, 1993).

Resolving the ethical dilemma legally

The law clearly states that, counsellors are required to abide by the ethical standards of their particular professional organizations. It is then advisable to stick to the laws governing the practice and avoid indulging in processes that would result to breaking these laws. Breaking the laws will have legal implications.

The law advises that the counsellor disclose to the clients/parents methods of treatment, the risks and benefits of the method and make sure the patient’s welfare and health is maintained (ACA Code of ethics, 2005). The client will have no legal edge since he/she was informed promptly.

The counsellor should inform the parents about the limitations, goals risks and benefits when counselling is initiated (Miller & Rubenstein, 1992). The parents will be aware of each these benchmarks hence cannot accuse the counsellor of withholding such information.

The counsellor should recognize conflicts of interest and inform all parties of the nature and directions of loyalties and responsibilities involved. This will help him to confidently carry out his duties in the sessions.

Regardless of the nature of his findings, the counsellor should not withhold results (Van Hoose, 1980). It is his obligation to report all his findings promptly. The law requires of the counsellor to report the results of any research of professional importance. The results here are unfavourable on Brett’s school counsellor (ACA Code of ethics, 2005).

Bias influence, personal values, and emotion in ethical dilemmas

Bias influence.

The patient (Brett) is a victim of professional ethics. Apparently, it is important to make him priority. Recommending a treatment is more important than the interests of the parents are. My perception is, once the kid begins recovering, the parents will be happy and thankful. However, resolving the dilemma is not priority while taking the schools counsellor to task will be important (Van Hoose & Paradise, 1997). It is an important step to show the credibility of my diagnosis and adherence to the code of ethics (Exploratory study of common and challenging ethical dilemmas experienced by professional school counsellors, 2009).

Personal values

Imposing personal values are commonplace in counselling. Treating Brett’s condition through a pharmacology approach is apparently more effective than the behavioural therapy approach. The parents are insistent that a therapeutic approach is better. Two, ignoring the school counsellor’s failure to diagnose the condition earlier is not priority to the parents; however, my recommendation is that, this should be reported.

The plight of the June and Ward family is moving. As a counsellor, I have developed emotions, especially toward the child Brett who is suffering. The child is oblivious of his problem. He is struggling innocently with a debilitating condition. Am feeling that it is my obligation to correct this condition and help the family go through this difficult phase in their lives. I have developed a special bond with the child and become protective.

My Recommendations to these problems

While bias, emotions and personal values might contribute positively, it is important to uphold professional ethics and rise against these personal influences, biases and emotions (Rosenbaum, 1982). Resolving the ethical dilemma should be prioritized, seconded by the treatment of Brett (Ethical Decision-making Models Across the Professions, 2003).

Adhering to the code of ethics and following the provisions of the law should remain the principals of my profession (ACA Code of ethics, 2005). This way I will be able to diligently and professional come over these personal influences, (Haas & Malouf, 1989). Consulting about the same with a close professional will also provide me with insight to manage this.

American Counselling Association (2005). Code of Ethics. Web.

Ethical Decision-making Models Across the Professions (2003). Web.

Exploratory study of common and challenging ethical dilemmas experienced by professional school counsellors (2009). Web.

Foreman (2006).Attention deficit hyperactivity disorder: legal and ethical aspects. Web.

Haas, L.J. & Malouf, J.L. (1989). Keeping up the good work: A practitioner’s guide to mental health ethics. Sarasota, FL: Professional Resource Exchange, Inc.

Kitchener, K. S. (1984). Intuition, critical evaluation and ethical principles: The Foundation for ethical decisions in counselling psychology. Counselling Psychologist, 12(3), 43-55.

Miller & Davis (2006) A Practitioner’s Guide to Ethical Decision Making. Web.

Sileo, F. & Kopala, M. (1993). An A-B-C-D-E worksheet for promoting beneficence when considering ethical issues. Counselling and Values, 37, 89-95.

Stadler, H. A. (1986). Making hard choices: Clarifying controversial ethical issues. Counselling & Human Development, 19, 1-10.

Van Hoose, W.H. (1980). Ethics and counselling. Counselling & Human Development, 13(1), 1-12.

Van Hoose, W.H. & Paradise, L.V. (1979). Ethics in counselling and psychotherapy: Perspectives in issues and decision-making. Cranston, RI: Carroll Press.

Forester-Miller, H. & Rubenstein, R.L. (1992). Group Counselling: Ethics and Professional Issues. In D. Capuzzi & D. R. Gross (Eds.) Introduction to Group Counselling (307-323). Denver, CO: Love Publishing Co.

Rosenbaum, M. (1982). Ethical problems of Group Psychotherapy. In M. Rosenbaum (Ed.), Ethics and values in psychotherapy: A guidebook (237-257). New York: Free Press.

Counsellor’s positions about ethical dilemmas

An interview with a family psychiatrist.

What professional ethical code do you adhere to as a professional?

I adhere to the ACA code of ethics. It has ready resolves for dilemmas in this profession.

Please discuss an example of the most difficult ethical dilemma that you have faced as a counsellor.

I had this case; it was about an alcoholic teen since her mother was having and affair while still married. I had to keep the information regarding infidelity to the father. However, I had to find a way to treat this kid without tearing the family apart. Her knowledge was to remain confidential while her well being was entirely dependent on the union of the father and the mother.

What is the most common ethical concern or dilemma that you see or experience professionally?

Issues of confidentially have become prevalent. Parental rights are becoming a pressing issue. And most of these cases involve teenagers who know their rights.

As a counsellor, how were you trained to deal with ethical dilemmas and do you feeling your training was adequate?

As a counsellor, resolving ethical dilemmas through seeking the most rational, legal and professional approach from the ACA code of ethics is the most reliable method of addressing ethical dilemmas. My training was good. I feel it suffices in managing the psychological well being of other humans.

If you needed assistance in dealing with an ethical question or concern, what would be your likely course of action? Why?

• In the event that I feel am not sufficiently equipped to proffer a solution, I call my fellow practitioners for advice or referral.
• I always make sure is study the ethical codes before embarking on treatment.
• The code of ethics is a clear guide to resolving ethical dilemmas.

Interview with a counsellor

As a counsellor, how does confidentiality cause ethical dilemmas?

When a patient shared very sensitive info and says it’s confidential whereas if the info is divulged to parents can save or help treat him.

What is the most commonplace ethical dilemma faced by counsellors today?

Confidentiality issues and parental rights

Can you briefly expound on that?

Many patients do not want to share. However, parents are insistent that this information be divulged to them since they have the rights over the children (Van Hoose, 1980). However, the ethical consideration is to seek a balance between breaking the law to correct the problem and finding appropriate measures so as not to abuse the code of ethics in the profession; Seeking parental and patient consent in resolving a problem (Miller & Davis, 2006.

Counsellors find ethical dilemmas as intricate to resolve especially when decision-making models help find the problem what do you do in this case.

Infringing the patients rights would result to legal implications. There are no provisions that allow infringing of these rights (ACA, 2005).

As a counsellor, resolving ethical dilemmas through legal and professional approaches from the ACA code of ethics addresses ethic al dilemmas.

How is that?

Using models of solving ethical dilemmas helps the counsellor address, diagnose, and treat patients. The same also provides a guideline to resolving ethical dilemmas professionally.

Findings about commonplace ethical dilemmas faced by counsellors

Ethical dilemmas and their causes: most counsellors face ethical dilemmas throughout their professional background. My survey on what are the commonplace ethical dilemmas faced by counsellors often shows that, almost all counsellors face similar ethical dilemmas. The issue of questions revolving around what information can be released to the parents is commonplace ethical dilemma. Another commonplace ethical dilemma is parental rights. This leads to the context of confidentiality.

This makes confidentiality to be cited as the most commonplace cause of ethical dilemma. This is often related to teenage related cases. Young adults recommend that the counsellor keeps the information they divulge as confidential.

Different approaches in refraining from diagnosis dilemmas : Due to the sensitivity of some information divulged, counsellors confess divulging bits of information to the parents where teenagers are involved. This information has however been beneficial in the long run. The counsellor pointed out that, this information ended strengthening the family and correcting the problem.

However, most Counselors admit that they would rather stick to the code of ethics and the legal guidelines than risk this approach. They fear going to that extent is unprofessional and risks ones career.

Decision making models used : Almost every counsellor finds the practical 7 steps ethical decision-making model. They confirm that it is ideal for resolving ethical dilemmas.

My take about these Counselors views : I believe going to the extreme of positively contributing to the well being of a family is important and bold. About parents, they want to know what a counsellor discusses with their children. This alright, however, most parents want all information regardless of confidentiality. School Counselors cannot play the role of a professional psychologist due to such parental influence. Actually, it is frustrating not being able to assist a child who you relate with daily when you also know the child’s parents and see the problem both parent and child are facing.

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IvyPanda. (2021, November 23). Ethical Dilemmas in Counselling and Treatment Methods. https://ivypanda.com/essays/ethical-dilemmas-in-counselling-and-treatment-methods-case-study/

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IvyPanda . (2021) 'Ethical Dilemmas in Counselling and Treatment Methods'. 23 November.

IvyPanda . 2021. "Ethical Dilemmas in Counselling and Treatment Methods." November 23, 2021. https://ivypanda.com/essays/ethical-dilemmas-in-counselling-and-treatment-methods-case-study/.

1. IvyPanda . "Ethical Dilemmas in Counselling and Treatment Methods." November 23, 2021. https://ivypanda.com/essays/ethical-dilemmas-in-counselling-and-treatment-methods-case-study/.

Bibliography

IvyPanda . "Ethical Dilemmas in Counselling and Treatment Methods." November 23, 2021. https://ivypanda.com/essays/ethical-dilemmas-in-counselling-and-treatment-methods-case-study/.

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91 . We will take responsibility for our own wellbeing as essential to sustaining good practice with our clients by: a . taking precautions to protect our own physical safety b . monitoring and maintaining our own psychological and physical health, particularly that we are sufficiently resilient and resourceful to undertake our work in ways that satisfy professional standards c . seeking professional support and services as the need arises d . keeping a healthy balance between our work and other aspects of life

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Case Study Application of an Ethical Decision-Making Process for a Fragility Hip Fracture Patient

In Canada, up to 32,000 older adults experience a fragility hip fracture. In Ontario, the Ministry of Health and Long Term Care has implemented strategies to reduce surgical wait times and improve outcomes in target areas. These best practice standards advocate for immediate surgical repair, within 48 hours of admission, in order to achieve optimal recovery outcomes. The majority of patients are good candidates for surgical repair; however, for some patients, given the risks of anesthetic and trauma of the operative procedure, surgery may not be the best choice. Patients and families face a difficult and hurried decision, often with no time to voice their concerns, or with little-to-no information on which to guide their choice. Similarly, health-care providers may experience moral distress or hesitancy to articulate other options, such as palliative care. Is every fragility fracture a candidate for surgery, no matter what the outcome? When is it right to discuss other options with the patient? This article examines a case study via an application of a framework for ethical decision-making.

INTRODUCTION

Every year, over 30,000 Canadian older adults experience a fragility hip fracture. The Ministry of Health and Long Term Care of Ontario has promoted best practice recommendations which advocate for immediate surgical repair, within 48 hours of admission, in order to achieve optimal recovery outcomes. ( 1 , 2 ) The majority of patients are good candidates for surgical repair; however, given the risks of anesthetic and trauma of the operative procedure, surgery may not be the best choice for all. The patients at higher risk of poor outcomes perioperatively deserve the opportunity to explore options and articulate their values. Unfortunately, as a short pre-operative interval predicts the best outcomes, patients and families face a difficult and hurried decision, potentially with limited time to voice their concerns, and little to no information on which to guide their decision.

From a systems perspective, quality of care and health outcomes have not always incorporated the patient-centred perspective. ( 3 ) Patient-centred care is “a moral concept and philosophy, considering it to be the right thing to do when designing and delivering respectful, humane, and ethical care”. ( 4 , 5 ) Patients and families have reported in the past that they feel left out of crucial conversations and decisions surrounding care, ( 6 ) and that relevant information is not always provided. ( 7 )

To better understand the underlying ethical complexities which arise from critical decisions in the acute care setting, this paper will examine a case study to demonstrate application of the Corey et al . ( 8 ) 8-step framework (see Appendix A ) for ethical decision-making.

Ms. Jones is 93 years old and lives in a Long Term Care residence. She was admitted to hospital with a fragility hip fracture after being found on the floor in the middle of the night. Ms. Jones has dementia and is unable to make her own decisions. She has limited mobility, previously used a walker. Her two daughters are at her bedside. They state her health has been declining over the last few weeks, with increasing confusion and she now rarely leaves her room.

On admission, the team discovered a pleural effusion, taking up much of her right lung. Her pre-operative assessment also revealed a heart murmur; the resulting echocardiogram demonstrated a heart in very poor condition, with significant valve issues. Between her cardiac and pulmonary function, the surgery poses an increased risk of perioperative complications—she may never survive the surgery, or come off of the ventilator once she is intubated.

Interprofessional teams (surgery, anesthesia, nursing) are of differing opinions. The issue at hand is very difficult. The family is informed that the risk of not having surgery will likely result in death, yet in this patient’s case, proceeding with surgery carries its own risk. The family is left with an hour to think things over. Should they pursue the palliative care route or proceed with surgery?

Step 1. Identify the Problem or Dilemma

In our case study, 93 year old Ms. Jones is admitted to hospital with a fragility hip fracture. As a first step, we must recognize that there is actually an ethical dilemma; in this case, the dilemma is whether the patient should proceed with surgery or not, given her underlying medical conditions and potential for perioperative complications. We also need to acknowledge that there is an underlying assumption from all involved (staff, Ms. Jones’ family) that surgery will occur, and that health-care providers (HCPs) may not clearly articulate the option of ‘no surgical intervention’. The stakeholders who are required to proceed through the decision-making process include the patient and family, the surgical team, anesthesia, nursing staff, social work, and potentially the palliative care team and bioethics team.

Step 2. Identify the Potential Issues Involved

There are several assumptions made when a patient presents to the hospital with a fragility hip fracture: a) the fracture will be repaired; b) the patient will recover; and c) the patient will eventually go home or to rehabilitation. With a critically ill, frail, and/or previously compromised patient, this standard trajectory should be questioned. Barry and Edgman-Levitan ( 9 ) promote an ideology of patient-centredness, with the argument that an intervention should only be considered standard if there is ‘virtual unanimity amongst patients about the overall desirability… of the outcomes’.

The first potential issue is the ‘standard’ intervention of surgical repair—the assumption to proceed with the surgery, as directed by best practice recommendations. Is this standard intervention appropriate in all patients with a fragility hip fracture? A second potential issue arises with the patient and their family—the presumption that the acute medical issue will be resolved and the patient will eventually return home. Given her underlying health, this concept is in jeopardy. To add to the complexity, Ms. Jones is likely not able to articulate her wishes and values, as she has dementia. Finally, there is the potential issue of moral distress experienced by health-care providers (HCPs) who feel uncomfortable with the expectant surgical trajectory of this patient, and may feel they are not empowered to advocate for the wishes of the patient.

As health-care professionals, we are guided by moral principles in our decision-making process, namely, autonomy, non-malfeasance, beneficence, justice, fidelity, and veracity. ( 10 ) A focused examination and application of the principles to the case study will help to support potential resolutions for the identified issues.

The spirit of ‘patient-centred care’ endorses that patients should be involved at their level of choice to make an autonomous decision. ( 11 ) However, it is important to recognize that no decision is made in isolation. ( 12 ) The decision at hand is not a simple or straightforward one; literature demonstrates that patients and families have a difficult time with making decisions at time of a critical illness, identifying fear, worthlessness, and a lack of autonomy within the hospital system. ( 7 ) Differing levels of patient and family participation requires an individualized approach to convey meaningful, accurate, and timely information. ( 8 ) Older adult patients tend to take a ‘non-participative’ stance in their care. They often have limited participation in the process for decision-making for a variety of reasons, thereby increasing the risk of their inability to understand or find value within the end decision. ( 6 , 7 , 13 )

Non-malfeasance

Hospitalization can cause the patient to experience “needless mental and physical suffering” ( 14 ) in any number of ways (i.e., pain, waiting for surgery, uncertainty of outcomes, patient/family relationship stress). Evidence indicates that the number of different HCPs involved causes immense anxiety to the family, especially when they do not hear the same message from all members of the team. ( 13 , 15 ) HCPs must ensure that they are not withholding information, or are untruthful as to the options in order to expedite a decision. A study by Ekdahl, Andersson, and Friedrichsen ( 13 ) found that physicians perceive they are ‘too short’ of time for patients to participate in the decision making process, that decisions were ‘too complex’ and ‘time consuming’ to fit into the schedule. Ekdahl et al. ( 13 ) also found that physicians feel frustration with the ‘health-care production machine’, especially in those older adult patients with multiple co-morbidities.

Beneficence

Beneficence promotes wellbeing; or is an action that is carried out to benefit another. ( 8 ) The hospitalization ‘process’ promotes assessment of a patient, treatment of the illness, followed by a physical approach to recovery (allowing recovery to be measured against specific milestones), and discharge in a timely manner. ( 15 , 16 ) This ‘process’ may promote beneficence in an overarching global perspective of the system; however, on an individual level, it often falls short. On an individual level, key actions that have been found to be beneficial and meaningful are open communication and sharing of information. ( 6 , 7 , 14 , 17 )

“Practitioners have a responsibility to provide appropriate services to all clients”. ( 8 ) Older adult patients may not receive information about options available, especially if the HCPs feel that it would take too much time to thoroughly explain, or if HCPs assume that patients are too ill to participate in the decision-making process, ( 13 ) or if the assumption is made that all patients want to proceed with surgery. Focusing on each older adult’s individual health goals is time-consuming—in this case, the patient has dementia, and a family meeting would be required. The concept of patient-centred care revolves around patient and HCP partnerships, yet older adult patients face unique problems with hospitalization—a slower communication process, a decreased level of functioning, and a degree of family involvement. ( 14 ) Can we provide this type of relationship and communication effort equally for every patient? Or only for those patients who may be at higher risk of negative outcomes?

Fidelity and Veracity

Fidelity involves fulfilling ones’ professional roles, creating a trusting relationship, and veracity ensures that we are truthful and honest to the patients. How do we ensure that as a HCP we are providing an unbiased opinion? Do we take the same amount of time to present patients with the option of conservative, non-surgical treatment, including palliative care, as we take to advocate for surgery? The HCP team assumes that patients will commit to surgery; however, a patient often displays a suboptimal understanding of the risks and benefits of surgery. ( 18 ) Similarly, there is the very real risk of bias towards an argument of palliative care in those frail patients or those with dementia. HCPs must return to the voice of the patient through their family, to understand that patients’ identity, their meaning of life, and desired goals which emphasize the patients’ dignity. ( 12 )

It is important to acknowledge assumptions that the patient and family may have made upon admission to hospital—that surgery will occur and the patient will recover. Have we presented the patient and their family with as much information as they need to make a decision in a clear format (without medical jargon)? In addition to understanding risks of surgery, it is paramount that the family understands the non-surgical option may result in death or decreased function (if any functional ability returns). It is in an acute situation such as this that families require truthful and open communication with physicians, nurses, and other members of the health-care team. ( 11 )

Self Care (HCPs)

Can we consistently provide care that prioritizes a patient’s values? HCPs are not always able to preserve all of the values and interests at stake. ( 19 ) We know that the most common cause of moral distress in nursing is prolonged, aggressive treatment which we do not believe will be likely to have a positive outcome. ( 20 ) As a HCP, we must look to root causes operating within the larger system, to prevent and/or respond to feelings of moral distress. ( 19 )

From a systems perspective, does the hospital provide an avenue for exploration of patient values within a timely fashion? Is there a framework in place to enhance the HCP’s understanding of moral distress and provide strategies for coping with situations such as these (i.e., an opportunity for a team debriefing with the entire team, or opportunities for learning how to deal with situations that may cause moral distress)?

Step 3. Review the Relevant Ethics Codes

The philosophy of patient-centred care within the hospital encourages active listening, respect, and an attempt to understand individuals. The Canadian Medical Association (CMA) supports “practicing the profession of medicine in a manner that treats the patient with dignity and as a person worthy of respect”. ( 21 ) The College of Nurses of Ontario (CNO) supports the view that nurses “must use the client’s views as a starting point”. ( 22 ) Across all HCPs is the similarity of the need to listen, understand, support, and advocate for a respect of patients’ values with the expected course of treatment.

The importance of collaboration with the patient and respecting a patient’s values are highlighted within similar statements: ”…it is the patient who ultimately must make informed choices about the care he or she will receive”. ( 21 )

Step 4. Know the Applicable Laws and Regulations

In Ontario, legislation and common law require that the wishes of patients or substitute decision-makers be respected. ( 22 ) However, in many systems, health care is not truly patient-centred; rather, patients are required to adapt to the system. ( 11 ) A number of initiatives have been undertaken in the last few years in an attempt to improve the focus of patient-centredness, with the principle assertion that patients should be involved at the level of their choice. ( 11 )

Step 5. Obtain Consultation

It is important to realize that we bring our own biases to the decision-making process, making it difficult to view the current patient/family’s situation objectively. As an individual HCP, our previous experiences will have an impact on the messaging that we provide. From a systems perspective, we are likely to pose a ‘knowledge’ bias towards meeting treatment based outcomes—for example, surgery within 48 hours, immediate post-operative mobility, and the expected length of stay for this type of patient.

Inter-disciplinary consultations with patients and their families ensure review of unbiased information about the risks and benefits of proceeding with surgery, allowing for a fully informed decision. In addition to discussing the operative plan with the surgical team, there is an opportunity to provide Ms. Jones’ family with other options that may be available to her. Consultation with extended family members, clergy, social workers, or an ethics team may help the family to reflect on the patient values; what this illness means to them as a family unit, and how best to proceed. A discussion with palliative care may help the family to better understand what symptom management consists of for their mother. Social work may also be able help explore community services available to the family in this situation—for example, is the patient able to return to home with the future of wheelchair dependence? Are there any other options which may be available to this patient and her family that were not originally considered? How do we, as HCPs, ensure that the family is afforded the opportunity to obtain all the necessary information from differing disciplines to make an informed choice?

Step 6. Consider Possible and Probable Courses of Action

In order to fully understand the options, it is helpful to outline all the possible and probable courses of action that are open to Ms. Jones and her family.

• Surgical team offers a ‘purposeful pause’ to discover Ms. Jones’ core values; to discuss the consequences of a) delaying surgery, b) proceeding with surgery, and c) the non-surgical intervention. From an ethical and legal perspective, this may meet the concept of patient-centred care, but does not likely provide the patient and her family with all the information they need to make an informed choice. They may have more questions that the surgical team may not be able to answer, or they may request more time to consider. Additionally, the patient and her family would still be expected to adapt to the system in place in order to make a decision within the proposed wait time frame (admission to surgery less than 48 hours).
• Advocate for a family meeting with the primary nurse, social work, palliative care team, clergy, internal medicine, in addition to the surgical (surgeon, anesthesia) team, to fully explore both options, and to explore what the ‘non-surgical’ option would mean. From a legal and ethical perspective this embodies the concept of patient-centred care, with as many members of the health-care team at the table to help Ms. Jones’ family fully explore their options.
• Apply the current standard of care recommendations to Ms. Jones’ situation, without consideration of the patient’s needs, values, or preferences. From an ethical and legal perspective, this approach does not represent patient-centred care.

Step 7. Enumerate the Consequences of Various Decisions

With the first option, the surgical team takes a ‘purposeful pause’ to discover the patient’s core values and discusses pros and cons of a surgical intervention. Often, this may be most ‘efficient’ way to deal with the situation at hand. It may also be the preference of the patient; some patients have reported that they value this limited level of involvement—“I get a description of what is going to happen”. ( 13 ) As a consequence, there will be a number of patients who will want to have a greater sense of involvement other than a simple description of planned events. The first option does recognize the principle of autonomy, but does not follow the principle of justice; practitioners have the responsibility to provide information about other options which may be available. The principles of beneficence and non-maleficence are not completely met, as the team approaches the solution primarily to benefit the system (i.e., efficiency). The principles of fidelity and veracity are also partially met, as the surgical team provides an honest perspective, although it may be biased towards proceeding with surgery.

The second option, offering the patient and her family a meeting with all stakeholders, strongly aligns with the fidelity and veracity principles. The information offered is truthful and complete, and is in Ms. Jones’ best interest, as it attempts to discover her values that will affect the family’s final decision. Principles of beneficence and autonomy would be met with patient empowerment through information sharing, and secondly, by allowing the patient and family to arrive at their own decision with that information. As a consequence, taking the time to arrange for a family meeting with all stakeholders may not be possible for all patients, and the principles of justice and non-maleficence are brought to the forefront for future patients. A potential consequence could be harm to the patient, as the time it takes to arrange a meeting could push the time to surgery beyond the recommended 48 hours post-admission, placing the patient at greater risk of negative post-operative outcomes.

The third option is one of passive action, with a lack of communication and recognition of patient-centred care values. Ms. Jones would be placed on the operating room list, and the surgical repair will occur. Consent must legally be obtained for the surgery; however, the family may not think of key questions to ask that may be relevant in this situation. The onus remains on the HCP to provide a full explanation of all options to the family. The only benefit would be to the system, as the procedure will be carried out in a timely manner. Ms. Jones may benefit from the surgery; we cannot assume that surgery is a negative option. As a consequence of this option, HCPs do not explore patient values, and this option is against almost all of the ethical principles. Additionally, this option is likely to cause the highest moral distress amongst staff, as they are unable to meet the unique needs of Ms. Jones and her family.

Step 8. Choose what Appears to be the Best Course of Action

Virtue ethics asks us if we are doing the best action for our patients, and compels us to be conscious of our behaviours. ( 8 ) We need to take the necessary time to discover the patient’s values within the unique situation they are now experiencing. Simply stated, we need to remember that they are a person, with feelings, emotions, past experiences, future hopes/plans, and usually an element of fear and anxiety. The goal is to work with Ms. Jones and her family to decide together on the current care plan and the best plan for action (or inaction), a plan that truly aligns with the patient’s values.

From an ethical perspective, the best course of action is to hold a family meeting with all stakeholders to discover Ms. Jones’ values about a meaningful life and a meaningful death, and come to a consensus as to what the right decision is for this patient. ( 12 ) The team must ensure that the patient and the family have all the necessary tools in which to make this decision. Have we provided them with all the information required? Do they understand the information? Do they understand the consequences of their decision? From a systems perspective, we need to continue to strive towards engaging patients and family members more fully and consistently in care and decision-making processes. ( 6 ) Dissemination of lessons learned from assisting patients and families through difficult decision-making may be helpful to other health-care teams experiencing similar moral conflicts.

As a next step, the HCP team may consider development of an educational reference for future patients to assist with similar decisions, including promotion of an advanced care plan to help communicate goals and concerns to HCPs. ( 12 , 18 ) Additionally, decision aids, such as videos and brochures, can help deliver information to patients and their families. ( 9 ) The use of readily available technology, such as iPads and cellphones, means that families are better able to access these materials at any time of day. A recent Cochrane Review demonstrated that, in comparison to usual care, decision aids can increase knowledge, resulting in a higher proportion of patients choosing the option which most aligns with their values. ( 23 ) Providing patients with information that outlines potential options with risks and benefits clearly explained can also meet many of the ethical principles that are to be considered with ethical decision-making.

The in-depth review of the case study has helped us to examine the underlying issues that come into play when helping this patient and her family to make a critical decision. Although each patient is an individual, literature tells us that many perceive the concept of patient-centredness to represent an ‘involvement in their care’. The level of involvement may vary from person to person, but all patients want the care they receive to reflect their values and preferences, and to make them feel that they have been treated as a whole person. ( 24 )

Clinicians also like to believe that they deliver patient-centred care, yet the characterization of the concept will vary with the health-care provider, their relationship with the patient, and the circumstances surrounding the admission to hospital. Recognizing that there is potential for an ethical dilemma when patients present with a critical illness is important to ensure that we continue to act upon the key concept of understanding a patients’ values and proceeding to align provision of care with those values.

ACKNOWLEDGEMENTS

The author wishes to acknowledge Dr. Tracy Trothen (Queen’s University) for her time and expertise as a ‘practical ethicist’.

Appendix AFramework for Ethical Decision-Making (Corey et al ., 2014)

• Identify the problem or dilemma
• Identify the potential issues involved
• Review the relevant ethics codes
• Know the applicable laws and regulations
• Obtain consultation
• Consider possible and probable courses of action
• Enumerate the consequences of various decisions
• Choose what appears to be the best course of action

CONFLICT OF INTEREST DISCLOSURES

The author declares that no conflicts of interest exist.