RESOLVING ETHICAL DILEMMAS

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RESOLVING ETHICAL DILEMMAS

• MODELS FOR MAKING DECISIONS
• Erika L. Liljedahl, Psy.D.
• The Chicago School of Professional Psychology

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Ethical Decision Making Models

• Dr. Erika L. Liljedahl will be presenting four
  different ethical decision making models which
  will assist mental health professionals in
  trouble shooting ethical dilemmas. These models
  help guide the thought process when one is faced
  with an issue that is not clearcut. The
  objectives of this talk are to provide a brief
  history of ethics, to teach the steps of the four
  models, and to help mental health professionals
  apply the steps in order to more competently
  handle the "gray" areas when making decisions.
  Dr. Liljedahl highly recommends using an ethical
  decision making model and documenting the steps
  in the thinking process. She believes that this
  is an essential step in forensic documentation
  and litigation prevention.

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Objectives of this talk

• Students will learn several Ethical Decision
  Making Models.
• Students will learn how to apply the models to
  classes and in their careers with youth and
  adults.
• Students will become more familiar with how to
  handle the gray areas when making decisions
  using the Ethical Decision Making Models
  presented.

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Contents of talk

1. What are ethics? Values and ethics
2. Brief history of ethics
3. Who makes unethical decisions?
4. Presentation of 4 Ethical Decision Making Models

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What does it mean to be ethical?

• The World English Dictionary says In accordance
  with principles of conduct that are considered
  correct, especially those of a given professional
  or group
• Merriam-Webster says Conforming to accepted
  standards of conduct
• Knowing the difference between right and wrong,
  and choosing the right
• Having virtue, good moral reasoning
• Having a positive, good value system, which might
  include doing good things in the world, be hard
  working, be honest, treat others as you want to
  be treated, be loyal to your family.

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Values vs. Ethics Code

• It is possible that your values will oppose what
  the ethics code or law states.
• Example You are attracted to your former client
  and the client has verbalized that the attraction
  is mutual.
• The APA code states you must wait 2 years.
• The ACA code states you must wait 5 years.
• So do you develop a relationship after 2 years? 5
  years? Or is having a sexual relationship with a
  former client altogether against your value
  system?

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Brief History of Ethics

• Origin of ethics is in Ancient Greece 460BC
• Philosophers such as Socrates, Plato and
  Aristotle wished to impart knowledge on how to
  argue thoughts and to be successful, but also
  developed views on being ethical and moral.

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Socrates

• learned from the Oracle of Delphi to know
  thyself. Knowing thyself (and values) increases
  knowledge and wisdom. Wisdom leads to increased
  critical reasoning and problem solving skills.
• Knowledge and
• wisdom ?
• leads to acting
• Ethical.

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In summary

• Greek philosophers set the stage for ethical
  decision making through examination of ideas that
  were abstract, such as the virtue of wisdom,
  critical thinking, Socratic questioning such as
  playing Devils advocate, and even through
  ethical dilemmas presented in Greek tragedy on
  stage.

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• So if having knowledge, wisdom and knowing
  thyself assist with making good ethical
  decisions, then what kind of a person in todays
  time makes unethical decisions?

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One study showed that individuals that are more
apt to make unethical decisions at work are
those

• who obey authority figures unethical directives
  or act merely to avoid punishment,
• who manipulate others to orchestrate their own
  personal gain,
• who fail to see the connection between their
  actions and outcomes,
• who believe that ethical choices are driven by
  circumstance. (Kish-Gephart, J.J., et al. 2010)

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Another interesting note from this study

• Egotistic work places are more likely to promote
  an everyone for themselves environment, which
  promotes more unethical behaviors.

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So how can one be as ethical as possible, whether
or not one is in a supportive or an unsupportive
work environment?
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Knowing at least one Ethical Decision Making
Model is recommended to assist with problem
solving through ethical dilemmas (the gray
areas).

• In this talk, I will review.
• 3 clinically-related Ethical Decision Making
  Models, and
• 1 non-clinically related Ethical Decision Making
  Model

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CLINICALLY-RELATED ETHICAL DECISION MAKING MODELS
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Two major perspectives

• Positive Ethical Models
• The focus is on pursuing highest ideals
• Defensive Ethical Models
• The focus is on thinking of the worst scenario,
  avoiding punishment

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Model 1 Ethical Decision-Making Model in
Forensic Psychology Positive Ethical Model

• Source Bush, S.S., Connell, M.A., Denney,
  R.L. (2006). Ethical Practice in Forensic
  Psychology A Systematic Model for Decision
  Making. Washington D.C. American Psychological
  Association.

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Steps

• Identify the problem
• Consider the significance of the context and
  setting
• Identify and utilize ethical and legal resources
• Consider personal beliefs and values
• Develop possible solutions to the problem
• Consider the potential consequences of various
  solutions
• Choose and implement a course of action
• Assess the outcome and implement changes as
  needed

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Case Study Confidentiality of minor with
suicidal thoughts

• Joe is your 16 year old client who came to
  therapy because of having low self esteem and
  being depressed about his parents divorce. Both
  the mother and father are fighting for custody of
  Joe. In the course of therapy, Joe reported that
  he has begun having thoughts of self harm.
• Let us examine this case using Model 1.

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Step 1 Identify the problem

• The problem
• Suicidal thoughts. Hospitalize or not.
• Confidentiality Is it your ethical
  responsibility to talk to the parents? Do you
  have a duty to tell the parents or because Joe is
  a minor?
• Should you monitor his progress and not involve
  the parents at all?

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Step 2 Consider the significance of the context
and setting

• The client is a minor. Do the parents know about
  his psychological status? Do the parents know
  their son is in therapy? What would they do if
  they found out he is seeing a counselor and is
  suicidal?
• Which parent do you talk to? How do you determine
  who has legal guardianship?
• What harm could come if you tell the parents? Or
  not tell the parents?

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Step 3 Identify and utilize ethical and legal
resources

• Look at your ethics code (APA, ACA, etc)
• Look at the law about privacy and duty to warn
• HIPAA on confidentiality
• State laws Illinois Mental Health
  Confidentiality Act
• Look at journal articles, books, case studies
• Review position statements of your relevant
  national association
• Consult with colleagues

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In the case of Joe

• In general, ethics codes will have the following
  components
• Do no harm.
• No disclosure without consent (unless mandated by
  law).
• Limitations to confidentiality include suicidal
  or homicidal ideation/intent.
• Confidentiality with minors.

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(405 ILCS 5/) Mental Health and Developmental
Disabilities Code (Illinois)

• Any minor 12 years of age or older may request
  and receive counseling services or psychotherapy
  on an outpatient basis without the consent of the
  minors parent or guardian. Outpatient counseling
  or psychotherapy provided to a minor under the
  age of 17 shall be limited to not more than 5
  sessions, a session lasting not more than 45
  minutes, until the consent of the minors parent
  or guardian is obtained.  The minors parents
  shall not be informed without the consent of the
  minor unless the facility director believes such
  disclosure is necessary. 

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U.S. Department of Health Human Serviceson
HIPAA.

• Permitted Uses and Disclosures Serious Threat to
  Health or Safety.
• Covered entities may disclose protected health
  information that they believe is necessary to
  prevent or lessen a serious and imminent threat
  to a person or the public, when such disclosure
  is made to someone they believe can prevent or
  lessen the threat (including the target of the
  threat).

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Step 4 Consider personal beliefs and values

• How do you feel about breaking confidentiality in
  this case? Is it necessary? You believe that you
  might alienate Joe if you broke confidentiality.
• You value life and improving relationships
  imminent harm or not, you want to inform family
  to intervene. In other words, is your core value
  to involve family as much as possible?
• You believe that more emotional distress would
  enter the equation if the parents would know that
  Joe is depressed and suicidal.

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Step 5 Develop possible solutions to the problem

• Utmost importance Perform a suicide lethality
  assessment.
• Inform Joe what your duties are as a therapist
  (your ethical duty of preserving life and the
  possibility involuntary hospitalization).
• Engage Joe in a logical discussion about the pros
  and cons of telling his parents.
• Joe could invite his parents into the session and
  could inform them with the therapist.
• If Joe does not want to inform his parents, have
  Joe check in with you during the week and call
  the suicide hotline for additional support.

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Step 6 Consider the potential consequences of
various solutions

• During a suicide lethality assessment, you
  determine whether Joe is passively or actively
  suicidal. Joe could be hospitalized.
• After discussing the pros and cons of telling his
  parents, he can decide to tell them or not.
• If Joe does not want to inform his parents, Joe
  might have less support. His parents might
  continue fighting without even considering Joes
  psychological status.

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Step 7 Choose and implement a course of action

• If passively suicidal
• Decision To continue monitoring Joe in therapy
  sessions, to have him call suicide hotlines for
  support. Encourage Joe to tell his parents, seek
  support form trusted friends and family.
• If actively suicidal
• Decision Hospitalize. Encourage Joe to tell his
  parents, and/or inform Joe hat his parents will
  be informed. Seek support from trusted friends
  and family.

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Step 8 Assess the outcome and implement changes
as needed

• If not actively suicidal Is monitoring Joe in
  therapy sessions sufficient to ward off suicidal
  thoughts? Did he involved family or friends for
  support?
• Does Joe need a referral for possible medicine
  management?
• If actively suicidal How did Joe react to the
  hospitalization? How did his parents react?
• Is there anything more you need to do as an
  ethical mental health professional?

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Model 2 Ethical Decision-Making Strategy

• Source Koocher, G.P. Keith-Spiegel, P. (2008).
  Ethics in Psychology and the Mental Health
  Professions Standards and Cases. Oxford
  University Press New York.
• Chapter 2 Making Ethical Decisions and Taking
  Action, written by Edmund Burke.

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Steps

1. Determine whether the matter truly involves
   ethics.
2. Consult guidelines already available that might
   apply as a possible mechanism for resolution.
3. Pause to consider, as best as possible, all
   factors that might influence the decision you
   will make.
4. Consult with a trusted colleague.
5. Evaluate the rights, responsibilities, and
   vulnerability of all affected parties.
6. Generate alternative decisions.
7. Enumerate the consequences of making each
   decision.
8. Make the decision.
9. Implement the decision.

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Case Study

• A student told a teacher about another student
  threatening her on Facebook and the school had to
  decide how to proceed. 

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Step 1 Determine whether the matter truly
involves ethics.

• Is this an ethical issue for the teacher?
• Does this case involve your ethical standards?
  (E.g., APA General Principles of beneficence and
  nonmaleficence, fidelity, responsibility,
  integrity, justice)
• Does the teacher have to do anything at all since
  the threat was online?
• Is there an ethical duty to protect the student
  because he/she is a minor?

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Step 2 Consult guidelines already available that
might apply as a possible mechanism for
resolution.

• What are the schools policies regarding
  cyber-bullying?
• Is there a decision-tree in place at the school
  to deal with cyber-bullying and harassment?
• What does your ethical code state?
• Do the parents need to be informed?
• What are your values in such a case?

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School Code Illinois General Assembly

• Character education. Every public school teacher
  shall teach character education, which includes
  the teaching of respect, responsibility,
  fairness, caring, trustworthiness, and
  citizenship, in order to raise pupils' honesty,
  kindness, justice, discipline, respect for
  others, and moral courage for the purpose of
  lessening crime and raising the standard of good
  character. Sec. 27-12.

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Internet safety education curriculum (IL School
code Sec. 27-13.3)

• (1) Safe and responsible use of social networking
  websites, chat rooms, electronic mail, bulletin
  boards, instant messaging, and other means of
  communication on the Internet.
• (2) Recognizing, avoiding, and reporting online
  solicitations of students, their classmates, and
  their friends by sexual predators.
• (3) Risks of transmitting personal information on
  the Internet.
• (4) Recognizing and avoiding unsolicited or
  deceptive communications received online.
• (5) Recognizing and reporting online harassment
  and cyber-bullying.

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Illinois Law on cyber-harassment Harassment
through electronic communications (720 ILCS
135/1-3).

• Class B misdemeanor if person is convicted of
  harassment (720 ILCS 135/2) (from Ch. 134, par.
  16.5, Sec. 2. Sentence.
• A second violation constitutes a Class A
  misdemeanor (minimum of 14 days in jail, or maybe
  240 hours of community service).
• If harassment continues (3), Class 4 felony. If
  there is a threat to kill, it is an automatic
  Class 4 felony.     

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Step 3 Pause to consider, as best as possible,
all factors that might influence the decision you
will make.

• What was the threat said on FB? Was it vague or
  specific? How many times has this happened? Is it
  a one time occurrence or repeated?
• Consider the harassed students safety ability
  to concentrate in school.
• Consider if one student is being threatened,
  other students could be in the same situation.
• Think the worst scenario could happen.

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Step 4 Consult with a trusted colleague.

• Read the law and policies appropriate to this
  case.
• Talk to your immediate supervisor, the Principal
  of the school, your colleagues about the school
  policies or lack thereof.
• Consult with books, journal publications, the law
  for cases that are similar.
• Possibly involve the police.

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Step 5 Evaluate the rights, responsibilities,
and vulnerability of all affected parties

• Children have the right to be safe and learn in a
  safe environment.
• The harassing child has the right to be heard
  which may lead to be tried in a court of law.
• Teachers have the right to teach in a safe
  environment. They also have the right to provide
  a character education component into their
  curriculum.

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Step 6 Generate alternative decisions.

• Some solutions
• Ask for the student to print the FB page
• Someone (teacher, counselor, Principal,
  Superintendent) would talk to each child
  separately
• Talk to both children together
• Involve the parents
• Involve the police

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Step 7 Enumerate the consequences of making each
decision.

• Ask for the student to print the FB page
• Decide if there is harassment.
• If harassment exists then go to the next step.
• If harassment does not exist If the wording was
  misconstrued by the student, then provide
  education on what constitutes harassment. You
  might want to decide on what caused the
  misinterpretation. Does the student have a
  learning disability? Is the student overly
  suspicious of people? Did someone else influence
  the student?

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Step 7

• Someone (teacher, counselor, Principal,
  Superintendent) would talk to each child
  separately
• Each child could tell his/her story without
  hesitation. This confidentiality would likely
  allow each student to speak in an uninhibited
  manner.
• Talking to the harassed student separately would
  likely shield the student from some additional
  unnecessary grief. Showing the grief in front of
  the harasser might reinforce the harassing. The
  harassing could become more covert.
• There might be something going on in the
  harassers life that would be useful information
  to the behaviors.

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Step 7

• Talk to both children together
• Conduct a conflict resolution session without
  involving the police or higher authority, such as
  the Superintendent.
• Involve the parents
• Appraise the parents about the situation and
  involve them in the conflict resolution.

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Step 7

• Involve the police
• Pros A juvenile record is created for the
  student harasser in case that the harassing will
  be ongoing. This record will likely lead to
  psychological intervention of forensic
  psychologists, to assist the juvenile to
  rehabilitate his or her behaviors.
• Cons There is a record that will follow the
  juvenile, even if he or she rehabilitates,
  however note that this record is sealed and can
  only be accessed by some law enforcement.

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Step 8 Make the decision andStep 9 Implement
the decision

• What would you do?

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Model 3 Feminist Ethical Decision-Making Model

• Source Anderson, Gail (1997). Women Therapy.
  Introduction Children, Adolescents and Their
  Powerholders in Therapy Settings, 20, 2, 1-6.

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Steps

1. Recognizing a problem
2. Defining the problem
3. Developing solutions
4. Choosing a solution
5. Reviewing process
6. Implementing and evaluating a decision
7. Continuing reflection

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Case Study Confidentiality

• A 12 year old girl is forced to go into therapy
  because of acting out at school. During the first
  session with the adolescent, the therapist finds
  out that the girl is actively abusing marijuana
  and possibly ecstasy with her friends. The
  parents do not know this information.
• What do you do? Do you tell the parents?

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Steps 1-2

• (1) Recognizing a problem and (2) Defining the
  problem You are uncertain what to do. What are
  your values that interfere with a decision?
• If you tell the parents, you run the risk of
  alienating the girl. If you do this, more harm
  can come.
• If you do not tell the parents, they will not be
  able to intervene and get the girl treatment.
  They can sue you since the girl is still a minor.
  You also run the risk of the girl getting
  arrested, creating brain damage, and the worst is
  overdosing and causing death.

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Step 3 Developing solutions

• You tell the parents
• You tell them to assist with maintaining their
  daughters safety.
• You do not tell the parents
• As cited in this article, Snyder believes
  children are of worth and full citizens that
  share the basic rights to life, safety,
  happiness, equality of treatment, equality of
  opportunity, reasonable self-determination and
  due process. This is from a feministic approach
  egalitarian.
• The law is behind this decision Illinois law
  allows 12 year old to hold some power for
  maintaining confidentiality.

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Step 4 Choosing a solution

• What is the best fit both emotionally and
  rationally? Does the solution meet everyones
  needs, including mine? Can I implement and live
  with the effects? (Anderson, 1997, p.4)
• If you do not tell the parents you should be
  aware of the law

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Please note 740 ILCS 110 (Illinois Law) for
children between 12 under 18 years old) about
records

• (3) the parent or guardian of a recipient who is
  at least 12 but under 18 years, if the recipient
  is informed and does not object or if the
  therapist does not find that there are compelling
  reasons for denying the access. The parent or
  guardian who is denied access by either the
  recipient or the therapist may petition a court
  for access to the record. Nothing in this
  paragraph is intended to prohibit the parent or
  guardian of a recipient who is at least 12 but
  under 18 years from requesting and receiving the
  following information current physical and
  mental condition, diagnosis, treatment needs,
  services provided, and services needed, including
  medication, if any.

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Step 5 Reviewing process

• Would I want to be treated in this way?
• Does the decision feel right?
• Would this decision withstand the scrutiny of
  others?
• How are my values, personal characteristics
  influencing my choice?
• Have I taken the clients perspective into
  account?
• These questions are from the article.

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Step 6 Implementing and evaluating the decision

• Carry out the decision
• Is this solution the best I can do?
• Observe consequences
• Reassess the decision
• How has this decision affected the therapeutic
  process?
• These questions are from the article.

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Step 7 Continuing reflection

• What did I learn?
• Have I changed as a result of this process? How?
• What would I do differently?
• How might this experience affect me in the
  future?
• These questions are from the article.

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NON- CLINICALLY-RELATED ETHICAL DECISION MAKING
MODEL
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DEPARTMENT OF DEFENSE

• Model Ethical Decision Making Plan
• Source United States Department of Defense

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10 Steps TotalSteps 1-4

• Define the problem (state the problem in general
  terms and decisions to be made)
• Identify the goals (short and long term goals)
• List the appropriate laws or regulations
• List the ethical values at stake

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Steps 5-7

• Name all the stakeholders (identify persons who
  are likely to be affected by a decision and what
  is at stake for each person)
• Gather additional information (take time, ask
  questions, demand proof when appropriate, check
  your assumptions)
• State all feasible solutions (list solutions that
  have already surfaced, produce additional
  solutions by brain storming with associates, note
  how stakeholders can be affected by each
  solution)

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Steps 8-10

• Eliminate unethical options (eliminate solutions
  clearly unethical, eliminate solutions with
  short-term advantages but long-term problems)
• Rank the remaining options according to how close
  they bring you to your goal, and solve the
  problem
• Commit to and implement the best ethical solution

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SUMMARY

• According to Martin and Bush (2008), Knapp and
  VandeCreek identified 5 common steps after
  reviewing several Ethical Decision Making Models
• Identification of the problem
• Development of alternatives
• Evaluation of alternatives
• Implementation of the best option
• Evaluation of the results

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References Books and Journals

• Anderson, Gail (1997). Women Therapy.
  Introduction Children, Adolescents and Their
  Powerholders in Therapy Settings, 20, 2, 1-6. 
• Bersoff, D.N. (2008). Ethical Conflicts in
  Psychology, Fourth Edition. American
  Psychological Association Washington D.C. 
• Bush, S.S., Connell, M.A., Denney, R.L. (2006).
  Ethical Issues in Forensic Psychology A
  Systematic Model for Decision Making. Washington
  D.C. American Psychological Association  
• Kish-Gephart, J.J., Harrison, D.A. Trevino,
  L.K. (2010). Journal of Applied Psychology. Bad
  Apples, Base Cases, and Bad Barrels
  Meta-Analytic Evidence About Sources of Unethical
  Decisions at Work, 95, 1, 1-31.
• Koocher, G.P. Keith-Spiegel, P. (2008). Ethics
  in Psychology and the Mental Health Professions
  Standards and Cases. Oxford University Press New
  York. (Chapter 2 Making Ethical Decisions and
  Taking Action, written by Edmund Burke, pages
  20-40).
• Martin, T.A. Bush, S.S. (2008).
  NeuroRehabilitation. Ethical considerations in
  geriatric neuropsychology, 23, 447-454.

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References E-Resources

• HIPAA U.S. Department of Health Human
  Services http//www.hhs.gov/ocr/privacy/ 
• Illinois General Assembly School Code
  http//www.ilga.gov/legislation/ilcs/ilcs4.asp?Doc
  Name010500050HArt2E27ActID1005ChapterID17S
  eqStart149700000SeqEnd156200000
• Mental Health and Developmental Disabilities
  Code http//www.ilga.gov/legislation/ilcs/ilcs5.
  asp?ActID1496ChapAct40526nbsp3BILCS26nbsp3B
  52FChapterID34ChapterNameMENTALHEALTHActNam
  eMentalHealthandDevelopmentalDisabilitiesCod
  e2E
• National Conference of State Legislatures on
  Cyber-harassment (720 ILCS 135/1-2)
  http//www.ilga.gov/legislation/ilcs/documents/072
  001350k1-2.htm
• State laws Illinois Mental Health
  Confidentiality Act http//www.ilga.gov/legislat
  ion/ilcs/ilcs3.asp?ActID2043ChapterID57
• United States Department of Defense Ethical
  Decision Making Plan http//www.ryerson.ca/ethic
  snetwork/downloads/model_I.pdf
• U.S. Department of Health Human Services on
  HIPAA http//www.hhs.gov/ocr/privacy/hipaa/under
  standing/summary/index.html
•  

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Recommendations

• Know your Ethics Code
• Know what the law requires of therapists
• Take the higher road
• Do what minimizes harm to clients and others, and
  to your person ethical values
• Think clearly
• Document your thinking process and use of an
  Ethical Decision Making Model
• If there are any questions, consult consult
  consult!

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Thank you for your attention!