Psychiatric Mental Health Ethical Scenario: The Case of Paula

Group Therapy has multiple ethical issues, and one of the most frequent and usually seen in the involuntary group members are, informed consent and confidentiality. Ethically a counselor must instruct patients about theirs rights and responsibilities and advise them of any possible concern they could experience, if they choose to follow treatment. So, informed consent is very important when participation is mandatory, and all psychologist, counselor, and therapist must obtain from patients, and it is important because the counselor must follow guidelines during their sessions. A counselor becomes complicated when a patient becomes an involuntarily member in a group therapy, because the incorporation of the patient places limitations on the trail of the sessions in the group. Members should join to a group therapy of their own will, and with adequate information on the goals, rules, fees, confidentiality, rights and responsibilities of group members (Tuckman & Jensen, 1977). It is a must that new members know the consequences of breaching rules of the group, and the importance of treating other group members with respect and avoiding arguments. It is also vital for the group counselor to instruct the need for confidentiality by group members. A counselor may face several ethical issues in counseling, from bias or double relationship, involuntary patient, breach of confidentiality, moral dilemmas and other significant factors. In this case study we will find some ethical dilemmas that usually are encountered by counselors and supervisors (Sederer L, 2013). This ethical issue happened at LF Mental Wellness Center during my clinical hours of psychotherapy rotation. I’m an FNP, currently pursuing my PMHNP and performing my clinical rotation at LS clinic Center. Asuncion is the psychiatrist PMHNP, and Paula the LMHC, which is my clinical supervisor and preceptor.

Ethical Problems 

Basically, the ethical problem started when Paula was requested to violate confidentiality by giving personal information about her patients during a periodical report. One more ethical issue I experienced, was when a patient refused medical care. It seems to happen due to an inappropriate informed consent, because an involuntary group therapy admission of a patient, and a breach of confidentiality, that occurred during treatment. The administrator requested to Paula a list of patients that were treated on monthly basis, and a list of community providers with whom she refers and consults. This data was demanded to complete a periodical report. Paula was concerned about disclosing this information, as it is her ethical responsibility to protect her client’s confidentiality. Her unwillingness to provide the names is due to her prior experience, when the administrator revealed confidential information to others, particularly to her secretary. Moreover, Paula witnessed this secretary sharing confidential information with other employees not involved in the case. Paula seeks guidance to her boss on how to proceed to maintain her ethical, moral, and legal responsibilities without risking her job.

Ethical Principles Involved

From the perspective of Paula and mine, justice includes taking steps to guarantee the protection of the clients and to implement the appropriate ethical code. Non-maleficence and beneficence comprise upholding privacy. Throughout the process the administrator, should respect Paula’s autonomy and knowledge about the situation and the clinic environment. Regarding fidelity, Paula is likely to work against disclosing confidential client’s information, including their participation in counseling (Glosoff & Pate, 2002). From the position of the patients and guardians, justice would include Paula and the clinic system respecting their privacy. Glosoff, Herlihey and Spence (2000) said that most individuals seeking counseling assume their information will be kept in confidence. Regarding non-maleficence, to avoid harm, personal information shouldn’t be disclosed unless the patient/guardian gives consent. Under the category of beneficence, some patients/guardians may be comfortable providing information to contribute to a report to improve services in the future. Autonomy would allow for the patients/guardians to make their own choices about whether to be included in this report without Paula passing judgment or imposing their own goals (Herlihy & Corey, 1996). To support fidelity, the patients/guardians may see Paula’s responsibility to keep the promise of confidentiality.

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First, Paula was asked to violate confidentiality by providing identifying information about the clients for a report. Second, the clinical setting included inappropriate practices, as both the administrator and the secretary had shared confidential information with others. Third, by not providing an appropriate informed consent to the patient and guardians had provoked a rejection to treatment. Therefore, increasing patient’s stress and fear to be treated (Sederer L, 2013). As a PMHNP student I must follow institution’s policies, but these policies required from me to violate my ethical obligations. However, since I’m a student of the clinic, it is implied I agrees with the general policies and principals of the institution (ACA, 2005). Since these policies require me to violate ethical obligations, I should inform clinic’s administration to change the standard, so I not required to breach confidentiality (ACA, 2005). Managing confidentiality is an extensive and stimulating issue (Isaacs, 1999). The ACA Code of Ethics establishes trust and confidentiality as “two cornerstones of any counseling relationship, and counselors are expected to discuss with clients how, when and with whom client’s information is to be shared” (ACA, 2005).

All Possible Courses of Action

Several choices can be made in this case, fluctuating from completely ignoring the situation, to giving data without asking for it, with countless choices in between. The purpose of it, is to inspire flexibly all the options, regardless of penalties, and to guarantee all available options considered. Consequently, possible paths of action, may include: to ignore the situation; to get more info about the situation, with prior events, local policies, to consult with the ACA Ethics and Professional Standards Department, other professionals within the district, other supervisors with counseling experience; to comply with the request and make the requested list in a appropriate manner; refuse to follow the request based on ethical responsibility; to contact every patient for permission to reveal information; educate the director/administrator about ethical requirements and negotiate to present the information in such a way to meet theirs’s goals without compromising confidentiality; and present the information in a coded format to protect the patient’s privacy (Phillips, E., 2007).

Also, she may ignore the situation, but the request may finally result in the information no longer being needed, or to cause Paula to appear resistant or disobedient to her boss. This could become the motivation for a huge fight for power between the two, and the purpose of protecting patient privacy may be lost. If she gathers more information and understands more about everyone’s priorities in the situation with a clear review of precedents and policies, this may disclose a solution that could satisfy everyone. Paula and the administrator could engage in a open dialogue to assess if the number of patients seen and the general list of providers offering services would serve for his report. The administrator could still require Paula to submit all the names of agencies and patients she counsels, or he might allow Paula to report this data without any identifying information. Paula could submit coded data without breaking ethical violations.

Actual Course of Action with the Rationale

The clinical supervisor has responsibility in the resolution of ethical dilemmas, when a counselor is under supervision. The ACA Code of Ethics states “supervisors should educate supervisees about client rights including privacy and confidentiality” (ACA, 2005). Counselors must guarantee that aids will follow confidentiality. The ACA Code specifies supervisors will “ensure that supervisees inform clients of their right to confidentiality and privileged communication” (ACA Code, 2008).

Whereas I understand her responsibility as a counselor and supervisor to follow the ACA Code of Ethics (ACA, 2005), Paula is also required to remind others of such responsibilities and discourage from disclosing confidential client information to the administrator without signed consent forms. As the supervisor, Paula is responsible to guide my critical thinking process about many ethical issues that arise in my clinical work, to instruct how to apply appropriate ethical codes, to be knowledgeable of prevalent ethical violations and how to minimize them (ACES, 2009). If she revealed information about the patients to the administrator this would be a clear violation of the ACA (2005) and ASCA (2004) codes. It will be important for Paula to work with team involved together to ensure the confidentiality of the patients is maintained and no ethical violation occurs. Paula’s first step is to gather information from the principal about specific requirements of his periodical report. She would meet ethical guidelines by opening communication with her director and administrator about this issue. If they continue to insist upon knowing the names of patients seen, the next step would be to consult. Paula might consult with any other mental health providers who would likely be bound by similar ethical guidelines. Paula could talk with them about how they plan to proceed with the request to provide the confidential information and consult with other clinical counselor supervisors to determine how they have guided supervisees to act when faced with similar ethical dilemmas. She can discuss their joint responsibility to uphold confidentiality so that he does not view her failure to submit client names and associated agencies as blocking progress (Kaplan, 1995). The relationship between Paula and the patients could suffer irreparable harm from the disclosure, resulting in patients withholding information from her, and to could prevent them from seeking counseling in the future and undermine treatment goals and progress (Phillips, 2007). The final step is to implement the course of action. It is reasonable to expect that Paula and the administrator will find an acceptable and ethically sound solution to this dilemma.

Influences Shaping Decisions

Obtaining permissions from the affected parties would protect Paula from violating confidentiality. Doing so, may also raise questions from patients concerning who will have access to the information and how it will be used. This may cause students to remove from counseling due to fear of others knowing about their personal challenges. Paula could educate the administrator about applicable ethical codes. She could approach this discussion with him in a professional and tactful manner, mentioning detailed segments of ethical codes that stress the importance of privacy and confidentiality. Therefore, the supervisor may collaborate to find the best solution. The applicable ethical codes in this case encourage counselors to consult when met with ethical dilemmas, as consultation increases the probability of seeing the situation from multiple perspectives to identify an appropriate solution (ACA, 2005; ASCA, 2005; ASCA, 2004). Again, the consultation process may take some time, causing Paula to appear defiant. It is also possible that even with consultation, no concrete solution can be found to satisfy all parties. Generating the lists as requested and submitting them promptly would certainly pacify the administrator. But, this would evidently be a violation of the ethical code to protect confidentiality (Kaplan, 1995) and might lead to reasonable complaints from patients. A flat refusal, even in the name of compliance with ethical standards of protecting privacy, will be unprofessional and defiant on Paula’s part. It is possible the administrator would understand her objection, but this is not likely based on the power differential between them.

In summary, in this case, Paula confronted several ethical dilemmas.  I outlined the ethical dilemmas and considered multiple professional ethical standards to guide my recommendations, attempting to support professional ethics by maintaining the best interests of Paula’s patients and justifying potential actions based upon best practices. As trusted savers in the counseling profession, it is our desire that consistent and disciplined analysis of ethical dilemmas continue to guide our practice.

 References

American Counseling Association. (2005). ACA code of Ethics. Alexandria. VA: Author.

American School Counselor Association. (2005). The ASCA National Model: A Framework for School Counseling Programs. Second Edition. Alexandria, VA: Author.

Association for Counselor Educators and Supervisors. (2009). Best practices in clinical supervision. ACES Task Force Report at the 2009 Annual ACES Conference in San Diego, CA.

Corey, G., Williams, G., & Moline, M. (1995). Ethical and legal issues in group counseling. Ethics & Behavior, 5(2), 161-183. Retrieved from: http://dx.doi.org/10.1207/s15327019eb05

Glosoff, H. & Pate, R. (2002). Privacy and confidentiality in school counseling. Professional School Counseling, 6(1), 20-27.

Glosoff, H., Herlihy, B., & Spence, B. (2000). Privileged communication in the counselor client relationship: An analysis of state laws and implications for practice. Journal of Counseling.

Herlihy, B., & Corey, G. (1996). ACA ethical standards casebook. (5th ed.). Alexandria, VA.                              American Counseling Association.

Isaacs, M. L. (1999). School counselors and confidentiality: Factors affecting professional choices. Professional School Counseling, 2 (4), 258-267.

Kaplan, L. S., (1995). Principals versus counselors: Resolving tensions between different practice models. School Counselor, 42 (4), 261-268.

Phillips, E. (2007). The dilemma of practicing and teaching confidentiality within the clinic.

Sederer L. (2013). The Right to Treatment and the Right to Refuse Treatment. Retrieved from: http://careforyourmind.org/the-right-to-treatment-and-the-right-to-refuse-treatment/

Tuckman, B. and Jensen, M. (1977). Stages of Small-Group Development Revisited. Group & Organization Management, 2(4), pp.419-427.