1) Presenting issues –
Ethics within counselling is broadly defined by acting in the best interest of your client, whether that be in maximizing their goals, and rights, whilst also minimizing harm. The ethical codes and principles that result from this definition are designed to balance any sense of power that the counsellor may have over the client (Stein, 1990). Moreover, the ethics that guide the practice expand even farther than that, in encouraging the consideration of your organization, profession and the greater community as a close second to your client (Axten, 2002). The BACP explains that; “Our ethics are based on values, principles and personal moral qualities that underpin and inform the interpretation and application of our commitment to clients and good practice.” (BACP, Framework Extract 1). With new and challenging ethical issues continuing to emerge in the field (Dufrene, 2011), it is important that a counsellor draws on a centralized, and specialized code of ethics. I will be primarily using the IACP code of ethics to determine my actions and resulting decisions in this case study. The BACP and APA will also be introduced as a secondary guide.
One of the most prominent ethical issues that presents itself, is that she has mentioned a history involving a potential suicide attempt and goes on to say later in the counselling session that she feels as though everyone in her life might be better without her. If there is a risk of Cathy potentially hurting herself, this needs to be reported to the appropriate authorities. Although Cathy may not be considering suicide seriously, it would be unethical to dismiss the concern altogether.
Cathy has a fear of appearing as though she can’t cope, meaning that she may be underplaying her true feelings, even with me. Cathy also mentioned that she had started drinking “a lot” in the evenings after she has put her children to bed. This has the potential to severely impact her judgment, which could have adverse effects on the children. It’s also worthy to note that the client had an overdose of painkillers while intoxicated. This plays out in conjunction with her having doubts that she’s capable of being a good parent. These specific issues are a shared ethical dilemma, as Cathy’s dependency on alcohol, holding back information and in-turn being a good parent, relies on co-operation between us, and not direct advisement (Bond, 2010).
Due to one of the children being 8 months old and the behaviours in which Cathy is presenting, I also need to begin an exploration of post-natal depression. At this point, there is the legal dilemma of ensuring the children are living in a suitable and healthy environment. The professional challenge of these dilemmas is ensuring that I utilize ethical and legal principles in a manner which ensures my credibility. Supposing I may empathize with Cathy and her challenges, avoiding necessary action, could be counter-productive in the long-term for both Cathy, her children and myself.
2) Consideration of ethical guidelines –
The BACP ethical framework under Putting clients first section 9 outlines that a practitioner should give serious credence when managing situations that involve protecting the client or others from harm. This also relates to Respect section 25 in which the BACP emphasises the importance of making the client aware of any “foreseeable limitations” of confidentiality before counselling begins. Good practice involves a collaborative and legal contract from which to work from in the sessions (Appendix A). Section 54 under Supervision also refers to any communication regarding the client to be consistent with the agreement of confidentiality made with the client prior to counselling.
The Irish Association for Counselling and Psychotherapy (IACP) gives us a clear commitment of four principles; Respect, Competence, Responsibility, and Integrity. Under, section 1.2.4 (Respect for the Rights and Dignity of the client), the ICAP advises that if there is a belief that the client is going to harm themselves, it should be first raised with my supervisor and inevitably the client, before disclosed to a third party, unless It’s urgent. It is a “statutory duty” to report suspected child abuse under the Children’s Act (1989), and the ICAP’s Children’s First Guidance notes that “If any risk is deemed to exist to a child who may be in contact with an alleged abuser, the counsellor/health professional should report the allegation to Child Protection Services immediately.” This guideline not only refers to sexual abuse but neglect, physical abuse, and emotional abuse.
Bond (1992) outlines three situations in which one must break confidentiality; when the client authorizes such a breach, the information is already in the public domain, or when the public interest outweighs that of confidentiality. The third reason is compatible in the case of Cathy’s children and would be a defensible reason if done in “good faith” (Jenkins, 2006). The more narrow and refined perception is that of only breaking confidentiality when authorized by client or law (Corey, 2011). Cathy also may be in the early stages of becoming alcohol dependent, the ICAP notes under 2.2.3 (Competence) that service should be refused if the client is believed to be impaired.
The intricacies arise when you consider non-maleficence (IACP, Principles, Section 5), a commitment to avoid harming the client. Many practitioners consider this one of the most significant ethical principles. I must be cautious in managing the harm done to the client whilst following ethical guidelines (Kitchener, 1984). Accordingly, confidentiality is what makes therapy possible, and gives the client a space to share the most vital of information, whether it be beneficial to their own treatment, or information that calls for confidentiality to be broken (McLeod, 2013). This, consequently, presents practitioners with an ethical dilemma, as for counselling to remain a trusted and viable field, disclosure needs to be scrutinized and only executed when all the ethical ramifications have been considered for both the client, counsellor and profession (Fisher, 2008).
3) Practical approaches –
A) As the urgency of the harm Cathy can inflict on herself and potentially her children are at my discretion (1.2.4 ICAP), I could immediately contact child protection services, my supervisor, and make a crisis referral. This could be divulged to the client with no collaboration, adhering to a respect for the client’s autonomy (1.1.4 ICAP, Section 3 APA). Conversely, this could do more harm than good. Albeit I would be acting in a manner to ensure the safety of Cathy and her children, Cathy has a very weak support system, and this would only isolate her further. Social isolation has been known to be directly related to suicide, which the client has a history of (Trout, 1980). It would also most likely cause an early termination of services, without pre-termination counselling, causing a sense of abandonment and potentially disillusionment in the entirety of the field, which could prevent Cathy from reaching out for alternative support. Section 8 of the APA’s (American Psychological Association) ten guidelines to avoid ethical pitfalls discusses the importance of pre-termination counselling for the well-being of your client. It refers to an obligation to your client to walk them through the next steps, why it would be beneficial for them, and what will happen next. Overall it would also cause a conflict with the principle of Responsibility in the IACP ethical guidelines, in that I am to act in a trustworthy and reputable manner towards the client and my profession.
B) I could ignore the dangers of the potential issues I am faced with, and continue the sessions of counselling. This, ordinarily, would be purposely engaging in malpractice and disregarding section 2.1 and 3.4.1 of the IACP guidelines. This could lead to not only endangering Cathy’s well-being and her children’s but put me at legal risk. Granting the law accepts that professionals may make errors in judgment, knowingly making these errors are not accepted. It is expected of me that I define the potential issues clearly, consult the IACP guidelines, evaluate the rights, responsibilities, and welfare of all affected parties, generate as many alternative decisions as possible, evaluate the likely outcome, choose the most beneficial decision and take responsibility for the consequences of that decision. (IACP; Bond, 2010).
C) The extent to which Cathy is dependent on alcohol and if her depressive state is due to post-natal depression are important areas of exploration before any action is taken. Once these issues have been moderately addressed, I believe it would be appropriate to approach my supervisor and a consultant of CPS with all the information, to build a more accurate picture. Cathy is in an isolated position, a single mother who does not want to appear weak in front of people she knows. This means that the support network provided by my services could be definitively important for Cathy, and as such, her permission to disclose or discuss the course of action could be fundamental. This falls under section 1.1.4 in the IACP ethical guidelines, in which you respect and work with a client’s personal autonomy and the BACP’s emphasis on making the client aware of potential breaches of confidentiality (Respect, Section 25 & Supervision, Section 54). It could be appropriate to forward the idea of an Alcoholics Anonymous group and for new risk assessments to be completed for the safety of both Cathy and her children (Appendix B, C). If she’s open to these ideas and seems driven to address these issues for her children, the only third party that would need to be involved could be a crisis consultancy and the intervention of my supervisor. If there are signs of post-natal depression, it would be best to report this information to CPS. Post-natal depression can cause a mother often to be unaware of their neglect, in terms of disengagement, unresponsiveness and little support for their child’s development (Bonnin, 2004). This also opens the possibility of referral under the IACP principle 3 of Responsibility and section 3.3.1, as the client may need specialized care, notably for post-natal depression. It could also be responsible to offer the client a referral to another competent counsellor if Cathy feels as though this course of action has caused a rift in the therapeutic alliance. This could likely result in a hindrance of healthy progress (Miles, 2015). Pre-termination counselling will be of the utmost importance at this point, as outlined by the APA. This will be my chosen practical approach moving forward.
4) Framework for my decision making –
I will be using Bond’s 2010 six-stage model to ensure that my decisions are ethically sound. Stages 1 and 2 have been completed prior through section 1-3. Further analysis of ethical principles and guidelines could be utilized to ensure my decisions are appropriate. I have respect for the APA’s (American Psychological Association) ten points on avoiding ethical pitfalls. Number 9 on this list alludes to “sticking to the evidence”. Interestingly, this section talks about the fact that failing to communicate with child protection services can mean that integral information is left unrevealed. For example, Cathy could have been under CPS investigation in the past and this information could be extremely important in moving forward with current concerns. Number 3 on the list also discusses the respect of the client’s autonomy in making them aware of my limits of confidentiality, expertise and alternative treatment or service approaches (Smith, 2003). Stage’s 4 and 5 of Bond’s model is to identify all the possible and best courses of action, which I have done in section 3.
Stage 5, the evaluation; I would imagine that Cathy may be resistant to admitting to a dependency on alcohol, nevertheless would potentially be amicable about a new risk assessment (Tarter, 1984). I have also utilized surrounding literature in ensuring I take a great deal of care in both my evaluation of the client’s needs, the level of disclosure necessary, and the ramifications of such on both the client and the therapeutic relationship moving forward (Kitchener, 1984; Mcleod, 2013). Even though the IACP has offered an individualized approach, I think that the BACP provides a stronger framework in terms of core principles. Despite being criticised for drawing inspiration from other fields, this generalization could be poignant in justifying one’s actions (Sivis, 201; Figure 1).
5) Practicality of moving forward –
I would reiterate the contractual agreement I have with the client (1.2.7, 4.2.2, IACP; Respect, Section 25 & Supervision, Section 54, BACP; Appendix A), specifically the limits of my confidentiality. After having explored the possibilities of post-natal depression and Cathy’s dependency on alcohol, I would discuss the next steps as outlined in option C under section 3. The following strategy would be discussed with my supervisor prior; I would make it clear that I respect Cathy’s self-determination and autonomy, and that I want this to be a collaborative approach going forward.
A new risk assessment would beneficial in ensuring that Cathy receives the appropriate support and expertise (Appendix B, C). Attending alcoholics anonymous could provide reassurance for both myself and Cathy in relation to her own well-being and that of her children. I would also stipulate that it could give her a much-needed support network, in which she wouldn’t have to carry the fear of appearing vulnerable (Cobb, 1976). Hopefully under the pretence of collaboration, and the benefits outlined, Cathy would be open to the idea of pursuing these options and moving forward with treatment (Anderson, 1996). Compromise promotes pragmaticism and intrinsic motivation, most importantly for the shared dilemmas of the case (Walton, 2014; Jones, 1976).
If this has caused complications within the client/counsellor relationship, I would also give Cathy the option of a referral to another competent counsellor and pre-termination counselling. This is to ensure that healthy progress continues for Cathy, as deemed most beneficial by the resulting ethics, supervisory direction, and the client’s individual needs.
6) Justification of my actions and decisions –
I believe I have referred to all appropriate guidelines and laws throughout my evaluation, decision making, level of disclosure, and practicality of moving forward. I have put a great emphasis on the IACP due to it being a specialized code of ethics in relation to counselling, and the laws of the United Kingdom and Northern Ireland, that Govern areas of the practice. I have also used the BACP, APA, a contractual agreement, and much of the surrounding literature regarding ethics not only in compliance with the IACP, but to provide an individualized ethical approach to the client’s situation. This combination has universally guided my actions and decisions in dealing with this client, Cathy, in good faith and to the best of my ability, with the presented challenges of the case in mind.
Providing justice, I exhibited caution in breaching confidentiality, particularly in relation to the children, by exploring the different facets involved in the evaluation of their well-being. This gave me an informed picture when approaching my supervisor to discuss further action, as prior information only alluded to thoughts of suicide and the possibility of child neglect (Bond and Mitchels, 2008). Abiding by the Children’s Act (1989), and the ICAP’s Children’s First Guidance notes, I also outlined contacting a CPS representative for advice, upon timely exploration of the details.
Providing self-respect, I related back to Jenkin’s (2006) point, in that I must have a level of certainty when breaking confidentiality in the public interest. Presenting autonomy and trustworthiness, I referred to the needs and autonomy of the client, by simultaneously addressing the isolated state of Cathy and breach of confidentiality, in creating a collaborative approach regarding disclosure, to the benefit of all parties (IACP, 1.1.4; BACP, Respect, Section 25 & Supervision, Section 54).
Providing beneficence, I also stipulated building a support network outside of counselling and the plan is dependent on the client’s co-operation as a show of goodwill in terms of efforts towards a resolution/progress. I have also ensured that the client’s risk of suicide or self-harm is established by thorough risk assessments (Appendix A, B). Providing non-maleficence, based on both the assessment and cooperation of Cathy, I limit the level of disclosure and ultimately hope to reduce the level of harm that it could bring to the client and the profession (IACP, Principles, Section 5).
I have also prepared for the possibility of a referral to more specialized care due to post-natal depression, or a rift in the therapeutic alliance due to disclosure, which I have designed to include pre-termination counselling. This enforces as stated, non-maleficence and beneficence, two of the most prominent ethical principles, as outlined by Kitchener in 1984 and readily utilized by myself.