RESOLVING ETHICAL DILEMMAS

1. RESOLVING ETHICAL DILEMMAS MODELS FOR MAKING DECISIONS Erika L. Liljedahl, Psy.D. The Chicago School of Professional Psychology

2. 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.

3. 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.

4. Contents of talk • What are ethics? Values and ethics • Brief history of ethics • Who makes unethical decisions? • Presentation of 4 Ethical Decision Making Models

5. 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.

6. 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?

7. 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.

8. 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.

9. 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 Devil’s advocate, and even through ethical dilemmas presented in Greek tragedy on stage.

10. So if having knowledge, wisdom and knowing thyself assist with making good ethical decisions, then what kind of a person in today’s time makes unethical decisions?

11. 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)

12. Another interesting note from this study: • Egotistic work places are more likely to promote an “everyone for themselves” environment, which promotes more unethical behaviors.

13. So how can one be as ethical as possible, whether or not one is in a supportive or an unsupportive work environment?

14. 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

15. CLINICALLY-RELATED ETHICAL DECISION MAKING MODELS

16. 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

17. 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.

18. 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

19. 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 parent’s 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.

20. 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?

21. 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?

22. 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

23. 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.

24. (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 withoutthe consent of the minor’s 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 minor’s parent or guardian is obtained.  The minor’s parents shall not be informed without the consent of the minor unless the facility director believes such disclosure is necessary.”

25. 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).”

26. 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.

27. 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.

28. 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 Joe’s psychological status.

29. 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.

30. 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?

31. 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.

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

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

34. 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?

35. Step 2: Consult guidelines already available that might apply as a possible mechanism for resolution. • What are the school’s 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?

36. 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.

37. 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.

38. 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.

39. 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 student’s 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.

40. 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.

41. 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.

42. 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

43. 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?

44. 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 harasser’s life that would be useful information to the behaviors.

45. 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.

46. 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.

47. Step 8: Make the decision andStep 9: Implement the decision • What would you do?

48. 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.

49. Steps: • Recognizing a problem • Defining the problem • Developing solutions • Choosing a solution • Reviewing process • Implementing and evaluating a decision • Continuing reflection

50. 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?