“There
is nothing distinctively Christian about counseling,” one of the class members
argued. “There is no uniquely Christian form of surgery, Christian auto
mechanics, or Christian cooking, and neither is there Christian
counseling.” Gary Collins (1988, p.17)
cited four disctinctives in response to the challenge that Christian
counsellors do not have any unique contribution to their clients compared to a
secular counsellor. These four distinctives are; Unique Assumptions; Unique
Goals; Unique Methods; Unique Counsellor Characteristics. As a Christian
Counsellor in training, I believe that my Christian worldview do provide a
unique way of perceiving and assisting my clients.
In
this paper, I will attempts to assimilate Case Study 4 and present how as I
intend to respond to Nora, as a Christian Counsellor. This paper will focus on
the following areas and present them in order; identify issues present;
synthesise two ethical decision making model; arrive at resolution; and
describe ways of engaging with Nora and the issues identified.
This
beginning section of the paper will examine the case study for issues using
seven different context suggested by Terence O’Sullivan (2011). The different
contexts are; service-user movements, professional context, societal context,
legal context, policy context, organisational context, interprofessional
context (2011, p. 18). The service-user movements identified in Case Study four
is involving Nora in evaluation and decision making process. However, in this
case, the dilemma present itself as Nora ignoring the boundaries of not
touching in a counselling relationship and continuing to expect hugs. The
original context of the service-user movement is general and involves policies
and organisational service changes and improvements and not immediately
applicable in Nora’s case but will be highly relevant for prevention and future
service protocol. Issues identified in professional context are the expectation
that I assert professional values and adhere to codes of ethics such as that of;
Christian Counsellors Association of Australia, Psychotherapy & Counseling
Federation of Australia and Australian Association of Social Workers. The main
issues in consideration would be issue of client abandonment, dual relationship
and maintaining appropriate touch. Societal context depicts the awarenesss of
social dynamics, societal structure and cultural climate (O’Sullivan, 2011).
Nora’s church culture encourages hugs and she might believe that all Christians
hug each other. Whether she is consciously aware of the differences or not, the
issue is the differences in culture and also the need to help Nora be aware of
the context in which hugging is inappropriate. O’Sullivan presented position
legal positions on a spectrum where one end, social work values should precede
law and the other extreme establishes that social work should be based on law
(2011). In Nora’s case, I would be legal obliged to report abuse of both Nora
and Melanie and also balance that legal obligation with my duty to
confidentiality and protect Nora’s privacy. Some other potential legal issues,
apart from implications of duty to report domestic violence and duty to report
child abuse, would be possible malpractice suit and future licensing issues
related to client abandonment and dual relationship. In Australia, a
psychologist or counsellor is required to maintain a minimum of two years after
termination of therapist-client relationship before entering into sexual
relationship of any kind (PACFA, p. 15; ASSW, p. 13; CCAA, p. 4). However, the
issue of entering into multiple relationships is complex and has serious
repercussions, especially for the client, in my opinion should be avoided.
Assuming that I work as part of a counselling organisation, issues such as the
ease of transferring Nora to another counsellor, the support provided by the
supervisor(s) and how a decision is usually made in the organisation would
affect how I can and would respond in Nora’s case. Interelated to organisation
context is interprofessional context. Issues surfaced in interprofessional
context would be the extensiveness of my network and if I will be able to
identify a suitable counsellor to transfer or collaborate with in Nora’s case.
This
section of the paper will be devoted to application of two ethical decision
making models; the Feminist Model of Ethical Decision Making (Hill, Glasser
& K. J. Harden, 1998) and A Model of Ethical Decision Making by Lorna L.
Hecker (2010, p.19-28).
The
Feminist Model of Ethical Decision Making is a model that emphasise on equal
power and maximum involvement of the client throughout all stages of the
decision making process (Corey, Corey & Callanan, 2011). This section of
the paper will work through all the steps of Feminist Model.
The
first and second step of the model is to respectively, recognise or be aware of
the problem and define the problem in terms of identification of stakeholders,
cultural values of stakeholders and expectations, codes of ethics and other
legal standards. The previous section of this paper has been dedicated to
define the issues (the rationale-evaluative analysis of the problem) and will
not be repeated in this section. Hence, the paper will now discuss the other
important aspect of the model, the feeling-intuitive process where the
therapist examines his or her “emotion, intuition, and the power differences
between the client and therapist, and recognition that cultural biases are
inherent in value-based decisions” (Hecker, 2010). The first step is the
recognition of areas of uncertainty. Uncertainty identified would be Nora’s
motives to continue to expect physical embrace despite my explanation that
touching is not appropriate. I wonder if boundaries have been adequately
established on the onset. Other uncertainties are; the health of relationship
between Nora and Simon; the next course of action in the therapeutic
relationship; why am I experiencing strong sexual attraction to Nora. I wonder
if the sexual attraction is a mirror neuron response from Nora’s sexual
attraction to me or other issues I have in my life that has propelled me
towards desiring to be Nora’s sexual partner?
The
second step of the model addresses concerns, feelings of the stakeholders. “The
horror and intrigue of attraction to patient – a very common experience among
therapists – and the temptation or fear of acting on that attraction have been
difficult for the profession to face honestly and realistically.” (Pope &
Vasquez, 2011) I could be feeling confusion, struggles between professionalism
and strong sexual attraction, doing what is ethical versus remaining objective
and wanting to save Nora from her pains and struggles. I could be feeling anger
at Nora and the situation. I could be feeling disrespected and frustrated with
my efforts to establish boundaries and being ignored. Nora could be feeling
confused and vulnerable. She could be feeling a desire for me to fix her
problems by being intimate with her. She might be feeling avoidance and the
need to escape into another world where the relationship problems with Simon
does not exist and everything else is well with me showing her care, attention
and concern. Kenneth Pope & Melba Vasquez listed the following consequences
for having sex with the therapist;
Ambivalence,
Guilt, Emptiness and isolation, Sexual confusion, Impaired ability to trust,
Confused roles and boundaries, Emotional Liability, Suppressed rage, Increased
suicide risk and Cognitive dysfunction, frequently in the areas of
concentration and memory and often involving flashbacks, intrusive thoughts,
unbidden images and night mares (Pope, 1988b, 1994, 2001)”.
Plausible solutions, as part of the third
step, are; transferring Nora to another therapist; continuing to work with Nora
together with a fellow therapist; work with Nora in group settings. The option
of transferring Nora to another therapist may not be viable, as Nora has
expressed that she will not see any therapist if she could not work with me. I
feel trapped and at the same time concerned about Nora. The next option of
collaborating with another therapist on Nora’s case sounds more plausible. This
option satisfy Nora’s request to continue to work with me, while the additional
therapist will change the dynamics of the therapeutic relationship and possibly
help me keep my behaviour in check during the sessions and point out any
unconscious behaviour that may be perceived as suggestive and inappropriate. I
feel hopeful with addition of another therapist. However, I do want to be
careful about managing the dynamics to ensure that the other therapist and I do
not over power Nora. Working in group setting with Nora is another option, Nora
might be able to observer suitable therapist-client behaviour from other
clients. We may also consider a combination of group and two-to-one sessions.
Choosing
a solution is step four of the model. I would suggest video recording the very
next session as an immediate measure to address the situation. During the next
session, I would suggest a combination of two-to-one and group sessions as the
intermediate solution, with tentative possibility of resuming one to one
sessions when certain conditions are met. I would hold the tentative belief
that it might serve Nora well for her to become aware of the changes in the way
she dresses, the high possibility of transference and counter-transference and
the goals of her counselling sessions with me.
Step
five of the model is review of the process assimilating a different choice. I
would not want to be terminated by my counsellor without reasonable follow up
or handing over to another therapist. In case of termination before exploring
other alternatives, I would feel abandoned or dismissed as beyond care or help.
I would feel powerless as a client and rejected by the counsellor. This option of
terminating the counselling relationship does not feel right, I wish to provide
least harm and most care to the fullest of my ability to my client at all
times.
In
step six of the model, I would implement the solution with the client. Thereafter
actively observe and explore the result of the solution with Nora. We could set
a time to evaluate the progress and result of the solution. In this case, Nora
and I could touch base at the end of every session and evaluate if the sessions
has been useful. Also I will continue to observer and evaluate with my
supervisor to see if the strong sexual attraction to Nora is still present. The
other colleague could also keep an eye on the dynamic and pull us up if we got
out of line.
The
final step of the model is the reflection stage. In this stage I reflect on
what I have learned through this experience with Nora. This experience has
caused me to understand that I need to establish the boundaries clearly on the
onset. During the informed consent process at the beginning of the therapeutic
relationship, I need to establish my values and make them known to the client.
This
section of the paper assimilates the next decision-making model from Lorna
Hecker (2010). The model has two main stages, therapist awareness and action
phase of decision making. The first step of awareness; “Awareness of Therapist
and Client Memes” This is the step when I reflect on my values and with clarity
express my values to Nora. Hecker suggest that good working knowledge of client’s
(Nora’s) values will provide insight into the potential types of clinical,
ethical or legal situations. The first two steps of Hecker’s model are
pre-emptive.
“Awareness of Potential Ethical Issues” is
another area the therapist should be prepared. Hecker suggests understanding
potential ethical issues through “classes, readings, clinical experience,
supervision, continuing education, legal counsel etc. “Know your professional
code of ethics; know and practice core competencies; know the local, state, and
federal laws that relate to practice; keep up with research; be aware of
ethical or legal land mines” In this case, this awareness might involve
awareness of abuse cases that involve repressed memories, dual or multiple
relationships, client abandonment, client previously treated by unethical
therapist.
In
the third step of the model, “Define the Ethical Problem”, I identify the issue
or dilemma that is confronting me. In this case, one of the dilemma is the need
to establish boundaries of touch but not cause Nora to feel reject. Another dilemma
is the need to remain professional and provide the best de-centred and
objective care versus strong sexual attraction and desire to save Nora. Also,
there is a duty to report and suspicion that Melanie might not be safe however
Melanie is not the main client and Nora has not revealed any details or
evidence to confirm the suspicion. There is a need to weigh the legal
obligations and issue of confidentiality commitment to Nora. Hecker (2010)
further reminds the counsellor to manage ambiguity and prevent foreclosing a
decision prematurely.
In
the fourth step, “Gather information from all relevant sources and formulate
and weigh all possible alternatives”, Hecker suggested reviewing step one and
two to “consider all courses of action and possible ramifications of each
decision” and fill the gap in information for the purpose of making the “best
ethical decision” (Hecker, 2010). Hecker suggested a list of questions in this
step that I will attempt to answer herein.
“With
each person’s happiness being equally important, what action will produce the
most good for the most people?” (Hecker, 2010) In this case, continuing
counselling with Nora but establishing boundaries and conditions that will
prevent dual relationships might produce the most good for Nora and myself. The
following set of questions address ethical principles.
“Have
you respected each person’s autonomy?” (Hecker, 2010) In this case, I would
seek to respect Nora’s autonomy by explaining all possible options and
involving her in each step of the decision making process.
“Have
you adhered to the maxim of nonmaleficence?” (Hecker, 2010) In this case, I
would seek supervision to ensure that I am accountable for all my actions and
that I would only implement a solution that has gone through much deliberation
with supervisor, reflected to Nora. In addition, I have to be careful not to
act in a way that might jeopardise Nora by antagonising Simon.
“Have you been advocating for justice?” (Hecker,
2010) Although Nora is my main client and I have so far been focusing on
treating Nora justly, I have duty to report and ensure Melanie’s safety if she
was suffering abuse or in danger of being harmed. I would process this feeling
with a supervisor and ensure documentation of the process to facilitate any
eventualities that might occur from a follow-up of the issue. I might be able
to communicate with the child’s welfare department to understand the rules
around duty to report and any other obligations that binds me.
“Is there fidelity in your action?” and “Is
there veracity in your action?” (Hecker, 2010) are closely related questions. I
endeavour to honour my commitment to counsel Nora, consider termination of the
counselling relationship as the last resort, always have Nora’s well-being as
the foremost important factory and at the same time be as truthful as possible
to Nora, supervisor, colleagues and other stakeholders.
“Have you promoted beneficence?” (Hecker,
2010) Apart from making sure that actions taken will be for Nora’s best
interest, I could explore the possibility of Nora working on her relationship
with Simon and Melanie. Carl Roger (1961) suggest that a healthy therapeutic
relationship is instrumental to providing an environment where the client can
become fully functioning.
“Are
you willing to make your decision and ethical imperative for all to follow? How
would you defend your course of action?” (Hecker, 2010) These questions are important
parts of step four and answer directly to outcome six of the assessment. I will
return to this question in the following section.
Hecker’s
model has a unique question not present in the feminist model. This question
assimilates the scenario through adopting the perspective of a person who the
therapist looks up to. “In this situation, what do you believe Christ would do?”
(Hecker, 2010) I believe that Christ would reveal the truth of the situation
including what is in the heart of Nora in a gentle and truthful manner. Christ
would also show much grace to Nora.
“What
intuitively do you think you should do?” (Hecker, 2010) Intuitively, I think I
should seek counsel from a supervisor and involve another therapist in the
session as soon as possible. Or perhaps set the next appointment with Nora with
at least a couple of weeks in between so I can work on the strong emotions with
a supervisor before I meet her again.
“What
do the stakeholders want?” I believe that Nora wants to be loved and feel safe.
She possibly wants someone to sooth her emotions. Carl Rogers (1961) postulate
that every living being has innate desire and motivation to self-actualise.
In
step five of Hecker’s model, I would work with Nora to select the best ethical
alternative and implement the decision. This step is similar to a combination
of step four and first half of step six
of the Feminist model.
Hecker
(2010) suggested “monitor the decision and the outcome of the decision,
reevaluate if necessary” as step six of the model. In this step, I would be
evaluating the level of satisfaction from the result of the solution. I would
be careful to set up benchmarks to measure the level of satisfaction prior to
implementing the solution.
Hecker’s
model listed cautious documentation of the response as the final step. I
believe this is an important step that has not been highlighted in the feminist
model. I would endeavour to document the thought process, decision-making
process and supervision process related to this case.
Both
models have really valuable focus for ethical decision-making. In the
feeling-intuitive process of the feminist model, I have touched base with some
emotions that will need processing and I might not have realised those emotions
if I had chosen to apply another model. Hecker’s model has two valuable steps
that have invoked deep reflections for me. One of them is to see the situation
from the perspective of someone I look up to. The other invaluable step is the
documentation step.
This
next section of the paper presents the solution in entity. The solution that I
have formulated using the two models, involves Nora in every step of the
decision-making, implementation and evaluation. First part of the solution will
involve creating space for supervision and awareness of situation. I endeavour
to do this by giving some time before the next appointment with Nora. Depending
on the urgency of Nora’s needs and after consultation with supervisor, I would
suggest 2 to 4 weeks before the next appointment. There may be a recorded phone
call mid term to do a check-in. During the break in appointment, I would seek
to process case with my supervisor and formulate a list of issues to discuss
and several options for discussion with Nora.
I
will suggest video recording of the sessions after the break, an alternative
would be to leave the counselling door open or invite another counsellor be in
close proximity. Nora will be informed that these measures are put in place to
ensure her safety and she has the full autonomy to choose any of the options.
This is the first initiative to engage Nora in the process and empower her to
choose and formulate safety measures for herself.
During
the session, I will cover the list of issues about the situation. I would take
time to ensure that Nora understands the legal, ethical, social implications of
the situation. These may be done by inviting another therapist, with Nora’s
permission or going through documentations such as codes of ethics etc. This is
another stage where Nora is engaged in choosing how she wishes to be informed. I
would also make sure that Nora understands her options and provide evidence of
the detrimental effects of taking the counselling relationship beyond therapist
and client.
The
second part of the solution would involve engaging Nora to formulate her goals.
With goals, we are more likely to become more task-oriented and also understand
what resources are required to arrive at those goals. The goals can be
benchmarks for counselling progress and help to keep us in line. Or the goals
might reveal that Nora needs another therapist who has special skills that I do
not possess. This will be a legitimate and compelling reason for Nora to seek
another therapist.
The
next part of the solution would comprise development of further safety measures
to ensure that I provide maximum non-maleficence service to Nora. Nora and I
could come up with ways that can ensure that we continue the counselling
relationship in strictly professional manner. Some of the options are listed
above in step four of the feminist model. In this part of the solution, I would
encourage Nora to engage in examine her emotions and need to connect with me in
a manner that is different from therapist-client. I believe that if I show
authenticity and no judgement or negative emotions towards Nora examine her
feelings about me, Nora might be able to process the feelings objectively and
safely. However, I will maintain an open option for Nora to explore her
feelings for me separately with another therapist if it is so required by her.
Following
building safety measures, I would engage in Nora observing and regular review
of the solution implemented. We may use the benchmarks set during goal setting
to plot the progress and consider how and where Nora wish to continue working
on.
Returning
to Hecker’s question in step four of the model, “Are you willing to make your
decision and ethical imperative for all to follow? How would you defend your
course of action?” (2010, p.22) I am willing to make my decision and ethical
imperative for all to follow. In addition, I would defend my action with full
and detailed documentation of each encounter with Nora and my supervisor will
be kept informed. I would also as far as possible insist on video recording one
to one sessions as a safety measure.
In
conclusion, I recognise that it is easy to examine the scenario in a removed
and professional manner when it is purely a case study. The ethical situations
are often more complex and difficult in reality, especially when emotions are
influencing the decision making process.
This
case study has highlighted the importance of establishing boundaries and values
on the onset of the counselling relationship. It has also brought to light the
importance of having a supervisor and network support in one’s counselling
practice. I have definitely benefited from examining the case study through the
two different decision-making models. I hope to examine other cases using other
models in order to formulate a model that is as comprehensive as possible.
References
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