With reference to the BACP Ethical Framework evaluate the ethical, professional and audit issues which may arise in a given counselling setting. In order to evaluate the ethical professional and audit issues which may arise in a given counselling setting, I must first choose an ethical framework model. I will then use the model I choose to outline all the stages of the ethical process I have used to come to my decision on the ethical dilemma. The model I choose for my ethical decision making is by Lynne Gabriel & Roger Casemore.
Stop, think, identify the situation or problem
The ethical dilemma is whether or not to tell the client that her mother is suffering from a terminal illness with a prognosis of 6 months to live. I need to break the dilemma down further, to understand exactly what or who is at risk. If I tell her, I will be breaking the confidentiality of a dying woman to her doctor. How will I feel about betraying a dying woman’s confidentiality even if she has not directly confided in me? This would make me uncomfortable.
The doctor did not swear me to confidence? Do I take it for granted that the conversation was confidential, even though it was in passing? Is this something I need to discuss with him? Yes I think I should discuss this with him. Are there also any legal implications involved as a counsellor working within the GP practise which I need to consider? I will need to review my contract.
If I do not tell her and she moves away and her mother later dies, will that push my client over the edge, she has already mentioned she has considered overdosing. Are her suicidal thoughts due to the Prozac (medication) she is using? “You may have thoughts about suicide when you first start taking an antidepressant. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment with Prozac”. (Gomez,C 2010).
If I tell my client she will feel the need to stay, instead of moving to Scotland with her husband, possibly cause the breakdown of her marriage. If I don’t tell my client it will cause resentment against her husband for forcing her to move and possibly cause the breakdown of her marriage. If I don’t tell my client, she may feel betrayed by me. If I were the dying woman, I would want my confidentiality respected. On the other hand if it were my mother I would want to know to be able to make her final days more comfortable.
Construct a clear description
Taking into consideration the client’s, age, gender, race, ethnicity, culture, religion, sexual orientation, disability, language, and socioeconomic status and consider these factors when working with the client to form my decision.
The client is a 34 year old female, she is married (the assumption she is heterosexual). Her cultural background and ethnicity is Italian, she lived with her parents until she was married and now lives on the same street as them. Her religious status is not mentioned, (an assumption she is Catholic). She does not have any known disabilities. Language is not a barrier as she has lived in England since she was a child. Her socioeconomic status is she does not work.
Issues of difference, her age, gender, sexual orientation, disability and language are similar to mine. Having lived in an Italian family for over 3 years, I have a deep understanding of her race, culture and religion. Also coming from an ethic minority, where family and respect of religion plays an important role in the cultural upbringing. The real issues of difference between us would be of race, leaving home at eighteen and work.
Italian children are taught to respect, love and look after their parents. When parents age or are ill it is the responsibility of the child to make sacrifices and look after them. This is similar in my culture. I would take this to supervision, as it would be good for me to explore and evaluate my own values and beliefs. I would also look at the management of my self and my own limitations as a counsellor. Supervision would help to keep myself and my client safe.
Whose problem is it?
The doctors’ as he has broken confidence in telling me. He has broken the doctor/ patient confidentiality. This is a recurring theme in my process. The practise, as the doctor has broken patient/doctor confidence. There are legal implications. Mine as a counsellor ensuring my clients well being. Also the legal aspect if under my contract all information mentioned in a practise setting should be taken as confidential. At present my client is unaware. I would need to speak with the doctor, the practise manager and my supervisor to clarify and appraise my role in this dilemma.
Review in terms of the Ethical Framework
The action which is prohibited/required in relation to this dilemma is to do with my contractual agreement. If it is broken then it will affect me legally and professionally and so I will be prohibited from telling the client. The rest would come under my moral principles.
Consider the moral principles and values
- Being trustworthy: If I betray the doctors’/ mother’s and practises’ confidentiality. Then I will not be honouring the trust placed in me.
- Autonomy: If I tell my client, I will be taking her autonomy away from her.
- Beneficence: If I tell my client I will not be promoting her well-being.
- Non-Maleficence: I will need to consider carefully any malpractice issues and also the clients’ vulnerability.
- Justice: I need to be fair and respect human rights, of my client but also her mother.
- Self-respect: I would not be able to respect myself if I told my client.
The support available will be by the supervisor, practise manager, mentor, other colleagues and the BACP ethical helpline. This is support available on a professional level. The doctor may also be a source of support. Emotional support without breaking confidence can come from their partner, family members and friends.
Initially take it to supervision, assess the legal requirements of contractual obligations. Assess my ethics, feelings, beliefs and courses of action. Take her mother on as a client; Disregarded. Impact on the daughter if she knew she may be guarded towards discussing the whole situation with me. Her daughter may not know. Impact on me, I would be bound by confidentiality to my client and would no longer be in a dilemma as she is now also my client. However, the mother would then be my client and what impact would this have on my motives and outcome of the work I do with her. This would be unethical of me.
Tell my client; Disregarded. I would need to ensure I was not breaking any legal responsibilities I have undertaken. If so the impact on me could be loss of professional membership. I could be sued. The impact on my own ethics, feelings and beliefs would have been discussed with the supervisor.
Impact on my client; she may confront her mother and tell her father breaking her relationship with her mother as she may not want her husband to worry about her. This might cause problems for her marriage and possibly lead to its complete breakdown. This could make her strong enough to stand up to her husband and assert herself. The thought of losing her mother might give her the strength to think about what is really important to her. It might make her feel this is the end, if her mother dies she will not be able to cope and she may to commit suicide.
Do not tell my client; my course of action. Instead in the next few sessions ask her to discuss her feelings about leaving and what family means to her. What importance she puts on her parents and spouse. Ask her how she would feel if she never saw her parents again and then if she never saw her husband again. Maybe use Gestalt empty chair theory and get her to speak to herself/her husband/whoever she chooses to allow her to see the situation from different views.
Impact on my client- is getting her to think about who is really important to her. Impact on me, knowing what I know will I feel guilt if my client decides to go to Scotland and then her mother dies. Would I have done everything in my capacity as a counsellor to ensure my clients mental well being before ending our work if she moves? If she moves she will no longer be under my care or my responsibility. However, this is a fact that I know will cause my client immense mental pain and have I left her vulnerable. I would want to feel that I have helped her make an informed decision about her future regardless of her decision. Having allowed her to look at all her options and discuss what is important to her and allow her to make an informed decision would make me feel that I had prepared her as much as possible in my role as a counsellor.
My role is not to tell her what to do but to allow her to open dialogue with herself and for her to gain self awareness of her true feelings, thoughts, emotions and desires. I would feel justified in my decision and at ease with my ethics and moral and principles.
The client I allowed her to make an informed decision as to her future without any feelings of guilt or having the options taken away from her, by her having to do the right thing, which is expected of her culturally. My practise and the law would be happy with the decision as no confidences have been broken. Some of my professional peers and the media may have different views, I respect their views. I needed to find a resolution I was satisfied with ethically and morally.
On coming to my decision I used the model, whilst constantly asking myself such questions as listed below. I had more questions than answers, but it was these questions that helped me.
When the doctor breached confidentiality, was he making me a part of his dilemma? Why would he breach confidentiality knowing her daughter was my patient? He may feel that the family should be aware of her situation. As they may be able to support her and because he is bound to confidentiality, he is unable to tell the family himself. Is this his personal dilemma? Is the doctor looking to me for support? I think I should discuss the doctors’ motives with him
The impact it may have on my client, their welfare is now at risk, resulting in the aforementioned scenarios (see section one). The welfare of her mother, although she is not my client, but nonetheless a woman in her final days wanting to die without her family knowing. If I told my client would it cause the mother undue distress?
Also the therapeutic relationship I have with my client is now under pressure. How difficult will it be for the relationship if I decide not to tell her? Will this be in mind throughout the sessions? How will it disrupt the relationship and process? Will she feel betrayed when she finds out? Will she blame me for not telling her breaking the therapeutic relationship? On the other hand if I tell what boundaries am I breaking? Whose confidences am I breaking? I feel I would be breaking the confidences of the doctors’, the mothers’ and the practises’.
Will transference occur? Will she want to push the boundaries? Will she feel that we have a special relationship because I told her? Will my position become more powerful in the therapeutic relationship? What does confidentiality mean to me? Confidentiality is very important to me. “Confidentiality – the highest levels of confidentiality possible according to the law and the setting. Responsibility means being responsible to clients, the profession and society.” (Jones et al, 2000, pg 9).
As a responsible counsellor should I not carry the same ethics to the well being of others and respect their confidentiality? What are my feelings and ethics with regards to this? How would I feel if a doctor had broken my confidence? If I am honest to my own beliefs then as a responsible human being I would carry the same ethics to other people not just my client.
To measure the ethnicity of clients in a GP practise using the counselling service, a simple record form with name, age, gender and ethnicity would be produced. This would be handed to the client in the waiting room prior to the session. The client would then be told to hand this to the counsellor on entering the session. This is enable confidentiality of the information.
The counsellor will then collate the information and keep it under lock and key which they alone can access, ensuring confidentiality. The information will be available to the counsellor and practise manager on request. The counsellor will then write a report on their findings outlining not only ethnicity but also gender and age of the clients to find out what age group and gender and ethnicity area accessing the service.
- BACP. (2010). Ethical Framework for Good Practice in Counselling and Psychotherapy. Lutterworth: BACP
- Gabriel, L., & Casemore, R. (2010). Guidance for ethical decision making a suggested model for practitioners. Lutterworth: BACP
- Jones, C., Shillito-Clarke, C., Syme, G.,Hill, D., Casemore R.and Murdin, L. (2000) Questions of Ethics in Counselling and Therapy.
- Gomez,C. The Italian Way of Taking Care of the Parents(2010) Available at: http://www.ehow.com/how_6862132_italian-way-taking-care-parents.html:(Accessed: 23 August, 2010).
- Mothersole, G (2004) CORE: what is it good for? Counselling & Psychotherapy Journal August 2004 18 – 21