Step 1: Ethical Issues Involved

Sam, as a counsellor, has been seeing John and another client who as per Sam’s assessment is John’s partner of 5 years, and both are committed to making the relationship work long-term. First, Sam is not sure whether both John and the other client know they are consulting the same counsellor or whether they know they are both engaging in counselling at all. As per the Hong Kong Professional Counselling Association Code of Ethics (HKPCA) (2011), counsellors are required to observe beneficence, responsibility, integrity, justice and respect. In observing the welfare of clients, development and growth of clients should be encouraged. The primary role of the counsellor is to promote clients welfare while respecting their dignity. Further, the principle of respect requires that the clients’ right to confidentiality, privacy and self-determination be respected. Besides, the counselling plans should be consistent with the circumstances and abilities of clients, and such plans should be reviewed regularly to identify their effectiveness.

In the case of Sam, counselling both clients as a couple would be more effective in promoting growth and development in that underlying issues could be solved. However, since Sam is seeing both clients separately and is not aware if the clients know they are simultaneously engaging in counselling, introducing the idea of combining their sessions could be a disregard of their rights to privacy, confidentiality and self-determination. On the other hand, counselling them as individuals may not lead to the desired growth and development. The ethical issue is thus whether Sam should combine the sessions of the two clients and make it a joint couple session as opposed to individual sessions and how should this be done, should continue with usual sessions or should terminate the relationship with both clients and refer them to other professionals with appropriate guidance.

 Step 2: Possible Ethical Traps

Ethical traps are situations where an individual believes that he/she is making the right decision when they are making the wrong decision. Ethical traps commonly lead individuals away from ethical practice down to other paths that look appropriate and safe. It is thus significant to be aware of such traps and avoid them. Professionals commonly feel they are experienced and can make all decisions with total awareness. However, since professionals such as counsellors have other roles and multi-task, it is common to respond to a situation without taking time to evaluate one’s reactions. In the case of Sam, there are several ethical trap possibilities.

One of the ethical trap is objectivity trap. Professionals fall into this trap when they solve an ethical problem by applying their common sense and believe they can remain objective in any ethical situation. Sam is trained and has experience on how to help clients facing different issues. Based on this, Sam can easily believe that he will remain objective and make the appropriate ethical decisions. Being objective means that one leaves opinions, biases and interpretations when reviewing a situation. In the case of Sam, he has already interpreted that both clients are in a relationship and can quickly form an opinion that counselling both of them will be more effective based on his experience and in so doing fall into the objectivity trap.

The other possible ethical trap is circumstantiality trap. Professionals fall into this trap by spending much time considering the circumstances of the situation and believing that the wrong or right ethical decision is based on the prevailing circumstances. In professional practice, weighing all the circumstances can lead to one responding in an unethical manner. Having been counselling both clients, Sam can easily weigh the circumstances and base the ethical decision on such circumstances. While this would work outside the professional, ethical decision-making process, it will not work in the case of Sam, who has to observe codes of ethical practice.

 Step 3: Preliminary response

The primary role of a counsellor is to stimulate the welfare of clients. The code of ethics dictates that the client and counsellor work to review counselling plans for continued effectiveness while respecting the choices of the client. Counsellors should also recognise the support network and consider enlisting the support of family members and friends when appropriate. At all times, clients have the liberty to choose to continue with a counselling relationship (HKPCA, 2011). Furthermore, if the counsellor decides to change the role, informed consent should be sought from the client. Again, when appropriate, counsellors should also work towards removing any barriers that inhibit client growth and progress with informed consent.

In the case of Sam, the code has provided a room to change the counselling relationship from an individual relationship counselling to couple counselling with informed consent. Considering that counselling the clients as individuals can be a barrier to the growth of both clients in that, they are seeking relationship counselling, changing the role to couple counselling can be beneficial to the growth of both clients. The circumstance surrounding the decision is that both clients are seeking counselling from Sam which indicates that they need relationship counselling. The preliminary response is that Sam should seek consent from both clients to change the role from individual counselling to couple counselling. Considering that he does not know whether both clients are aware that they are both receiving counselling, both clients should be informed about the benefits of couple counselling without revealing that they have both been receiving counselling from Sam to protect their privacy and confidentiality. Sam should inform both parties about the benefits of couple counselling and encourage them to enrol for couple counselling for maximum benefits. The consent should seek to have them enrol for couple counselling as a couple as opposed to revealing their current counselling status. The information that the clients have both been receiving counselling from Sam should not be discussed with either party, and this should only be revealed after the clients bring up the issue.

 Step 4: Possible consequences

From the above response, several concerns are likely to occur. First, the couple can consent to the couple counselling but after learning that they have both been seeing the same counsellor as individuals, pull out of the session. The code of ethics gives them the right to choose to continue with the counselling relationship (HKPCA, 2011). The result would be that both clients could pull out of the relationship and risk having their long term relationship crumble. Again, advising the clients to undergo couple counselling without telling them they have been seeing the same counsellor individually could create distrust between the couple and Sam. It will be hard for Sam to continue with the sessions while ignoring what has happened in the past together with the awkwardness. Furthermore, if the clients get to know that they have been receiving counselling individually assuming they are not aware, it could increase the problems in the relationship and Sam can end up creating more problems as opposed to helping the couple grow.

While counselling the clients as a couple could lead to maximum benefits, it is hard for Sam to achieve this without compromising on the rights of the clients to confidentiality and privacy. Assuming both clients are unaware they are both receiving counselling, it is hard for Sam to change the sessions to couple counselling without diverging sensitive information to the clients. Sam could potentially reveal information based on experience and the whole thing workout, but this would be unethical and could lead to professional problems if it does not work out.

 Step 5: Ethical resolution

The code of ethics states that if a counsellor is providing services to two or more people who are in a relationship, the counsellor should clarify who is the client and the nature of the relationship the counsellor will have with the involved individuals. However, if it is evident that the counsellor may be required to perform conflicting roles at any time, the counsellor can adjust, withdraw or clarify the roles appropriately. Furthermore, counsellors should promote, accuracy, truthfulness and honesty while being responsible to the profession and society (HKPCA, 2011). Trying to change the role from individual counselling to couple counselling has the potential to compromise the integrity, responsibility and respect principles. Again, continuing with the current sessions can also compromise their responsibility in that their primary responsibility is to promote client welfare while respecting their dignity. Sam cannot continue to pretend that these are two clients with autonomous needs while the circumstances dictate otherwise.

In light of these considerations, I propose that Sam should refer both clients for couple counselling to other relevant professionals apart from him. Sam should avoid trying to retain both clients and compromise their welfare or act unethically. While the primary role of Sam is to advocate for the growth and development of both clients, this cannot be done at the detriment of other factors. Even when counselling the clients as a couple could be beneficial, the ethical decision is for Sam to follow ethical guidelines and avoid compromising them. Changing the role to couple counselling can lead to Sam creating a conflict of interest or can lead to him taking on conflicting roles. Referring the clients to appropriate professionals with significant guidance will ensure that Sam observes the ethical principles while ensuring the clients have appropriate guidance to achieve growth and development. If Sam is professionally asked why he withdrew and referred the clients, he has a clear cut reason based on ethical practice thus eliminating ethical traps.

Self-Reflection

This case presents several anticipated dilemmas. There are several aspects of these dilemmas that would be difficult for me to deal with. First, if I decide to refer the clients to another professional, I cannot reveal the actual reason for the withdrawer to avoid compromising the privacy and confidentiality of the clients. However, the clients can interpret my withdrawer as a lack of competence or inability to help them solve their problems. This can affect my brand name as a private counsellor and destroy my professional practice. However, retaining both clients has the risk of contravening the code of ethics, which would also be detrimental to my career as a private practitioner. Based on the possibility of affecting my brand name, whichever decision I make, it will be hard to avoid seeking self-interests. How do I deal with the possibility of destroying my hard-earned career for the welfare of other people? Do I follow the ethics code and seek the welfare of the clients by referring them to another professional or do I assume I have no knowledge of their relationship and continue seeing them as individuals while pretending to follow the ethics code and safeguard my career? This would be a challenging decision to make.

Another aspect of this dilemma that would be difficult for me to deal with is that clients might not decide to see another professional even after my referral. Having seen them for several sessions and based on my experience, I could be having ideas on how to address their relationship if addressed as a couple. There is, however, no ethical way of doing this, and the only ethical option available might not result in any positive change. Thus referring the clients to another counsellor might not end up improving the welfare of the clients but seeing them myself as a couple could but would be unethical. The dilemma then becomes, follow the code of ethics and risk the clients not getting any help if they choose not to see the referred professional or see them myself and risk unethical practice while still benefiting financially.

Case Vignette: Mariah

Step 1: Involved Ethical Issues

Mariah is the school counsellor, and while the students are still minors, the parents have signed a form giving consent for their children to see the counsellor if they like. The students are thus never forced to see the counsellor. Bing is 15 years old, and according to the Hong Kong law, has not achieved the consenting age. Recently, Bing has been irritable at home, and while talking to Mariah, he relays his worries. First, he is same-sex attracted and is engaged in a relationship with his teammate. Second, he has been sniffing glue in the company of other friends to get away from their problems. Due to the glue-sniffing, Bing is having relationship issues with his partner. His mother is concerned about his irritability and calls Mariah to get an update on Bing’s progress.

While counsellors are expected to maintain confidentiality and privacy of the information of their clients, Bing is a minor and his parent has a right to know their progress. Requesting Bing to consent to his mother being informed about his condition might not work considering the sensitivity of his issues. The ethical issues involved is whether Mariah should diverge the details of Bing’s problems to his mother which might be good for family support to overcome his issues or should Mariah just maintain the confidentiality of the information and work out the issues with Bing. While the primary role of Mariah is to ensure that the welfare of Bing improves and he experiences growth, the question is how this should be achieved while still maintaining ethical conduct as required for professionals.

 Step 2: Ethical trap possibilities

Various factors can affect the decision-making process, including biological factors. The body produces impulses as a response to external and internal stimuli and can result in automatic responses. Professionals based on their experience, knowledge and skills tend to feel they can make decisions with full awareness, but they are human beings and prone to impulses. For professionals making decisions based on external or internal stimuli as opposed to laws and ethical standards can result in an ethical trap. Ethical traps are situations where one believes the right decision has been made while in fact, a wrong decision has been made. In the case of Mariah, there are several inherent ethical traps.

A major ethical trap is the circumstantiality trap. The circumstances surrounding the situation facing Mariah can easily change. The parents can easily demand to know what is going on with Bing. The problems facing Bing can easily deteriorate, or new developments emerge. If, for example, Bing graduates to using other hard drugs from glue sniffing, there would be a change in the circumstances. The change of circumstances can change how Mariah responds to the ethical situation. In normal circumstances, people make decisions by considering all the available information and then evaluating the most effective decisions. For professionals, this is not the case in that whatever the circumstance, laws and ethical codes have to be observed. Professionals should thus not spend much time thinking about the circumstance rather should focus on what laws and ethical standards dictate in the specific circumstance.

Another ethical trap is the values trap. Values are part of people, and as argued by Mashlah (2015), they are more than virtues or ethic and form the foundation of how people act, think and feel. In making decisions, values play a vital role in building perceptions and choosing between preferences.  For professional counsellors, the use of personal values such as religious convictions and moral standards will lead to an ethical trap. When faced with an ethical decision, counsellors should revert back to the ethical codes and standards as opposed to applying personal values. In the case of Mariah, she can apply her moral standards on drug abuse and same-sex marriage into making the decision on what to do. The problem, however, is that if asked which principles she applied in making the decision, she will be unable to quote any ethical principles or standards.

Step 3: Preliminary response

The International School Counsellor Association (ICSA) which guides school counsellors such as Mariah, adopted the code of ethics developed by the American School Counsellor Association (ASCA). As per the ASCA ethics code (2016), students should be treated with respect and as unique individuals. The counsellor should respect the beliefs, values, gender, and sexual orientation of the students while still acknowledging the vital role of parents in the development of their children. While confidentiality of information should be maintained, a breach is essential to prevent any serious or probable harm to the student. The harm is determined by age, nature, parental rights and setting. The obligation of confidentiality should be balanced with the parents’ inherent and legal right as the guiding voice in their children’s lives. If a breach is required, the counsellor should use the suitable and least invasive method.

Based on the analysis above, the counsellor should go ahead and respect the inherent right of parents to participate in the development of their children. Bing has already portrayed to the parents that he has a problem by being irritable at home for the last month. He is also sniffing glue. Research has shown that glue sniffing can cause death through several mechanisms and can damage the liver, kidney, bone marrow, brain and the heart (Tulsidas, 2010). The probability of death from glue sniffing is high for people with no abuse history (Haydock, 2012). Considering Bing sniffs glue to release stress, the relationship issue can cause his continued use and increase the probability of self-harm. This justifies the breach of confidentiality to inform the parents about the foreseeable harm. The ASCA (2016) code of ethics requires that counsellors report the results of their risk assessment to parent and should not negate even when the risk is low. Mariah should thus go ahead and set up a meeting with Bing’s parents and relay the risk assessment and discuss how to help Bing together with the parents.

Step 4: Possible consequences

While breaching confidentiality seems a good and ethical idea, it has several possible consequences. First, Bing may not appreciate that his parents are aware of his problems. The fact that a good rapport between Bing and Mariah developed quickly suggests that Bing needed someone to talk to about issues he is afraid to talk to his parents about. Bing has been irritable for the last one month, and his mother is unaware of what is affecting him. This is proof that Bing does not want his parents knowing about the issues affecting him. Thus, the breach can increase his burdens and increase the propensity to sniff glue. Bing has admitted that he sniffs glue to release his burdens and thus, an increase in burdens will increase the tendency to sniff glue. It is thus possible that rather than helping Bing address his issues, a breach of his confidentiality could cause a deterioration in his development.

Another possible consequence is that Bing’s parent might go into denial and refuse to accept the situation as it is. While they are aware Bing has some issues and are aware he is talking to Mariah, they might not accept the findings and risk assessment as provided by Mariah. Based on the cultural and social background, the parents may refuse to accept that Bing is attracted to the same sex or he is sniffing glue. If the parents go to denial, then it will be hard to resolve the issues facing Bing and can even withdraw their consent in which case Bing will have no one to talk to. This can have negative consequences for Bing and Mariah will have failed in her primary role in enabling Bing to experience growth and development.

Step 5: Ethical resolution

The code of ethics dictates that the primary obligation of counsellors be to the students. However, the vital role of the parents should be acknowledged. Students should be informed about the limits of confidentiality. The breach of confidentiality should only occur if it is necessary to prevent foreseen or serious harm to the student or others. While the ethical obligation of the counsellor is to the student, it should be balanced with an understanding of the inherent and legal rights of the parent (ASCA, 2016). Furthermore, the privacy of the student should be observed to the possible extent while balancing other interests such as safety of self and others, best interest and parental rights. The counsellor is also required to provide an effective intervention to address the needs of the students.

In light of the above considerations, Mariah should take the following steps. First, she should seek the consent of Bing to breach the confidentiality of the information and inform the parents about the status of his wellbeing. If Bing consents, Mariah should organise to meet the parents face to face and present her risk analysis. However, if Bing declines to consent, Mariah should consult more on why he is refusing and learn more about the family’s values and cultural background. This will inform her on; how to approach the parents to avoid denial or shock. Bing should also be aware that while he has refused to consent, the parents will still be notified about his situation. Once notified about the well-being, Mariah should collaborate with the parents to come up with an effective intervention to address Bing’s needs.  However, if Bing’s condition worsens as a result of the breach of confidentiality, Mariah should provide a list of resources for outside support as well as referral options.

Self-Reflection

One aspect of the dilemma that would be hard for me to deal with is speaking to Bing’s parents. In Hong Kong, same-sex marriage is illegal since 1991, and while efforts by different people and groups to lift the ban have been underway, this has not changed. As argued by Xie & Peng (2018), most Chinese people hold a conservative view of homosexuality and think same-sex marriage is wrong. Considering that Bing is attracted to the same sex, it might be difficult to break the news to the parents while still avoiding hurting their feelings. If the parents are conservative, they might try to resolve the issue by forcing Bing to end the relationship. Considering that my primary obligation is to Bing, breaching his confidentiality and informing his parents about his issue can have unforeseen consequences that can affect him more. Thus, it will be hard for me to break the news to the parents while still respecting their cultural and religious inclinations. While I have to respect Bing’s choices, how do I come up with an intervention in consultation of the parents who might have different choices for Bing than he has for himself?

Another aspect of the dilemma that would be hard for me to deal with is that people are different and different circumstances call for different solutions. As argued earlier, a circumstantial ethical trap is possible in this scenario. Following the ethical code while ignoring the circumstances could easily hurt Bing. However, making a decision based on the circumstances is unethical for me as a professional practitioner. In normal circumstances, people consider all the information before making a decision, but in my case, I have to consider all laws and ethical codes disregarding the circumstances. The hard aspect of dealing with is how to make an ethical decision while not focusing on the rightfulness or wrongness of the decision.

References

American School Counsellor Association (ASCA). (2016). Ethical standards for school counsellors. The school counsellor, 84-88.

Haydock, S. (2012). Poisoning, overdose, antidotes. Clinical Pharmacology, 122-135.

HKPCA. (2011). Hong Kong Professional Counselling Association Code of Ethics (2011 Revision). Retrieved 21 November 2019, from https://www.hkpca.org.hk/about/code-of-ethics/

Mashlah, S. (2015). The role of people’s personal values in the workplace. International Journal of Management and Applied Science, 1(9), 158-64.

Steinman, S. O., Richardson, N. F., & McEnroe, T. (1998). The ethical decision-making manual for helping professionals. Pacific Grove, CA: Thomson Brooks/Cole Publishing Co.

Tulsidas, H. (2010). Glue sniffing: a review. Proceedings of Singapore Healthcare, 19(4), 312-318.

Xie, Y., & Peng, M. (2018). Attitudes toward homosexuality in China: Exploring the effects of religion, modernizing factors, and traditional culture. Journal of homosexuality, 65(13), 1758-1787.