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Who are the parties that will be impacted by whatever course of action is chosen?
Janet and her client are the primary parties. Other parties could be any relationships Janet has with her regular AA meeting members. There is also an impact on the agency, her supervisor, and possibly other clients and clinicians that may be in the building when the client is there. Janet’s family could also be impacted.
What are the ethical issues involved in this clinical scenario, including conflicting and competing values of the parties involved?
The ethical issues involve Janet’s right to safety and the client’s right to treatment. Due to the clients presenting issues, and the fact that they were known before he started treatment, the supervisor has to help Janet sort out the harm to the client to end the therapeutic relationship against the harm to Janet currently and the potential harm to Janet if these behaviors that Larry is exhibiting continue and/or worsen. There is also the duty of the agency to provide services to clients struggling with complex substance use disorders and mental health disorders and the duty of the agency to protect its employees.
Questions 3 & 4
What are all the viable courses of action and what the possible benefits and risks for each?
Janet addresses her boundary concerns with support from her supervisor with Larry in session and sets clear expectations moving forward. If behaviors continue, lay out clear expectations of what will happen in regards to terminating services and pressing charges. Pro’s: Informs Larry of his behaviors and sets clear expectations moving forward. It can value the therapeutic relationship and use it as a teaching moment within the clinical relationship. Con: Potential for Larry to continue with these behaviors is high due to reported past behaviors. May put Janet in some risk. Based on strengths-based approach that allows for behaviors to be addressed in a supportive clinical environment.
Janet terminates the therapeutic relationship and discharges Larry from the practice. Pro: SAfety concerns of Janet have been validated. Con: Larry still may act in a way that is unsafe. The therapeutic relationship is harmed and Larry is at risk due to being in a vulnerable state in his recovery. The risk to the client must be taken into consideration based on code of ethics.
Larry is transferred to another therapist within the same agency or another agency that provides similar services.Pro: Janet is supported and Larry can continue in treatment. Con: behaviors are not addressed in a therapeutic manner, maybe missing a clinical opportunity for Larry.
Please include the pros and cons of each course of action based on relevant codes of ethics, laws, agency policies, licensing board regulations, reasonable and customary clinical theory and practice, and personal values including religious, cultural, ethical and political ideology.
Who will you, as a supervisor, consult regarding this clinical scenario and why? I would consult with our lawyer to verify that we are meeting our agency policies and procedures and acting in accordance with any legal standards. I would also consult with other supervisors within the agency to make sure we are finding the balance between the clients rights to services and the employee’s rights to work in a safe environment.
What is the best possible course of action to take in this clinical situation?
I would choose the first option and have Larry and Janet meet together with the clinical supervisor to address the boundary concerns and come up with a behavior plan that must be followed for Larry to continue in treatment. I would also offer larry resources if he feels he is unable to continue in the therapeutic relationship with Janet. I would prior to the meeting notify others in the building to be aware of the timing of the conversation and have a safety plan worked out in advance of the meeting depending on Larry’s usual behavioral presentation in the office. If Larry had a history of violent outbursts, I may include the police and/or security if appropriate.
How will you implement the decision, document the decision making process, and monitor and evaluate the effects of the decision
I would document my supervision with Janet, all communications with legal and other supervisors. I would document the visit with Larry and have in writing the behavioral plan and expectations moving forward. I would check in with Janet weekly or more frequently as needed to make sure she is feeling safe and the behaviors we outlined were being met.
I may feel differently depending on Larry’s presentation in the office during previous treatment. If he had angry outbursts for example, I would most likely take a different approach. It is a bit hard to judge with the limited information from the case presentation. There are many other factors that may change my thinking, such as Larry’s size, access to weapons, criminal history, previous domestic violence issues, age, for example.