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Who are the parties that will be impacted by whatever course of action is chosen?
Parties impacted include Janet, Larry, Janet’s supervisor, other agency personnel who may be experiencing or sensing Larry’s inappropriate boundaries, a potentially new counselor either within or outside the agency, potentially Larry’s family members, should he relapse.
What are the ethical issues involved in this clinical scenario, including conflicting and competing values of the parties involved? Janet has an ethical conflict, based on Larry’s increasing boundary violations. He has a personality disorder that is manifesting in the clinical relationship. Does one “fire” a client for behaving in a manner consistent with his diagnosis? The agency has ethical decisions to make, in terms of how to handle this situation. Obviously, Janet’s safety must be ensured, and that demands some sort of action that must be determined. Larry’s behavior could get him in legal trouble; does Janet/the agency handle it with or without legal involvement? Once can assume that an ethical decision was already made and Janet had revealed to Larry that she is in recovery. Otherwise, he may not have known to look for where she attends meetings. Perhaps that is a decision the agency may revisit.
Questions 3 & 4
What are all the viable courses of action and what the possible benefits and risks for each?
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.
1) Tell Janet she needs to either ignore or confront this issue on her own, despite her stated fear.
a. Pros: I fail to see any.
b. Cons: Janet is an LADC, and as such, has little to no training in working with personality disorders, so may have already missed important signs of Larry’s growing dependence, and may not be equipped to handle his potential reaction therapeutically. One could wonder if the agency made an ethically sound decision in placing Larry with Janet initially. This puts Janet in an unsafe position. She has already stated her fear, so to ignore this would be to leave the agency open to legal action should she get hurt. Janet is fearful so perhaps does not confront the issue and Larry is allowed to continue his behavior without any learning or constructive consequences, which defeats the purpose of his treatment. Janet may not feel safe going to AA meetings, which could compromise her own sobriety.
2) Supervisor meets with Larry and terminates Janet’s work with him, referring him to a new clinician within the same agency, after explaining to him why this is being done.
a. Pros: Larry is helped to understand why his actions are making Janet feel unsafe, and hopefully help him learn what appropriate boundaries are. Removes Janet from the situation. Perhaps keeps agency from any legal issues that could have arisen from leaving Janet to handle it on her own.
b. Cons: Larry will likely feel abandoned, and this could be compounded by Janet not being part of the interaction in which he learns that he is being moved to a new clinician. He shared his fears with her honestly, and he may see her as neither honest nor loyal. Despite her personal experience with the situation, she has an ethical obligation to treat him with dignity, honor and respect, which I do not feel she would be doing if she did not participate in the difficult conversation with Larry. He is at risk for relapse.
3) Supervisor and Janet determine they will meet with Larry together, respectfully share with him how his behavior is making Janet feel, and give him the choice of staying with a new clinician at the same agency or being referred to a clinician in another setting.
a. Pros: Larry’s autonomy would be respected. This could be a therapeutic intervention in which Larry receives respectful feedback about how his actions have negatively impacted Janet, and also receives feedback and suggestions for healthier ways to have a therapeutic relationship. Both the supervisor and Janet would be supporting one another, in the event Larry becomes angry or attempts to discredit the interaction at a later date. One would hope that agency policy exists to support this decision, and is in line with making sure Larry’s client rights are respected, and that his needs are a primary consideration.
b. Cons: Larry may feel abandoned and refuse to participate in a discussion about how to help himself or find solutions. He may relapse. He may decide that treatment providers are disrespectful of him, and refuse further treatment.
4) File PFA.
a. Pros: Janet would perhaps feel safe, and might feel supported by her supervisor and agency.
b. Cons: Because this appears to be a first time problem, involving the law in any way would be an overreaction, showing poor judgement and harming Larry. He has done nothing legally wrong. Larry’s rights include being allowed to participate in the decisions being made about his treatment, and filing a PFA would ignore this. While Janet may feel supported, Larry’s needs would have been completely ignored, and he would likely be further harmed by this decision.
Who will you, as a supervisor, consult regarding this clinical scenario and why? As a supervisor, I would be consulting my clinical supervisor as well. I would do this both to double check my own lines of reasoning and decision making, and to make certain I am in line with agency policy and the decision making process of my boss. I would be asking my boss if she felt there should be legal consult before taking action.
What is the best possible course of action to take in this clinical situation? In this situation, non-malfeasance and self-interest are not mutually exclusive, although at first glance, they may appear to be. I believe that there first needs to be constructive conversation with Janet to ascertain whether or not there were things communicated between Larry and her that may have given him an impression she was interested in some additional relationship outside of work, as well as exploration of warning signs she may have missed. Once this is done, Janet and her supervisor need to come up with how Janet will communicate her discomfort in a therapeutic and respectful way, as well as create a list of options to provide Larry. Since Janet has already stated she feels unsafe, it seems the safest and most ethical approach would then be to meet with Larry together, but let Janet take the lead in expressing her discomfort, offering options and providing Larry with insight into how his behavior has affected her. This can be turned into a learning process for Larry, if he is shown that he is not being abandoned by the agency, but that he can learn from this and make better choices in the future, and Janet can take care of herself and her safety concurrently.
How will you implement the decision, document the decision making process, and monitor and evaluate the effects of the decision? Implementation is as stated above. All clinician contacts with client should already be documented and included as part of the ongoing process of determining next actions. I would ask Janet to document the experiences that have made her uncomfortable. I would document all conversations I have with Janet, as well as those with my supervisor and any other sources I am advised to consult (i.e., legal, other agency resources). If there is agency policy related to this situation, I would document that I consulted that as well. Finally, I would document the process in the meeting with all three parties, and the outcomes of that meeting. Any follow-up, such as the referral process that Larry chooses, would be documented as well. Ongoing supervision of Janet to process what happened, what she has learned and how she will use this knowledge moving forward to become a more informed and effective clinician will continue to be noted as well.