Week 2 Homework Assignment (Ethical Issues in Clinical Supervision)

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  • #4534
    Patricia Burke
    Keymaster

    The following is a case scenario of a client with co-occurring conditions. After reading the vignette answer the questions which are based on Reamer’s systematic method of ethical decision making.

    Case Vignette

    Janet is a Licensed Alcohol and Drug Abuse Counselor working in a comprehensive outpatient Mental Health Agency that provides substance abuse and mental health treatment. She is a recovering alcoholic and attends AA meetings on a regular basis. She has been seeing Larry in individual counseling for 3 months as part his aftercare program after completing the agency’s Intensive Outpatient Program. Larry has a long history of relapse and had previously been diagnosed with Dependent Personality Disorder. He has talked to Janet extensively about his fear of abandonment. Larry begins to show up at the same AA meetings that Janet regularly attends. She never disclosed to him which meetings she goes to and had recommended that he attend men’s meetings. He also finds out where she lives and her home phone number. He begins showing up at the agency at times when he doesn’t have an appointment and leaving gifts for Janet. He also begins leaving intrusive, anonymous phone messages on her answering machine. Janet recognizes his voice. Janet brings this clinical situation to her clinical supervisor. She is frightened and feels threatened by Larry’s behavior and wants to terminate treatment with him and possibly file a protection from harassment order against him.

    You are Janet’s clinical supervisor. Answer the following questions based on Reamer’s Ethical Decision-Making Process in order to help her develop an ethically sound course of action in this complex clinical situation.


    Homework Questions

    Question 1

    Who are the parties that will be impacted by whatever course of action is chosen?

    Question 2

    What are the ethical issues involved in this clinical scenario, including conflicting and competing values of the parties involved?

    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.

    Question 5

    Who will you, as a supervisor, consult regarding this clinical scenario and why?

    Question 6

    What is the best possible course of action to take in this clinical situation?

    Question 7

    How will you implement the decision, document the decision making process, and monitor and evaluate the effects of the decision?


    To post your assignment, please reply to this topic below.

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    #16522
    Sindee Gozansky
    Participant

    Question 1
    Who are the parties that will be impacted by whatever course of action is chosen?
    Parties impacted include Janet (therapist), Larry (client), supervisor, potentially AA group members, Larry’s family (if any), employees at agency dealing with his random appearances.
    Question 2
    What are the ethical issues involved in this clinical scenario, including conflicting and competing values of the parties involved?
    In my opinion, ethical issues include client’s breech of therapist’s boundaries with harassing/stalking behaviors of her; agency duty to provide client with mental health/substance use treatment; therapist duty not to abandon client; if relevant, potential need to alert probation officer; therapist’s disclosure of AA attendance/recovery to supervisor and/or agency employees in dealing with this issue. Primary conflicting values seem to be around boundary violation/harassment and duty for provision of services to client.
    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.
    One viable course of action is to terminate Larry from Janet’s caseload and transfer him to another therapist. According to the ACA Code of Ethics, ethical issues should be resolved with all parties involved, but it is unclear if involving Larry in a conjoint meeting with Janet would be safe to her and if it would exacerbate his boundary infractions. Risks are that he will feel abandoned, increase his harassing/stalking behaviors of her, possibly drop out of treatment with new provider and relapse. If Janet also files for a protection from harassment order, cons are that it could escalate Larry, may be hard to enforce, may require more police interference at an agency where other clients will be triggered; pros are that it may provide more safety to Janet and reduce her fears. Cons of not filing an order to protect Janet could trigger her recovery and put her own recovery in jeopardy.
    Another course of action would be to meet with all parties, Janet, Larry and supervisor to create a plan of action going forward that would involve Larry ceasing the harassing behaviors and remaining in counseling with Janet, and only terminating or transferring if he defaults on the agreement. Risks would include that it may still put Janet on edge and keeps her at risk without legal backup. Pros are that Larry may not experience abandonment by Janet and be able to work through this issue by exploring other ways to seek emotional support without resorting to harassment/boundary violations.
    In either scenario, if Janet is unable to return to her regular AA meeting due to Larry’s attendance there or fear of it, she may lose her support group and the other AA attendees may also lose their fellowship with her. Similar cons may happen for Larry as well.
    Question 5
    Who will you, as a supervisor, consult regarding this clinical scenario and why?
    I would consult with my supervisor and/or agency director, my liability insurance provider and attorney, possibly a police mental health liaison, as they can all contribute to the ethical decision-making process and it is critical to document consultation as well.
    Question 6
    What is the best possible course of action to take in this clinical situation?
    I believe protection of Janet, the therapist, and the agency employees with do-no-harm actions to the client: file protection from harassment, transfer client to another counselor at the agency for continuity of care, allow Janet to return to her regular AA meeting comfortably with the legal order in place. It would be important for the facilitator at the AA meeting to know the potential threat of Larry appearing on premises if Janet were there to mitigate crisis.
    Question 7
    How will you implement the decision, document the decision making process, and monitor and evaluate the effects of the decision?
    The decision would be documented in progress notes, crisis notes, supervision logs, discharge summary, new therapist re-opening documentation. Monitoring with all agency staff involved and any legal interaction as needed.

    #16555
    dsinskie
    Participant

    Question 1
    Who are the parties that will be impacted by whatever course of action is chosen?
    The client, Janet, Janet’s supervisor, the agency, and possibly Janet’s family and the AA group.
    Question 2
    What are the ethical issues involved in this clinical scenario, including conflicting and competing values of the parties involved?
    The client has already stated his fear of abandonment so terminating treatment might have a negative impact regarding 1) relapsing and 2) validating his abandonment issues. However, if Janet doesn’t do anything, it could compromise her recovery as well.
    If the client actually conducts physical harm to Janet, then the agency could be liable as well.
    Filing legal charges is another ethical quandry as this will violate the client’s confidentiality being in a treatment program.
    We would hope that the agency has a protocol and procedures around this type of issue.

    Questions 3 & 4
    What are all the viable courses of action and what the possible benefits and risks for each?
    1. Do nothing and let the behavior to continue. Benefits might include not having to make the decision and risks are that the client assumes this behavior is appropriate and gets into trouble when doing this with another provider. Also risks are that janet or her family are harmed or janet relapses or quits her job. Agency runs a risk allowing this behavior to continue as more clients might do it, janet sues them, community learns of it and reputation is damaged.
    2. Meet with the client and explain his behavior is inappropriate and cannot continue. Outline a plan to help the client find another meeting and Janet continues to work with him. Benefits – client is supported and learns new behavior. Janet feels that she handled the decision appropriately and can help others when they run into similar issue. Risks – client relapses, client feels validated and continues his behavior. Client leaves agency.
    3. Meet with the client and explain that his case is being transferred to another clinician and why. Benefits, Janet feels listened to and supported by agency. Janet feels relief. Client learns about inappropriate behavior and uses this in therapy going forward. Risks – client relapses, client feels abandoned, client ups the ante. Janet feels like she failed the client.
    4. Call law enforcement and serve client papers. Benefits – client cannot harass Janet any longer. Janet feels relieved and safe. Risks – confidentiality is broken, client feels abandoned and attacked, client relapses, client ups the ante, client sues agency, client files complaints with regulatory body, client bad mouths agency.
    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.
    Question 5
    Who will you, as a supervisor, consult regarding this clinical scenario and why?
    I would consult with the Clinical Director and Medical Director of the agency. These directors are responsible for the policies and procedures of the agency. Additionally, the more consultation sought, the better the outcome/decision process
    Question 6
    What is the best possible course of action to take in this clinical situation?
    I feel that the best possible course of action to take in this situation is to sit with the client and address each issue; 1) attending Janet’s meeting 2) obtaining my number and address 3) the phone calls. The meeting should include a discussion of boundaries and confidentiality. Validating the clients rapport with Janet is important also as is a discussion that Janet is trying to abandon Larry but that boundaries are important and implemented to protect the client. The meeting should also include consequences if the behavior doesn’t stop.
    Question 7
    How will you implement the decision, document the decision making process, and monitor and evaluate the effects of the decision?
    I would implement the decision by advising the CD and MD of my decision and then calling the client for a meeting. I would carefully document the facts and why I feel I need to seek supervision around this, then document each step taken, i.e., meeting with the CD/MD, my decision making process, and the plan and then finally the outcome. I would also document if these issues arise again. If not, then the intervention was successful, if they did, then its back to the decision making process.

    #16606
    melissa cormier
    Participant

    Question 1
    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.

    Question 2
    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.

    Question 5
    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.

    Question 6
    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.

    Question 7
    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.

    #16607
    bethandrews.hope
    Participant

    Question 1
    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.
    Question 2
    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.
    Question 5
    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.
    Question 6
    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.
    Question 7
    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.

    #16608

    1. The parties impacted are Janet, Larry, the clinical supervisor, the Agency, Agency Staff and AA attendees. The social realms(families, community members, the recovery community) which are connected to these individuals may also be affected indirectly.
    2. Boundary violations, non-maleficence, breaking confidentiality and client rights to treatment…… Conflict between the supervisee’s safety and the client rights to treatment complicate these ethical issues.
    3 and 4. Four viable courses of action would be having a
    1. meeting with a client to discuss further treatment options,
    2. meeting the client to transfer him to another clinician,
    3. written or phone communication terminating treatment and subsequent referral
    4. involving Law enforcement.
    Complicating this decision is how the processing with the supervisee helps her make this decision. Honoring her valid feelings of being unsafe while balancing the client’s rights to treatment and clarity around the therapeutic relationship may be challenging. It may help to focus on the client before the counselor in making the decision.
    Possible risks for the client are that he may continue his confusion and inapropriate behaviors, challenging his social connections, mental health and efforts at recovery. Possible risks for the counselor include her safety, her efficacy in managing challenging clients, her professional work and her own recovery. The agency and supervisor are at risk for helping the client and the supervisee with professional treatment/ supervision. Without making ethical choices supporting professional treatment, the agency may also be inadvertently putting the outside community at risk.
    Benefits to all are in having client, counselor, the supervisor and agency staff feel safer and to have clear boundaries and guidelines for being successful. The efficacy of all these parties can be increased when all are supported by ethical and professional treatment, including informed consent, confidentiality guidelines, etc.
    5. My hope would be that within the agency, I would have my own supervisor of supervision who is experienced in both supervision-of-supervision as well as treatment of co-occurring disorders. If not, I would seek my own outside clinical supervisor or experienced professional to consult with on this matter – either with similar experience. I may also end up consulting law enforcement with a scenario to see what options they may have of support for this situation – without breaking confidentiality.
    6. To address the boundary violations, client rights to treatment, safety concerns for all parties – I would focus on meeting with the client to clarify innapropriate boundaries, illuminate further possible consequences and offer referral options within and beyond the Agency. It would be crucial to know the clinician’s decision about involving herself in this meeting (clinician with supervisor, just the clinician, just the supervisor) because she has been the main interventionist.
    7. After that decision has been made about the counselor’s involvement, if any at all, I woud proceed with the meeting, including sharing supporting documentation of inappropriate behavior and consequences. Discussion could include how law enforcement involvement may be involved if the boundaries are not held. The client would then chose his further treatment within or outside of the Agency. Harm reduction during this stressful time of change would be discussed to help client maintain his recovery. If the client continued treatment here, reviewing how the client is managing boundaries may be reviewed in session regularly (monthly).
    A written document clarifying what is discussed may be helpful to the client and will be kept in the client’s file. Myself, the counselor and whomever I consult with will also be keeping our own documentation about this incident.
    I will follow up with the counselor (possibly past and current now) to monitor the interations with the client. Treatment will also be reviewed regularly. I may also continue to process my continued supervision within my own supervision.

    #16630
    Esther Cyr
    Participant

    1. Who are the parties that will be impacted by whatever course of action is chosen?
    a. Client/clinician/supervisor/agency
    2. What are the ethical issues involved in this clinical scenario, including conflicting and competing values of the parties involved?
    a. Dual Relationship
    b. Abandonment of client
    c. Client dependency
    d. Clinician’s competence
    e. Clinical consultation to guide decision making
    3. What are all the viable courses of action and what are the benefits and risks of each?
    a. Address behaviors directly with client/review boundaries and set firmly with client/address gift giving policy/in consultation address countertransference/seek continued consultation to address possible abandonment of client and personal safety within the therapeutic relationship.
    4.
    A. Dual Relationships/: Pro: build therapeutic relationship with client/set firm boundaries in the therapeutic relationship to include following agency policy on gift giving and spending time with clients outside of the therapy sessions/address keeping clients confidentiality when at public meetings (AA). Cons: Addressing boundaries in a negative or aggressive voice or manner/being disrespectful to the client when addressing sensitive matter such as gift giving or following clinical outside the office/not remembering it is the clinician’s responsibility to maintain boundaries and confidentiality.
    B. Clinician’s competence and use of Consultation/ Countertransference: Pro’s: clinicians awareness of issues that create the countertransference/addressing countertransference in consultation/addressing fear of personal safety/seeking consultation on whether there is enough evidence of stalking behavior to require legal action or a transfer to another clinician due to countertransference issues/addressing clinicians AA meetings and how to manage own recovery in current situation. Cons: clinician may not be aware of how countertransference is connected to fears/ may not be able to make a clear, informed decision about how to proceed with the case/clinician may receive guidance in consultation and not have the emotional strength to follow through or inform the consultant due to various reasons/possible liability if a decision is made to transfer or close the case without proper rational for decision and/or appropriate documentation. Referring to code of ethics and agency policy where appropriate to support decision making.
    5. Who will you, as a supervisor, consult regarding this clinical scenario and why?
    I would first consult with my own clinical consultant to review the primary issues such as clinician’s countertransference/clinicians ability to manage boundary setting with this client due to not feeling safe/ abandonment issues for the client. Discuss if there is a legal and safety component that needs to be acted upon. Second, I would consult with the CEO of my agency regarding agency policy and identified issues that are a dilemma with possible legal issues and clinician’s safety. Possibly contact NASW’s Legal Assistance with questions of all precautions not to abandon the client and keep the clinician safe while complying with agency and code of ethics.

    6. What is the best possible course of action to take in this clinical situation? Addressing boundary setting, preventing abandonment of client, and properly addressing clinician safety.
    7. How will you implement the decision, document the decision making process, and monitor and evaluate the effects of decision? Clinical consultation notes will be detailed and complete on each meeting with the clinician to include identified issues, decision making process with pro’s and con’s and what action was taken and outcomes. Follow-up in consultation on case until all concerns are resolved. Keep my consultant and CEO updated on case throughout the decision making and action process. When case is resolved consult on resolution and if there were actions that might have been taken that would have made a positive difference in the case. Use this case as a learning tool to address future ethical dilemmas and as appropriate update agency policy as a result of this outcome.

    #16637
    CHELSEA SPEAR
    Participant

    Question 1

    Who are the parties that will be impacted by whatever course of action is chosen?

    Larry (the client), Janet (the counselor), clinical supervisor, other agency staff, and potentially other clients

    Question 2

    What are the ethical issues involved in this clinical scenario, including conflicting and competing values of the parties involved?

    Dual relationship- Larry has begun to participate in AA meetings that Janet attends

    Non maleficence- Larry could potentially be harmed by possible options to address the issue

    Boundary violations- Larry’s boundary violations caused an ethical conflict for Janet

    Counselor’s competence- since Janet is an LADC, it is outside her scope of practice to directly treat personality disorders

    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.

    Option 1- Transfer Larry to another agency
    Pros- Janet feels safe and supported
    Larry might get treatment better tailored to his diagnosis
    Larry might understand there was a boundary crossing
    Cons- Larry would likely feel abandoned
    Larry might not understand his own role in the decision

    Option 2- have Janet sit with Larry alone and explain her own discomfort with his pushing of boundaries and set firm limits
    Pros- The situation might take on less intensity if dealt with by the initial two parties
    Cons- Janet might be operating outside her scope of practice by handling it on her own
    Larry might not understand and continue to escalate
    Janet might feel unsupported

    Option 3- Clinical supervisor and Janet could meet with Larry to share concerns about what had occurred, set boundaries going forward, and attempt to repair working relationship
    Pros- Larry can have limits set without feeling abandoned
    Janet might feel supported by having her supervisor help in vivo
    Cons- Janet might not be able to continue to address the issue on her own after the initial session
    Larry might see supervisor’s presence as a threat

    Option 4- Larry could be transferred to a clinician within the agency who treats mental health disorders
    Pros- Larry gets tailored treatment
    Janet feels safe and supported
    Cons- Larry feels abandoned
    Larry might not understand his role in the matter

    Option 5- agency gets a PFA on Larry
    Pros- Janet feels safe
    Cons- Violation of HIPAA when it is unclear if he broke the law
    Would escalate situation

    Question 5

    Who will you, as a supervisor, consult regarding this clinical scenario and why?

    I would consult with my own clinical supervisor and my peer group

    Question 6

    What is the best possible course of action to take in this clinical situation?

    I would choose option 3, placing non maleficence as highest priority while also ensuring Janet felt safe and supported. I would attempt to use the situation as a learning experience for Larry and our firm boundaries into place to ensure safety was maintained. I would explore adding mental health counseling to his team

    Question 7

    How will you implement the decision, document the decision making process, and monitor and evaluate the effects of the decision?

    I would document my supervisions with Janet leading to the decision, all of my own supervision meetings and peer supervision meetings, and the written plan for implementation
    After we met with Larry, I would create an ongoing safety plan to review weekly with Janet to ensure that the decision had been successful and no further action was needed

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