Integrative Paper

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1 Integrative Paper Jill Edmunds University of Phoenix CCMH 515CA Professor Blerta Bena August 9, 2022

2 Scenario Charlotte is a newly licensed mental health therapist who gained employment with her favorite local university that is run by her church; this school has strict religious policies, requirements, and expectations for its students. Reprimands and expulsion due to conflicts with the student code of conduct occur frequently. She has been a lifelong member of the religion, and the university is a magnet for members worldwide. During her graduate work, Charlotte acknowledged her personal values that may pose an issue in her future clinical work, confident that she was prepared to be multiculturally competent. She felt stronger confidence with this first job because she studied at this university herself and feels very well acquainted with the cultural needs of the student population. Counseling is free to students, but the therapists must provide these students with an informed consent document from the university; this document includes a mandatory signature for disclosure of the information gathered through counseling to both the university and the student’s ecclesiastical leader. Eventually, Charlotte was given her first client, Sara, who is an undergraduate senior woman. The university has several policies that directly oppose the ACA’s 2014 Code of Ethics, especially regarding usual confidentiality practices and discriminatory policies in relation to students who are not heterosexual, as homosexuality is considered a sin, and homosexual behavior is against the student code of conduct. Months into the therapeutic relationship, Sara feels safe enough with Charlotte to disclose that she has been in a long-term relationship with another female student and has no attraction toward men. Sara was hoping to work through the indoctrinated shame she is feeling, noting that she has never felt happier and sees herself proposing to her girlfriend as soon as they are both graduated. The school requires its counselors to report breaches to the student code of conduct immediately. Sara did sign the disclosure

3 document, so now Charlotte is faced with either disobeying her employer’s policy or breaching the ACA’s 2014 Code of Ethics. Disclosure would most likely lead to the expulsion of Sara and her girlfriend unless they absolve their relationship; either outcome from disclosure would harm the mental health and wellbeing of Sara. Conflicting Perspectives There are several points of conflict that emerge from Charlotte’s perspective and the opposing forces at play. Charlotte is a fervent believer and steadfast member of her church; she shares the value that homosexuality is a sin. Further, Charlotte did agree to the university’s policies when she took the job, never thinking she was going to actually be faced with a student who had a mental health need that conflicted against the student code of conduct. Moreover, Sara was made fully aware of the disclosure policy when they went over the extensive informed consent document. Because she had been in therapy for months, Sara wasn’t thinking about the possible ramifications of her disclosure to Charlotte. Alternatively, Sara is a member of the ACA and is beholden to the 2014 Code of Ethics which has strict expectations about nondiscrimination, doing no harm, and confidentiality that stand in stark contrast to the university’s policies. Code of Ethics Charlotte must consider how the ACA’s 2014 Code of Ethics relates to the dilemma she is faced with. Section C.5. contains a straightforward requirement that counselors must not discriminate against a client based solely on their sexual orientation or partnership status. The school explicitly states that homosexual behavior is against school policy, while thoughts are permissible; because Sara is in a partnership, Charlotte is expected to discriminate against her because of the partnership in place. Further, if Sara was in a relationship with a male student,

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4 there would be no conflict with the school policy, which clearly indicates discrimination based on sexual orientation. One of “the fundamental principles of professional ethical behavior [is]… nonmaleficence, or avoiding actions that cause harm” (American Counseling Association, 2014, p. 3). Forcing Sara to choose between ending a loving relationship or expulsion would harm Sara’s mental health, a direct ethical violation. This is of the utmost importance as “the primary responsibility of counselors is to respect the dignity and promote the welfare of clients” (American Counseling Association, 2014, p. 4). And although Sara did sign a disclosure document at the beginning of the relationship, Charlotte is sure that she would not consent to the disclosure of this personal information now if asked again. Though not as unequivocal, this may still be in violation of section B.1.c. which states: “counselors disclose information only with appropriate consent” (American Counseling Association, 2014, p. 7). If ongoing consent is considered, Charlotte would not have the appropriate consent. Other codes of conduct that are common in the counseling profession do not contradict the codes previously discussed. In fact, the NBCC’s Code of Ethics (2016) adds to the ACA’s sentiments: counselors “shall not use counseling techniques or engage in any professional activities that discriminate against or show hostility towards individuals or groups based on gender, ethnicity, race, national origin, sexual orientation, disability, religion or any other legally prohibited basis” (National Board for Certified Counselors, 2016, p. 3). Charlotte should consider that this directly refers to the professional activity of disclosure that is discriminatory in its nature. Moreover, Charlotte may be in breach of the AMHCA Code of Ethics already, as she was not cognizant of the “possible conflicts of interest that may arise among counselors” and their employers (American Mental Health Counselors Association, 2015). Charlotte should have considered the full implications of the university’s policy before agreeing to abide by it.

5 Legal Considerations Along with the ethical implications of her situation, Charlotte must consider the legality of her predicament as well. In Utah, there are specific laws about the exemptions to confidentiality for mental health therapists (Confidentiality – exemptions, 2021). Counselors “may not disclose any confidential communication with a client or patient without the express written consent of” their client (Confidentiality – exemptions, 2021, para. 1). Technically, under Utah’s law, Charlotte would not be acting in an unlawful manner if she does disclose to the school, as the written consent for disclosure was required by the school before Charlotte could take Sara on as a client. Although, even if something is permissible under the law, that does not condone the act ethically. Charlotte may choose to seek legal counsel regardless of the legality of disclosure, especially if she has to choose between breaching her employment contract and acting unethically. Decision-Making Model The use of the Practitioner’s Guide to Ethical Decision Making provided by the ACA would be very beneficial to Charlotte’s current situation, especially because Charlotte is an ACA member herself. Charlotte would begin by identifying and defining her dilemma, preferably in writing to organize her thoughts (Forester-Miller & Davis, 2016). After this, she should apply the ACA’s 2014 Code of Ethics; the decision-making model mentions that many ethical situations can be ameliorated sufficiently in this single step (Forester-Miller & Davis, 2016). Additionally, the implications of the situation should be examined as they related to each of the ACA’s foundational principles; implications can also be discussed with ACA-compliant colleagues (Forester-Miller & Davis, 2016). Then, Charlotte may begin generating courses of action, considering the potential consequences involved with each plan (Forester-Miller & Davis, 2016).

6 Once a course of action is selected, Charlotte would be expected to evaluate it based on justice, publicity, and universality (Forester-Miller & Davis, 2016). Finally, she could then implement her plan of action (Forester-Miller & Davis, 2016). As discussed previously, the type of disclosure Charlotte is considering would be unethical when examined under the ACA’s 2014 Code of Ethics as per step two of the ethical decision-making model. However, if Charlotte chooses to act ethically and refrain from disclosure, she will need further ethical guidance on how to handle her professional obligations to her employers while protecting Sara. It would definitely be advisable for Charlotte to also seek support and counsel from an ACA-compliant colleague in conjunction with legal counsel as she seeks an ethical plan of action. The decision-making model is a wise tool to use when creating ethically compliant action plans, which Charlotte would need to do after seeking counsel of her own. Counseling Supervision If Charlotte were to have a supervisor in this situation, it could be a convoluted situation. Complexity would be involved if Charlotte’s supervisor was another counselor working for the university; in this situation, it would be implied that Charlotte’s supervisor also agreed to the university’s disclosure policies. This may create bias and duty for the supervisor to push for the unethical decision of disclosure. However, if Charlotte had a supervisor outside of the university’s influence, their involvement could be a beneficial tool as outlined in the decision-making model. As a supervisor, the primary obligation is to ensure client welfare in regards to the clients of the supervisee; they must “monitor the services provided by supervisees” ( American Counseling Association, 2014, p. 12). If the supervisor is to act ethically themselves, they should advocate for the confidentiality and wellbeing of Sara.

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7 Risk Management & Self-Evaluation Due to the complexity of Charlotte’s predicament, she should consider common risk management strategies. Corey et al. (2019) provide an extensive list of such strategies. The first item on the list is for counselors to “become aware of local and state laws that pertain to your practice, as well as the policies of any agency for whom you work” (Corey et al., 2019, p. 323). Risk management also involves consulting with colleagues and documenting any decisions. Most importantly, “the best protection against malpractice liability is to be concerned first and foremost with providing quality care and secondly to strive for ways to reduce risk” (Corey et al., 2019, p. 325). Charlotte should be consulting with colleagues and seeking out ethical solutions, but most of all, she should be considering how she can provide the best quality of care and advocation for Sara. Another possible tool for Charlotte to employ is self-evaluation. Especially in the context of diversity issues, self-evaluation is key to developing cross-cultural therapeutic competence (Corey et al., 2019). Because culture can refer to and include sexual orientation, cultural competency is an important skill for Charlotte to develop, especially when dealing with a cross- cultural relationship, such as the one between herself and Sara (Llorente, 2018). Because “ongoing self-assessment and self-reflection are necessary” even when not faced with ethically charged situations, routine self-evaluations promote growth, competency, and positive change (Corey et al., 2019, p. 491). Charlotte believed she was prepared for the possibility of conflicting values between herself and her clients; further, she felt she was prepared for the cultural demands of her occupation. Though Charlotte finds herself in a difficult situation, she can use it as a strong catalyst for the betterment of her future career, but most of all, as an opportunity to help and protect Sara.

8 Proposed Resolution Several studies can aid in directing Charlotte towards an ethical and evidence-based solution. While evidence-based practice is widely implemented in psychotherapy today, the definition of evidence-based practice commonly neglects evidence that these same practices have the same effectiveness for minorities (Kousteni, 2022). Charlotte may consider including cultural competency factors when evaluating evidence-based practices to employ in her cross-cultural therapeutic relationships (Kousteni, 2022). This is also an important consideration for her ethical decision-making, as cultural competency is a requirement for ethical counselors (Corey et al., 2019). Although diversity training would have been best prior to the manifestation of an ethical diversity issue, Charlotte would still benefit from diversity training, especially training specific to serving the LGBT community (McGeorge et al., 2014). One possible resource for skill development is the Handbook of LGBT-affirmative couple and family therapy by Benson (2013). It is highly suggested that Charlotte should pursue further training in regard to diversity and multicultural competency. There are clear ethical guidelines that Charlotte will need to comply with before moving on to the more ethically-ambiguous considerations; while taking any next step, Charlotte should be prioritizing Sara’s mental health above all else. It is clear that Charlotte should not disclose Sara’s breach of the student code of conduct to the university, as the wellbeing of her client is her ethical priority. Counsel would be highly recommended; this should come in the form of both legal aid and colleague discussion. Charlotte must find out what she is able to do under her current employment contract, and that may mean finding a new job. The sacrifice, though difficult, would be well worthwhile to uphold a high ethical standard. Colleagues could aid Charlotte in providing the most ethically sound course of action for Sara’s wellbeing. It is

9 proposed that Charlotte should refrain from disclosure, especially without renewed consent from Sara. Assuming legal compliance, Charlotte may seek revisions to her employer’s expectations as to comply with ethical codes in the future; otherwise, she may be faced with the difficult choice of ending her employment with the university as a form of risk management. Under no circumstances should Charlotte impose her own religious values on Sara ( American Counseling Association, 2014). Again, the priority for Charlotte must always be the wellbeing of her clients.

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10 References American Counseling Association. (2014). 2014 ACA code of ethics . https://www.counseling.org/docs/default-source/default-document-library/2014-code-of- ethics-finaladdress.pdf American Mental Health Counselors Association. (2015). Code of Ethics . https://www.amhca.org/HigherLogic/System/DownloadDocumentFile.ashx? DocumentFileKey=24a27502-196e-b763-ff57-490a12f7edb1&forceDialog=0 Benson, K. (2013). Handbook of LGBT-affirmative couple and family therapy. Journal of Marital & Family Therapy , 39 (3), 403–404. https://doi.org/10.1111/jmft.12025 Confidentiality – exemptions, Utah Code Ann. § 58-60-114 (2021). https://le.utah.gov/xcode/Title58/Chapter60/58-60-S114.html Corey, G., Corey, M. S., & Corey, C. (2019). Issues and ethics in the helping professions (10th ed.) [E-book]. Cengage Learning . https://bibliu.com/app/#/view/books/9781337680134/epub/OEBPS/02_9781337406291_t itle.html#page_2 Forester-Miller, H., & Davis, T. E. (2016). Practitioner’s guide to ethical decision making . ACA. https://www.counseling.org/docs/default-source/ethics/practioner-39-s-guide-to-ethical- decision-making.pdf?sfvrsn=f9e5482c_10 Kousteni, I. D. (2022). Toward an Extended View of Evidence-Based Psychotherapy: Diversity and Societal Factors. Journal of Humanistic Psychology , 62 (1), 31–43. https://doi.org/10.1177/0022167818762651

11 Llorente, M. (2018). Culture, Heritage, and Diversity in Older Adult Mental Health Care . American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9781615372119 McGeorge, C., Carlson, T., & Toomey, R. (2014). The Intersection of Spirituality, Religion, Sexual Orientation, and Gender Identity in Family Therapy Training: An Exploration of Students’ Beliefs and Practices. Contemporary Family Therapy: An International Journal , 36 (4), 497–506. https://doi.org/10.1007/s10591-014-9312-8 National Board for Certified Counselors. (2016). Code of Ethics . https://www.nbcc.org/assets/Ethics/NBCCCodeofEthics.pdf

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