ThompsonHMFT5102-3

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1 Applying Kitchener’s Model of Ethical Decision Making Haley Thompson MFT5102- Legal, Ethical, and Professional Development in Marriage and Family Therapy Dr. Leonard Bohanon Oct 22, 2023

2 Counselors face a variety of ethical dilemmas every day, and must be able to make decisions based on ethical principles and legal standards, while retaining respect and a positive relationship with their clients. Kitchener’s model of principle-based ethics is the foundation for the Ethics Code of the American Counseling Association [ACA], American Psychological Association [APA] and the American Association of Marriage and Family Therapy [AAMFT], and is used in tandem with virtue ethics in ethical decision making (Urofsky et al., 2008). Therapists must remain diligent in their knowledge of applicable Codes of Ethics and legal standards to make sound ethical decisions through critical thinking and self-awareness (AAMFT, 2015). The literature suggests that better integration of the model into ethics codes may be warranted to assist mental health professionals who may not only take different approaches to ethical decisions, but may also be limited on time and resources (Urofsky et al., 2008). A good example of this integration and its application is seen in the ethical framework of the British Association for Counselling and Psychotherapy [BACP], “ A practitioner’s obligation is to consider all the relevant circumstances with as much care as possible and to be appropriately accountable for decisions made ,” (BACP, 2018). In the following case study this essay will address the ethical dilemmas and how to apply Kitchener’s principle-based model to the situation. For the purposes of this paper, it will be assumed that the therapist is a member of AAMFT and is therefore obligated to adhere to the Ethics Code set forth as such. Ethical Dilemmas This case presents a few ethical dilemmas. First and foremost, is having to decide whether to accept the invitation and attend the ceremony. Secondly, though the therapist has already accepted the gifts, this is a behavior that needs to be discussed with the client. Lastly, the

3 relationship between therapist and medicine man needs to be discussed with both him and the client. All ethical standards need to be followed and most are applicable to this specific situation, however the three of these dilemmas mostly center around ethical standards: 1.2 - Informed Consent , 1.3 - Multiple Relationships , 1.13 - Relationships with Third Parties , 2.1 - Disclosing Limits of Confidentiality, 3.9 - Gifts . The dilemma that is most apparent is crossing the boundary line between the therapist- client relationship by attending the ceremony. Standard 1.3 of the AAMFT Ethics Code states MFTs cannot have multiple relationships with clients or their families outside of the therapy context. This includes business relationships, or social ones as pertaining to this instance. However, establishing rapport with clients, building up a positive relationship, and displaying sensitivity and respect for their culture is paramount to effective and successful therapy (D’Aniello et al., 2016; Sprenkle et al., 2009). When considering this dilemma, the therapist must also carefully consider the possible Implications of an “outsider” appearing at the ceremony. Though the therapist already works on the reservation, that does not immediately imply they are welcome to attend ceremonies or events in the community. There is a possibility that attending will draw questions or negative attention from the community. How would the community regard the medicine man if they found out the connection between the family and the therapist? The inclusion of someone outside of the community and culture might not be received well and could reflect badly on the medicine man. Could the therapist’s presence potentially harm the family because of stigma surrounding mental health or agencies outside of the traditional community? These are all factors that will need to be discussed with the client before deciding to attend the ceremony. However, becoming involved in the culture, even slightly, will likely strengthen the therapeutic bond by showing an appreciation and

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4 willingness to understand it (D’Aniello et al., 2016). Regardless of the decision, it is essential to establish clear, firm boundaries in this situation while retaining respect and cultural sensitivity for the client and their culture. Secondly, the dilemma of receiving gifts from the client. The therapist has already accepted the gifts, but was conflicted on whether it was the ethical choice or not due to the family’s financial situation and Standard 3.9 of the AAMFT Code of Ethics (2015). Nearly all Native American cultures place great emphasis on sharing and generosity (Houser et al., 2006). In this case, it is important to show cultural competence and respect by accepting the gifts, while at the same time discussing the situation with the client. This discussion can address the cultural significance of gifting, alongside the therapist’s position to accept gifts. The goal is to show respect and appreciation for the gift, and not embarrass or humiliate the client by declining it. It is also essential that during this conversation, the therapist makes it clear that there is no expectation or obligation for gifts, and work with the client to discuss alternatives for the client should they want to express their gratitude again the future. Alternatives may be a small card or letter, or perhaps something intangible that is still culturally significant, such as a blessing or a song perhaps. This allows the client to express their gratitude in line with their culture, without placing any undue burden, strain, or obligation on their shoulders. Personally, gifts are not an issue for me, though clear understanding needs to be established so there is no expectations or obligations. This is a controversial topic, but if someone wants to give me a small gift of their own free will then I believe in most circumstances I would accept it with gratitude, and potentially discuss their reasoning and culture behind it if I felt the conversation was necessary. Again, establishing rules and expectations, and explaining my position as their therapist and the ethics code I have

5 to follow regarding gifts will be vital to a healthy relationship and keeping to the code of ethics. It is important to show appreciation, without embarrassing or disrespecting the client or their culture (Sprenkle et al., 2009). If the client asks about giving a gift beforehand, then a discussion can be had about what the gift means to them, and if we can find an intangible alternative (or even a card/letter), instead of a physical gift. Choosing whether to accept gifts or not is a great example of how our personal morals affect our ethical decisions. Finally, there is the dilemma of working with the traditional medicine man. A working relationship has already been established, so this will only touch on a few brief points that would need to be considered in this situation. Confidentiality of client information and building trust with the client is priority in therapy, hence the first standards set forth in most codes of ethics begin with informed consent and confidentiality clauses. Keeping Standards 1.2, 1.3, and 2.1 in mind, a thorough discussion would need to be had with the client about the family’s information and the therapist’s legal and ethical requirements surrounding it. Part of her providing informed consent will have to include information regarding what can and cannot be shared with the medicine man (if any at all), and explaining that she must sign a form granting permission to share information with him. During this process, it will be necessary to inform, or remind, her that certain information will also have to be shared with Child Protective Services since they mandated the therapy and will be monitoring progress. A few questions that need to be considered are, “How much information is shared, if any? Again, the therapist must establish clear boundaries and give thorough explanations of their ethical and legal responsibilities so the clients understand they are not just shirking or disrespecting the medicine man, but are instead bound by the ethical code. Currently this does not seem to present an ethical dilemma since the medicine man is open to working with the

6 therapist, however in a similar situation this has the potential to present an issue as far as disclosing confidential information to third parties, and ensuring proper informed consent is given by clients (AAMFT, 2015). Foundational Principles of Ethical Decision Making Since the therapist has already made the decisions to accept the gift, and work alongside the medicine man, the decision that is left is whether to attend the ceremony or not. Before making that call, there is information that the therapist would need to help make the ethical decision. A few questions the therapist might ask include:  What is the significance?  Will I be expected to participate or is it acceptable to stand at the back?  Is this an intimate ceremony or a public (larger) one?  How will my presence be received by the community? For many Native American communities, there is no distinction between family members, or between different aspects of health (mental, physical, emotional) (Lettenberger- Klein et al., 2013). Family is a collectivist ideal and issues are handled as a supportive, intertwined community (Lettenberger-Klein et al., 2013). These facets of Native American culture are important to consider when working with Native American clients. This case is one example of how involved a community might become to help a family who is unwell in some aspect (in this case, mental health and family wellness), and work together to help them; ie. The medicine man that is open to working in tandem with you as their therapist. Lettenberger- Klein et al. (2013) suggest it is wise to approach therapy with these cultures from a holistic

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7 approach and to remain mindful of the potential implications of the decisions that are made during ethical dilemmas. A systemic therapist would do well to follow Kitchener’s model of ethical decision making. Kitchener established four processes that therapists must follow during ethical decision making (Wilcoxon et al., 2021). The first process: interpreting a situation as requiring an ethical decision. In this case, we know the situation requires an ethical decision based off the therapist’s conflicting feelings towards it and the options that are available. When considering the possible implications and ramifications of attending or not attending, a case can be made for both decisions that would standup to scrutiny by an ethics board. Process 2: formulating an ethical course of action, is comprised of two parts; intuitive level thinking, and critical- evaluative thinking (Wilcoxon et al., 2021). The intuitive level is the initial reaction to a situation. In this case, the intuitive level instinct might be to immediately accept the invitation because the therapist has grown close to the family and wants to show their support. However, the next step is that of critical evaluation, which moves through three tiers of justifying the decision against the ethical codes (Wilcoxon et al., 2021). This level requires a more nuanced understanding of the ethical guidelines and how to move forward when ethical codes conflict with each other. Refer to the framework presented by the BACP in which the therapist makes the most sound ethical decision they can, given their personal morals and the unique situation at hand (2007). The therapist must consider the situation and choose the course of action that results in the most beneficence and nonmaleficence towards the client, and then take responsibility for the outcome (Wilcoxon et al., 2021). In this case, the decision that might be the most beneficial for the family, is to politely decline the invitation and keep the boundaries clear. The most ethical choice may not always be the most alluring or satisfying one. The third

8 process “emphasizes the impact of virtue on ethical decision making,” and the therapist must find the balance between implementing their personal values and ethical principles (Wilcoxon et al., 2021, p.52). In this scenario, process three may look like the therapist carefully weighing the impact of their decision, and the intent behind it. Are they gaining anything from it? Is the client gaining anything from it? Do the benefits outweigh the risks of attending, and who is most at risk? Finally, process four is integrating an action plan. The focus of process four is a therapist being able to make a decision. The first three processes help therapists think about wise decisions and the implications of them, but the final process dictates therapists have a duty to make the most ethical choice they can, and then take responsibility for that choice. This process argues that not making a decision is making a decision, and when the therapist follows through on good intentions it is likely the decision made will help resolve the dilemma, or at the very least help identify it (Wilcoxon et al., 2021). Risks and Benefits of the Decision Deciding to attend carries a risk of the therapist-client boundary becoming muddled, leading to an unhealthy or unethical relationship between the two. However, many Native American cultures emphasize strong communal social bonds, and attending the ceremony will likely help strengthen the therapeutic relationship and build upon the trust that has been established. If I were the therapist in this scenario, my intuition would lead me to ask clarifying questions about the ceremony and its significance to the family, and what my presence would mean to them. It is likely that I would accept the invitation if the ceremony is not a small, intimate one, and I am reassured that it would not pose a risk of negative impact for the family or community. Before confirming this, it would be wise to consult a supervisor

9 or community leader to ensure that my presence will be welcome and beneficial to the family, and appropriate boundaries will continue to be maintained. References American Association of Marriage and Family Therapy. (2015). AAMFT code of ethics. British Association for Counselling and Psychotherapy. (2018). Ethical framework for good practice in counselling and psychotherapy . Retrieved Oct. 22, 2023 from https://www.bacp.co.uk/events-and-resources/ethics-and-standards/ethical-framework- for-the-counselling-professions/ D'Aniello , C., Nguyen, H. N., & Piercy, F. P. (2016) Cultural sensitivity as an MFT common factor. The American Journal of Family Therapy , 44 (5), 234- 244. https://doi.org/10.1080/01926187.2016.1223565 Houser, R., Wilczenski, F. L., & Ham, M. (2006). Culturally relevant ethical decision-making in counseling . Sage. https://dx.doi.org/10.4135/9781452225838 Lettenberger-Klein, C.G., Fish, J., & Heckler, L.L. (2013) Cultural competence when working with American Indian populations: A couple and family therapist perspective. American Journal of Family Therapy, 41 (2), 148-159. Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009). Common factors in couple and family therapy: The overlooked foundation for effective practice. New York, NY: The Guilford Press.

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10 Urofsky, R. I. (2011). Kitchener's principle ethics: Implications for counseling practice and research. Counseling and Values , 53 (1). Wilcoxon, A. S., Remley, T. P., & Gladding, S. T. (2021). Ethical, legal, and professional issues in the practice of marriage and family therapy . Pearson.

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