Ethical Considerations in Clinical Work with Young Children

Maggie Brett, L.C.S.W.

Erikson InstituteOctober 22, 2011

There are no experts, in the usual sense, in ethics or morality.  Objectivity (and the move away from subjectivity) in ethical judgments is increasingly achieved as one's ethical judgments are grounded in a broader and broader base of human experience ‑‑ both one's own personal experience and the experience of other humans shared in dialogue.

-David T. Ozar, Ph.D.

Overview

Lay a foundation: What are ethics? NASW Code of Ethics

Build a framework: Model of Ethical Decision Making

Put up a few walls: Abuse and Neglect Reporting, Informed Consent, Confidentiality

Agenda

It is not enough, to know, one should also use; it is not enough to want, one

should also act.

Geothe

Ethics are not feelings, science, following the law, religion, or culturally accepted norms (Santa Clara University)

Moral principals that govern a person’s or group’s behavior

A person’s or group’s responsibilities to the larger society

Behavioral expectations “Values in action,” (Levy, 1976)

What are ethics?

One’s own family and upbringing Culture Informal life contacts Religious background Education Professional experience Personal reflection

--David T. Ozar, Ph.D.

How do we come to develop a system of ethics?

Rooted in 6 Core Values: Service Social justice Dignity and worth of the person Importance of human relationships Integrity Competence

“Core values, and the principles that flow from them, must be balanced within the context and complexity of the human experience.”

NASW Code of Ethics

Does not state a hierarchy of values, so there can be reasonable differences of opinion.

Considers ethical decision making as a process which considers even competing values.

Requires the professional to look at conflicts between personal and professional values

Recognizes that there may be times that what is ethical by these standards may not be in accordance with the law or agency regulations.

Sets forth standards to which a professional should aspire or by which their actions could be judged.

Asks for a commitment to “engage in ethical practice.”

NASW Code of Ethics

Some specific ethical standards relating to responsibility to clients:

Promote well-being of clients Promote self-determination Informed consent Competence Cultural competence Avoid conflicts of interest Guaranteeing confidentiality and privacy

NASW Code of Ethics

Obligated to inform client in a way she/he can understand about all the parameters of treatment (e.g., purpose, risk, cost, etc.)

When client does not have the capacity to provide informed consent (e.g., a young child), professional has to seek consent of a 3rd party. The professional needs to ensure that the 3rd party is looking out for the client’s best interests.

Informed Consent

When a professional provides clinical services to more than one member of a family, it is essential that it is clear who the client is and what the boundaries are between family members.

When a parent’s goals for therapy are unrealistic or even harmful, it is the clinician’s responsibility to be clear about the limits of the treatment.

Conflicts of Interest

Privacy—the right of an individual to make decisions about how much of her/his thoughts, feelings, or information is shared with others

Confidentiality—the obligation of a professional to refrain from disclosing any information about a client, except under very specific circumstances

When a client is a young child, the parent makes all the decisions regarding confidentiality.

Clinician should engage the parents in a discussion about the release of information and its subsequent use.

Privacy and Confidentiality

Therapy has to be safe for all participants and parents need to know information about their children that allows them to parent effectively

Children should have consensual confidentiality rights

Parents should receive regular progress reports

Breach confidentiality to prevent serious harm

Sharing information about a child’s psychotherapy with parents

Related to the ethical standard of commitment to client’s well-being

Involves other ethical standards: conflict of interest, informed consent, and confidentiality

Child Abuse and Neglect Reporting

Ignorant of the full extent of reporting laws Feel it’s not in the child’s or family’s best

interest Feel it’s not serious enough Not sure if it really happened Is concerned about DCFS and its ability to

correct the situation Doesn’t want to disrupt the therapeutic

relationship Afraid of retaliation

-LeRoy G. Schultz

Why are some therapists reluctant to report?

Competing values Competing loyalties Differing perspectives because of

culture, religion, gender, ethnicity, etc.

-Braniff

Some root causes of ethical dilemmas

1. Identifying the alternatives2. Determining what is

morally/ethically at stake by reason of our social roles

3. Determining what else is morally/ethically at stake

4. Determining what should be done all things considered

5. Choose a course of action

An Ethical Decision Making Model(work of David T. Ozar, Ph.D.)

Recognize an ethical issue Get the facts Evaluate alternative actions Make a decision and test it (publicity,

universality) Act and reflect on the outcome

An Ethical Decision Making Model(Markkula Center for Applied Ethics at Santa Clara University)

Using Kitchener’s (1984) 5 moral principles (autonomy, nonmaleficence, beneficence, justice, and fidelity) as the cornerstone:

1. Identify the problem.2. Apply the Code of Ethics.3. Determine the nature and dimensions of the dilemma.4. Generate potential courses of action.5. Consider the potential consequences of all options and

determine a course of action.6. Evaluate the selected course of action. 7. Implement the course of action.

An Ethical Decision Making Model(based on1996 American Counseling Association model)

Reflective Practice needs to be infused in the process; part and

parcel of each step in ethical decision making.

Our own histories, vulnerabilities, and countertransference can influence our ability to make

ethical decisions.

Addendum to Framework

Act promptly and appropriately when a complaint is received

Remedy any harm done and work to avoid further harm

Apologize if appropriate Discuss with supervisor, manager, or

consultant ways to remedy current situation and/or prevent it from happening in the future

If clinician feels acted appropriately, may be necessary to bring in 3rd party for mediation or a second opinion

When things go wrong with a client

You’re a consultant for a Birth to Three program in one of the most impoverished parts of the city. The program struggles for resources, and the supervisor and 4 home visitors, while chronically overworked, are terrific advocates for their families. One of the home visitors, Maria, often brings one particular case to consultation. She visits a single, indigenous Guatemalan mother of a 18-mo-old, who immigrated here about 1 yr ago. They struggle during their visits because the mother’s dialect is one Maria doesn’t speak, and the mother’s Spanish is poor. They are a family with almost no resources, no extended family here. Maria has worked beautifully with the family for the past 9 months trying to help the mother connect to the community and its resources.

You’ve noticed that Maria hasn’t talked about the family in several weeks, and ask about them. Maria seems reluctant to talk about them. After consultation ends, Maria walks to the car with you and tells you that she saw the mother hit her child and was very troubled by it. Maria spoke to her supervisor who told her not to report the incident to DCFS because it would only serve to isolate the mother further. She is so fearful of authorities, and wouldn’t understand the investigative process. Besides, DCFS wouldn’t do as good a job as Maria does in working with the family. Maria is worried about losing her job if she goes over her supervisor’s head, but she is very worried about the child.

How do you handle this?

Vignette #1

Parents request counseling for their 5-yr-old son, Josh, because his preschool teacher has been concerned about his behavior. The teacher reports that Josh is difficult to manage; he has low frustration tolerance; and he is aggressive with peers. Parents do not see that behavior at home, but acknowledge that as an only child, Josh doesn’t experience much frustration at home. He pretty much gets what he wants.

You have identified Josh as your client, and see him for weekly sessions coupled with regular meetings with the parents. During one of your sessions with Josh, he discloses that he takes things that don’t belong to him, from other people’s houses, from school, from the store. He reports that he doesn’t know why he does this and doesn’t feel the need to stop. He is afraid, however, he’ll be in serious trouble if he’s caught, since he often overhears his attorney parents talk about their work, and begs you not to tell.

Do you talk to the parents about this, and if so, how?

Vignette #2

Parents bring in their 3-yr-old daughter, Tori, for evaluation and treatment. They describe her as headstrong, hyperactive, and deliberately misbehaving. While her behavior is a problem in most situations, her worst behavior “she saves for church,” which is mortifying for her parents. The 3-hr service on Sunday is the most important family time of their week, and while other children of all ages in their congregation behave, including Tori’s older brother, Tori can’t sit still. They have tried consequences; they have tried ignoring her behavior, but nothing has ever worked.

You observe Tori to be an engaging, curious, active child who seems to be developmentally where she needs to be. Tori’s parents want a specific outcome for therapy. How do you handle this?

Vignette #3

Action indeed is the sole medium of expression for ethics.

Jane Addams