In social work professions, experts have insisted time and again that the ideal defense against ethical dilemma is the ideal offense. Professionals ought to foresee ethical issues that might lead to dilemmas and talk about them frankly with both their clients and colleagues to avoid dilemma. Ethical dilemmas arise in many aspects ranging from confidentiality, client-therapists relationship, respect, professional responsibility, among others. For instance, in the course of therapy, some issues that are beyond a social worker’s competence may arise. Then a social worker should be deliberate about their professional roles and the limits of their competence to decide whether to treat their clients or to refer them to another specialist. Some of the issues may be minor, or the client-social worker’s relationship may be thus far successful, causing an ethical dilemma whether to disregard competency and continue with the therapy. However, the dilemma avoidance plan has been made easy by the American Counselling Association (ACA), which offers codes of ethics for therapists to follow. Besides, there are proven ethical decision-making models that help social work professionals in making ethical decisions straightforwardly. This paper depicts an ethical dilemma in a therapists-LGBTQIA+ client relationship case study concerning competency and an ideal offensive approach to the dilemma using the transcultural integrative model.
Marcus is a 23 years old male who is in substance addiction therapy. Earlier on, I advised him to associate with sober people. He recently mentioned that he is not able to make friends since he is most uncomfortable with people, especially women. Although Marcus is a Christian, he has not attended a service for several years. It then happens that he reveals to be an intersex, a trait that he does not talk about to anyone. He adds that only his family and a few other family friends are aware of it. This is not an isolated case as there us is an increasingly high number of LGBTQIA+ clients. Often, this statistic becomes relevant during the treatment process that concerns sexual or relationship issues. It is seldom realizing the client’s sexuality at the beginning of the therapy since sexuality is not part of addiction therapy. Besides, I am not trained or having experience in diagnosis or treatment of sexuality issues or dealt explicitly with clients from the LGBTQIA+ community.
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Like most clients with issues regarding sexuality, Marcus notes that I am not confident approaching the matter. However, he minifies the issue intentionally. Therefore, we may continue with the therapy and disregard the issues. Also, while it is evident that Marcus requires friendship therapy, he insists that I give him some tips to feeling comfortable with other people. He has even suggested that I tell his friends not to consider him wired.
Overview of the Dilemma
In Marcus’ case, there may be a link between his inability to conform to social groups and his sexuality. Besides, the perception of the Marcus family, peers, and himself on his sexuality may be rooted in his substance abuse. Marcus has indicated that he does not talk about his sexuality. This presents three choices. First, to help Marcus with his social relationships – an area that I am not competent, or refer Marcus to another trained and competent therapists, – which may not excite Marcus, or take no professional action at all. If I treat him, I will have overlapped the competence boundaries, and if I refer him, I may spoil our ongoing therapeutic relationship. Nevertheless, I may find the ethical decision for this case through one of the ethical decision-making models.
Transcultural Integrative Model for Ethical Decision-Making in Counseling
As mentioned earlier, the offensive approach to ethical dilemmas is guided by the ACA code of ethics and some proven ethical decision-making models. The Transcultural Integrative Model for Ethical Decision-Making has four steps through which one may examine a case and determine the appropriate ethical decision (Garcia, Cartwright, Winston & Borzuchowska, 2003). The steps include (1) interpreting the situation by fact-finding. This may involve identifying those involved and their worldview concerning the situation at hand. (2) Formulating an ethical decision. (3) Weighing competing for nonmoral values that back the course of action. (4) Planning and executing the selected course of action. These steps will assist in identifying the appropriate ethical decision in the Marcus case study.
Step One: Interpreting the Situation by Fact-Finding
Fact-finding entails examining the factual issues that regard the therapy at the point the dilemma arises. First, the therapeutic relationship with Marcus is currently rooted in substance abuse. The therapy progresses successfully, but the recommendation to associate with people who are not substance abusers has thus far not worked since Marcus is not able to mingle with most people. He has thus far preferred not to talk about his sexuality. Also, despite noting that I am not proficient with issues regarding LGBTQIS+, Marcus prefers that I suggest some tips to conforming in social groups, or informing some of his friends that he is not wiered.
That means Marcus wants help from me, regardless of the incompetence in LGBTQIS+ issues, so that minimal people know about his sexuality. The prevalent bisexual worldview may cause this in Christianity, which treats LGBTQIS+ as an outlier within the margins of sexuality may be the cause of his confidentiality (Roggemans, Spruyt, Droogenbroeck & Keppens, 2015). This worldview, which may be rooted in Marcus’ parents and their family friends – Christians, is biased and often propagate negative attitudes towards the LGBTQIS+ community. It is a critical issue that required intervention by a relationship therapist, with expertise in sociocultural issues such as Marcus. Although I have not had education, training, supervision or mentorship in relationships or in the domain of sexuality, he emphasis causes an ethical dilemma whether to treat him using general therapeutic knowledge or refer him to a specialist or to take no professional course if action.
Step Two: Formulating an Ethical Decision
The dilemma in this context concerns the boundaries of professional competence. This issue has ever been debated in different contexts, all providing different rationales. For instance, Koocher & Keith‑Spiegel (2017) suggests that under certain conditions, such as when a transfer would cause more problems, a therapist may cross boundaries of professional competence, with the consent of the client. The American Psychological Association recently cited that by “applying ethical decision-making models and by being informed about evolving practice standards in new areas of practice,” one may overlap their professional roles for the client’s best interest (Barnett, 2019. P.413). However, according to the ACA codes of ethics, “counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience” (2014, C.2.a, p.8).
In this context, the client is at consent with overlapping the professional competence of the therapist, the therapist has the best interest, but they lack adequate information regarding evolving practices. Note that the client’s consent calls for respect and confidentiality, as “counselors disclose information only with appropriate consent or with sound legal or ethical justification” (ACA, 2014, B.1.c). Besides, I have not had “appropriate education, training, and supervised experience” as required by the New Specialty Areas of Practice code (ACA, 2014, C.2.b, p.8). Therefore, the appropriate ethical course of action would be to convince the client about the beneficence of the transfer. Should they fail to accept the recommendation,, the best course of action is taking no professional action at all since it would compromise the informed consent.
Step Three: Weighing Competing for Nonmoral Values That Back the Course of Action
Often, people define their moral codes and locus of their ethical standards reside in them. Therefore, Marcus may not like the transfer since he has asserted that minimal people should know about his sexuality. This also compromises the informed consent and respect for confidentiality. In another perspective, I may not take any professional course of action, but help Marcus with his requests as they require somewhat general knowledge. Besides, his need for friends arose after the recommendation to associate with sober people. He might be okay without many friends or without conforming to social groups other than his family and family friends. Therefore, while I may not take professional action at all, I will casually help Marcus as he has requested in offering some general tips to conform with social groups.
Step Four: Planning and Executing the Selected Course of Action
Typically, the decision for the ethical decision is to take no professional course of action. This does not need any sequential development of concrete steps to follow. However, in the documentation of the current therapy, I will indicate that the client contended to not seeking professional help for his fairly socially cocooned situation. Also, the appropriate decision is a transfer, but it is limited or barricaded by the client’s informed consent and respect for confidentiality.
Firstly, I will inform Marcus of the competence gap that arises in our therapeutic relationship. Also, I will consult a specialist relationship therapist concerning the evidence-based strategies for forming healthy social relationships. These will aid Marcus in forming social relationships where he feels comfortable, without compromising his dignity in a relatively biased community against LGBTQIS+. I will also maintain informed consent and confidentiality of the client and avoid overlapping professional roles.
From the case study, several factors influence decision making in overlapping professional roles. Primarily, competence as viewed by therapists and clients, and the existing laws and ethical codes determine whether or not one can overlap the boundaries of their professional roles and competence. In this case, overlapping is barred by the ACA codes B.1.c – respect for confidentiality, C.2.a – boundaries of competence, and C.2.a – new specialty areas of practice. These codes are similar to the California Assembly Bill No. 15 for end of life (2015), which mandates that patients have legal and voluntary power to decide the course of their diagnostic decisions. Since the client, in this case, refuses a referral to a specialist, I will not take any ethical action at all, which solves the dilemma. However, I will consult relationship specialist concerning the evidence-based strategies to help the client form healthy social relationships, in the course of the current therapy.
Barnett, J. (2019). The ethical practice of psychotherapy: Clearly within our reach. Psychotherapy, 56(4), 431-440. doi: 10.1037/pst0000272.
California Assembly Bill No. 15. AB-15 End of life. Ch1, Part1.85, Sect 443 (2015 Oct 5).
Garcia, J., Cartwright, B., Winston, S., & Borzuchowska, B. (2003). A Transcultural Integrative Model for Ethical Decision Making in Counseling. Journal Of Counseling & Development, 81(3), 268-277. doi: 10.1002/j.1556-6678.2003.tb00253.x.
Koocher, G., & Keith‑Spiegel, P. (2017). Courses for Mental Health Professionals: Boundary Crossings and the Ethics of Multiple Role Relationships. Retrieved 6 July 2020, from https://www.continuingedcourses.net/active/courses/course066.php.
Roggemans, L., Spruyt, B., Droogenbroeck, F., & Keppens, G. (2015). Religion and Negative Attitudes towards Homosexuals. YOUNG, 23(3), 254-276. doi: 10.1177/1103308815586903.