Tuesday, April 17, 2012

Case Studies

A Marriage and Family Counselor Learns a Secret
Brief Summary

During a conjoint counseling session with the primary client, the wife, and her husband, the counselor recommends individual sessions.  During the session with the husband, he reveals his affair of 8 months, but declines the opportunity to involve his wife in the issue and suggests the counselor not bring up the issue to his wife.  He asks the counselor for further individual sessions (Herlihy & Corey, 2006).


One of the issues considered in this case is confidentiality.  Unfortunately, the counselor did not address confidentiality issues that pertain to sharing information between husband and wife prior to his session (Section A.2.a.), so the counselor is not at liberty to discuss the husband's secret with the wife.  According to the ACA Code of Ethics (ACA), (2005) section A.2.a. on informed consent, clients need to receive information related to confidentiality, and other rights and responsibilities of the client/counselor relationship.  Section B.4.a. (ACA, 2005) clarifies the importance of explaining confidentiality prior to beginning therapy.  Section B.4.b. (ACA, 2005) clearly states the counselor must define and discuss confidentiality issues with the primary client as well as others who will be involved in the therapy. Counselors should discuss limitations of confidentiality as well, and obtain agreement in writing (ACA, 2005).
Depth and Breadth of the Dilemma
The husband, wife, and counselor are all involved in this dilemma.  The husband has the right to confidentiality with his session with the counselor.  The wife is involved, even without knowing, because her husband's secret information may be affecting her directly.  Her psychosomatic responses in the situation may be a direct result of her sensing the husband's incongruous behavior and disloyalty. 

The counselor is involved in the dilemma as well.  She must keep the secret from her original client, a secret that may be an important piece of information to her understanding her illness.  If the counselor continues to provide services to the couple, it may be difficult for her to remain neutral to both clients.  If she agrees to marriage counseling, it will be difficult for her to be effective without revealing an (apparently) key component of the wife's difficulties.   Although it is disturbing the counselor did not receive informed consent or review her responsibilities to the husband prior to his session, ordinarily the counselor would still have to keep his secret from the wife. 

Additional Ethical Codes

The American Mental Health Counselors Association (AMHCA), 2010 states in Section A.2.a that confidentiality is a right given to all clients involved in mental health counseling with the counselor.  Section A.2.l, states when counseling families (together or individually,) each member has equal rights to confidentiality "within legal limits" (AMHCA, 2010, p. 3).

Furthermore, the AMHCA (2010) states in Section A.2.n. counselors may breach confidentiality if the client is engaging in behavior that could be harmful to a third party.  This may provide the counselor with a valid reason to tell the wife, although it should be taken under careful consideration.
Regarding informed consent prior to entering into a relationship with a client, Section B.2.a states the counselor must provide information related to issues of confidentiality as well as other aspects of counseling (AMHCA, 2010).  The counselor failed to provide adequate information regarding confidentiality and its limitations prior to counseling the husband.  Section B.3.a. states when counseling a husband and wife, each party must understand the relationship they have with each other.  Furthermore, this section clarifies this understanding should take place prior to beginning counseling. 

Section B.3.c. requires that if counselors believe they cannot objectively counsel the parties in a family or group situation, they must "appropriately clarify, adjust, or withdraw from roles" (AMHCA, 2010, p. 5).

Potential Actions

Although I realize everyone makes mistakes, informed consent and explaining confidentiality to clients is critical.  I would encourage the husband to tell the wife about his affair.  If he refused the opportunity, I would discontinue counseling for both parties, but would make every effort to help them find other separate counselors.  I would use the Hill, Glaser, and Harden's (1996) Model primarily because I have become most familiar with it, but also because I continue to appreciate the integration of intuitive factors when making ethical decisions.  

This would be the best solution if I were the counselor in the above case.  I would not be able to maintain neutrality because in general, I find the type of behavior he is engaging in despicable.  I would like to continue to counsel the wife, but it may be too difficult to keep information from her that seems so important in her recovery. 

The best solution would be for the husband to tell his wife about his affair.  Although I don't believe she would be amenable to him continuing the relationship (as he would like), it might offer the couple the opportunity to heal their relationship, or separate and as amicably as possible, find a way to work together for the sake of the children.
A Question of Boundaries

Brief Summary

A counselor agrees to counsel a good friend's son who is also the counselor's son's good friend.  The situation creates an uncomfortable situation between the counselor and her friend (the boy's mother).  Additionally, the counselor has created a dual relationship between herself and her client.  She is functioning as his counselor as well as being the mother of his best friend (Herlihy & Corey, 2006).

Dual Relationships

The counselor has entered into a dual relationship with her client.  She believes, at least initially that the benefit for her client outweighs the harm in counseling her good friend's son.  One of the potential difficulties is putting the client in the position (as an adolescent) to relate to the counselor in both roles.  This could be potentially harmful if he changes the way he relates to the counselor in their sessions because of the role she plays with him when he is at her house with her son.  Furthermore, the counselor claims her perspective of the client has changed because of his personal relationship with him.

Ethical Codes

As stated in the text (Herlihy & Corey, 2006), the ACA (2005) Ethical code of Ethics Section A.5.c. states dual relationships should not be entered into except when there is potential benefit to the client as stated in A.5.d.  Now that the counselor is providing services to her friend's son, she must promote the welfare of her client (Section A.l.a) which may prove difficult in light of her close relationship with the client's mother.  Although the situation does not seem to have hurt the client, it has become increasingly difficult in the counselor's relationship to the client's mother as well as in the relationship with the client as his friend's mother. 
There is a good chance that, eventually the dual relationship will cause a more significant dilemma, if not for the counselor, for the teen client.  Section A.4.a and A.4.b claim counselors must avoid harming their clients as well as minimize unavoidable harm, and counselors must be "aware of their own values, attitudes, beliefs, and behaviors, and avoid imposing" on clients (ACA, 2005).  This may become increasingly difficult with the influence of the mother's friendship.

Section 1.A.3.a. states counselors should "make every effort to avoid dual/multiple relationships with clients that could impair professional judgment or increase the risk of harm" (AMHCA, 2010, p. 3).  Furthermore, 1.A.3.b. states when a counselor is making a decision to enter into a dual relationship the counselor should seek consultation as well as using a reasonable decision-making model prior to making the decision.  Section 1.A.3.c. determines when these relationships cannot be avoided counselors should "take appropriate professional precautions such as informed consent, consultation, supervision and documentation to ensure that judgment is not impaired and no exploitation has occurred" (AMHCA, 2010, p. 3).

Potential Actions

If the counselor had consulted with an experienced peer, the recommendation would have been to help the mother and child secure services elsewhere, even with the hardship of distance.  The close friendship of the two mothers as well as the one between the boys should have been a red flag of warning for entering into this relationship.  I would use the Forester-Miller and Davis (1996) Model because it's straightforward and after identifying the problem, applies the ACA Code of Ethics.  After reviewing the ACA and the AMHCA ethical codes, it would be a difficult decision because it would disappoint the mother who was also a good friend, but I believe this would have been the best decision. 

American Counseling Association (ACA). (2005). 2005 ACA code of ethics [White Paper].  Retrieved from the ACA website:  http://www.counseling.org/Files/FD.ashx?guid=ab7c1272-71c4-46cf-848c- f98489937dda

American Mental Health Counselors Association (AMHCA). (2010). 2010 AMHCA code  of ethics [White Paper]. Retrieved from the AMHCA website:  https://www.amhca.org/assets/news/AMHCA_Code_of_Ethics_2010_w_pagination.pdf

Forester-Miller, H., & Davis, T. (1996). A practitioner's guide to ethical decision making [On-line]. Available: http://www.counseling.org/ resources/pracguide.htm

Herlihy, B., & Corey, G. (2006). ACA ethical standards casebook (6th ed.). Alexandria, VA:  American Counseling Association.

Hill, M., Glaser, K., & Harden, J. (1995). Chapter 2: A feminist model for ethical decision making. (1995). In E. J. Rave & C. C. Larsen (Eds.), Ethical decision making in therapy: Feminist perspectives (pp. 18-37). New York: Guilford Press.

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