MODELS FOR MAKING DECISIONS

Erika L. Liljedahl, Psy.D.The Chicago School of Professional Psychology

Dr. Erika L. Liljedahl will be presenting four different ethical decision making models which will assist mental health professionals in trouble shooting ethical dilemmas. These models help guide the thought process when one is faced with an issue that is not clearcut. The objectives of this talk are to provide a brief history of ethics, to teach the steps of the four models, and to help mental health professionals apply the steps in order to more competently handle the "gray" areas when making decisions. Dr. Liljedahl highly recommends using an ethical decision making model and documenting the steps in the thinking process. She believes that this is an essential step in forensic documentation and litigation prevention.

Students will learn several Ethical Decision Making Models.

Students will learn how to apply the models to classes and in their careers with youth and adults.

Students will become more familiar with how to handle the “gray areas” when making decisions using the Ethical Decision Making Models presented.

1. What are ethics? Values and ethics2. Brief history of ethics3. Who makes unethical decisions?4. Presentation of 4 Ethical Decision Making

Models

The World English Dictionary says “In accordance with principles of conduct that are considered correct, especially those of a given professional or group”

Merriam-Webster says “Conforming to accepted standards of conduct”

Knowing the difference between right and wrong, and choosing the right

Having virtue, good moral reasoning Having a positive, good value system, which

might include doing good things in the world, be hard working, be honest, treat others as you want to be treated, be loyal to your family.

It is possible that your values will oppose what the ethics code or law states.

Example: You are attracted to your former client and the client has verbalized that the attraction is mutual. ◦ The APA code states you must wait 2 years.◦ The ACA code states you must wait 5 years.

So do you develop a relationship after 2 years? 5 years? Or is having a sexual relationship with a former client altogether against your value system?

Origin of ethics is in Ancient Greece ~460BC

Philosophers such as Socrates, Plato and Aristotle wished to impart knowledge on how to argue thoughts and to be successful, but also developed views on being ethical and moral.

learned from the Oracle of Delphi to “know thyself.” Knowing thyself (and values) increases knowledge and wisdom. Wisdom leads to increased critical reasoning and problem solving skills.

Knowledge and wisdom leads to actingEthical.

Greek philosophers set the stage for ethical decision making through examination of ideas that were abstract, such as the virtue of wisdom, critical thinking, Socratic questioning such as playing Devil’s advocate, and even through ethical dilemmas presented in Greek tragedy on stage.

So if having knowledge, wisdom and knowing thyself assist with making

good ethical decisions, then what kind of a person in today’s time

makes unethical decisions?

“who obey authority figures’ unethical directives or act merely to avoid punishment,

who manipulate others to orchestrate their own personal gain,

who fail to see the connection between their actions and outcomes,

who believe that ethical choices are driven by circumstance.” (Kish-Gephart, J.J., et al. 2010)

Egotistic work places are more likely to promote an “everyone for themselves” environment, which promotes more unethical behaviors.

In this talk, I will review….

3 clinically-related Ethical Decision Making Models, and

1 non-clinically related Ethical Decision Making Model

Positive Ethical Models = ◦The focus is on pursuing highest ideals

Defensive Ethical Models = ◦The focus is on thinking of the worst scenario, avoiding punishment

Source: Bush, S.S., Connell, M.A., & Denney, R.L. (2006). Ethical Practice in Forensic Psychology: A Systematic Model for Decision Making. Washington D.C.: American Psychological Association.

1. Identify the problem 2. Consider the significance of the context

and setting 3. Identify and utilize ethical and legal

resources 4. Consider personal beliefs and values 5. Develop possible solutions to the problem 6. Consider the potential consequences of

various solutions 7. Choose and implement a course of action 8. Assess the outcome and implement

changes as needed

Joe is your 16 year old client who came to therapy because of having low self esteem and being depressed about his parent’s divorce. Both the mother and father are fighting for custody of Joe. In the course of therapy, Joe reported that he has begun having thoughts of self harm.

Let us examine this case using Model #1.

The problem: ◦Suicidal thoughts. Hospitalize or not.

◦Confidentiality: Is it your ethical responsibility to talk to the parents? Do you have a duty to tell the parents or because Joe is a minor?

◦Should you monitor his progress and not involve the parents at all?

The client is a minor. Do the parents know about his psychological status? Do the parents know their son is in therapy? What would they do if they found out he is seeing a counselor and is suicidal?

Which parent do you talk to? How do you determine who has legal guardianship?

What harm could come if you tell the parents? Or not tell the parents?

Look at your ethics code (APA, ACA, etc) Look at the law about privacy and duty to

warn◦ HIPAA on confidentiality◦ State laws: Illinois Mental Health Confidentiality

Act Look at journal articles, books, case studies Review ‘position statements’ of your

relevant national association Consult with colleagues

In general, ethics codes will have the following components◦Do no harm.◦No disclosure without consent (unless

mandated by law).◦Limitations to confidentiality include

suicidal or homicidal ideation/intent.◦Confidentiality with minors.

“Any minor 12 years of age or older may request and receive counseling services or psychotherapy on an outpatient basis without the consent of the minor’s parent or guardian. Outpatient counseling or psychotherapy provided to a minor under the age of 17 shall be limited to not more than 5 sessions, a session lasting not more than 45 minutes, until the consent of the minor’s parent or guardian is obtained.  The minor’s parents shall not be informed without the consent of the minor unless the facility director believes such disclosure is necessary.” 

Permitted Uses and Disclosures: Serious Threat to Health or Safety.

“Covered entities may disclose protected health information that they believe is necessary to prevent or lessen a serious and imminent threat to a person or the public, when such disclosure is made to someone they believe can prevent or lessen the threat (including the target of the threat).”

How do you feel about breaking confidentiality in this case? Is it necessary? You believe that you might alienate Joe if you broke confidentiality.

You value life and improving relationships… imminent harm or not, you want to inform family to intervene. In other words, is your core value to involve family as much as possible?

You believe that more emotional distress would enter the equation if the parents would know that Joe is depressed and suicidal.

Utmost importance: Perform a suicide lethality assessment.

Inform Joe what your duties are as a therapist (your ethical duty of preserving life and the possibility involuntary hospitalization).

Engage Joe in a logical discussion about the pros and cons of telling his parents.

Joe could invite his parents into the session and could inform them with the therapist.

If Joe does not want to inform his parents, have Joe check in with you during the week and call the suicide hotline for additional support.

During a suicide lethality assessment, you determine whether Joe is passively or actively suicidal. Joe could be hospitalized.

After discussing the pros and cons of telling his parents, he can decide to tell them or not.

If Joe does not want to inform his parents, Joe might have less support. His parents might continue fighting without even considering Joe’s psychological status.

If passively suicidal:◦ Decision: To continue monitoring Joe in therapy

sessions, to have him call suicide hotlines for support. Encourage Joe to tell his parents, seek support form trusted friends and family.

If actively suicidal◦ Decision: Hospitalize. Encourage Joe to tell his

parents, and/or inform Joe hat his parents will be informed. Seek support from trusted friends and family.

If not actively suicidal: Is monitoring Joe in therapy sessions sufficient to ward off suicidal thoughts? Did he involved family or friends for support?

Does Joe need a referral for possible medicine management?

If actively suicidal: How did Joe react to the hospitalization? How did his parents react?

Is there anything more you need to do as an ethical mental health professional?

Source: Koocher, G.P. & Keith-Spiegel, P. (2008). Ethics in Psychology and the Mental Health Professions: Standards and Cases. Oxford University Press: New York.◦ Chapter 2: Making Ethical Decisions and Taking

Action, written by Edmund Burke.

1. Determine whether the matter truly involves ethics.

2. Consult guidelines already available that might apply as a possible mechanism for resolution.

3. Pause to consider, as best as possible, all factors that might influence the decision you will make.

4. Consult with a trusted colleague.5. Evaluate the rights, responsibilities, and

vulnerability of all affected parties.6. Generate alternative decisions.7. Enumerate the consequences of making each

decision.8. Make the decision. 9. Implement the decision.

A student told a teacher about another student threatening her on Facebook and the school had to decide how to proceed. 

Is this an ethical issue for the teacher? Does this case involve your ethical

standards? (E.g., APA: General Principles of beneficence and nonmaleficence, fidelity, responsibility, integrity, justice)

Does the teacher have to do anything at all since the threat was online?

Is there an ethical duty to protect the student because he/she is a minor?

What are the school’s policies regarding cyber-bullying?

Is there a decision-tree in place at the school to deal with cyber-bullying and harassment?

What does your ethical code state? Do the parents need to be informed? What are your values in such a case?

Character education. Every public school teacher shall teach character education, which includes the teaching of respect, responsibility, fairness, caring, trustworthiness, and citizenship, in order to raise pupils' honesty, kindness, justice, discipline, respect for others, and moral courage for the purpose of lessening crime and raising the standard of good character. Sec. 27‑12.

(1) Safe and responsible use of social networking websites, chat rooms, electronic mail, bulletin boards, instant messaging, and other means of communication on the Internet.

(2) Recognizing, avoiding, and reporting online solicitations of students, their classmates, and their friends by sexual predators.

(3) Risks of transmitting personal information on the Internet.

(4) Recognizing and avoiding unsolicited or deceptive communications received online.

(5) Recognizing and reporting online harassment and cyber‑bullying.

Class B misdemeanor if person is convicted of harassment (720 ILCS 135/2) (from Ch. 134, par. 16.5, Sec. 2. Sentence.

A second violation constitutes a Class A misdemeanor (minimum of 14 days in jail, or maybe 240 hours of community service).

If harassment continues (3+), Class 4 felony. If there is a threat to kill, it is an automatic Class 4 felony.     

What was the ‘threat’ said on FB? Was it vague or specific? How many times has this happened? Is it a one time occurrence or repeated?

Consider the harassed student’s safety; ability to concentrate in school.

Consider if one student is being threatened, other students could be in the same situation.

Think the worst scenario could happen.

Read the law and policies appropriate to this case.

Talk to your immediate supervisor, the Principal of the school, your colleagues about the school policies or lack thereof.

Consult with books, journal publications, the law for cases that are similar.

Possibly involve the police.

Children have the right to be safe and learn in a safe environment.

The harassing child has the right to be heard which may lead to be tried in a court of law.

Teachers have the right to teach in a safe environment. They also have the right to provide a character education component into their curriculum.

Some solutions:◦Ask for the student to print the FB page◦Someone (teacher, counselor, Principal,

Superintendent) would talk to each child separately

◦Talk to both children together◦Involve the parents◦Involve the police

Ask for the student to print the FB page◦ Decide if there is harassment.

If harassment exists: then go to the next step. If harassment does not exist: If the wording

was misconstrued by the student, then provide education on what constitutes harassment. You might want to decide on what caused the misinterpretation. Does the student have a learning disability? Is the student overly suspicious of people? Did someone else influence the student?

Someone (teacher, counselor, Principal, Superintendent) would talk to each child separately◦ Each child could tell his/her story without

hesitation. This confidentiality would likely allow each student to speak in an uninhibited manner.

◦ Talking to the harassed student separately would likely shield the student from some additional unnecessary grief. Showing the grief in front of the harasser might reinforce the harassing. The harassing could become more covert.

◦ There might be something going on in the harasser’s life that would be useful information to the behaviors.

Talk to both children together◦ Conduct a conflict resolution session without

involving the police or higher authority, such as the Superintendent.

Involve the parents◦ Appraise the parents about the situation and

involve them in the conflict resolution.

Involve the police◦ Pros: A juvenile record is created for the student

harasser in case that the harassing will be ongoing. This record will likely lead to psychological intervention of forensic psychologists, to assist the juvenile to rehabilitate his or her behaviors.

◦ Cons: There is a record that will follow the juvenile, even if he or she rehabilitates, however note that this record is sealed and can only be accessed by some law enforcement.

What would you do?

Source: Anderson, Gail (1997). Women & Therapy. Introduction: Children, Adolescents and Their Powerholders in Therapy Settings, 20, 2, 1-6.

1. Recognizing a problem2. Defining the problem3. Developing solutions4. Choosing a solution5. Reviewing process6. Implementing and evaluating a

decision7. Continuing reflection

A 12 year old girl is forced to go into therapy because of acting out at school. During the first session with the adolescent, the therapist finds out that the girl is actively abusing marijuana and possibly ecstasy with her friends. The parents do not know this information.

What do you do? Do you tell the parents?

(1) Recognizing a problem and (2) Defining the problem: You are uncertain what to do. What are your values that interfere with a decision?

If you tell the parents, you run the risk of alienating the girl. If you do this, more harm can come.

If you do not tell the parents, they will not be able to intervene and get the girl treatment. They can sue you since the girl is still a minor. You also run the risk of the girl getting arrested, creating brain damage, and the worst is overdosing and causing death.

You tell the parents◦ You tell them to assist with maintaining their

daughter’s safety. You do not tell the parents

◦ As cited in this article, Snyder believes children are “of worth and full citizens that share the basic rights to life, safety, happiness, equality of treatment, equality of opportunity, reasonable self-determination and due process.” This is from a feministic approach: egalitarian.

◦ The law is behind this decision: Illinois law allows 12 year old to hold some power for maintaining confidentiality.

“What is the best fit both emotionally and rationally? Does the solution meet everyone’s needs, including mine? Can I implement and live with the effects?” (Anderson, 1997, p.4)

If you do not tell the parents… you should be aware of the law:

(3) the parent or guardian of a recipient who is at least 12 but under 18 years, if the recipient is informed and does not object or if the therapist does not find that there are compelling reasons for denying the access. The parent or guardian who is denied access by either the recipient or the therapist may petition a court for access to the record. Nothing in this paragraph is intended to prohibit the parent or guardian of a recipient who is at least 12 but under 18 years from requesting and receiving the following information: current physical and mental condition, diagnosis, treatment needs, services provided, and services needed, including medication, if any.

Would I want to be treated in this way? Does the decision feel right? Would this decision withstand the scrutiny

of others? How are my values, personal characteristics

influencing my choice? Have I taken the client’s perspective into

account?

These questions are from the article.

Carry out the decision Is this solution the best I can do? Observe consequences Reassess the decision How has this decision affected the

therapeutic process?

These questions are from the article.

What did I learn? Have I changed as a result of this process?

How? What would I do differently? How might this experience affect me in the

future?

These questions are from the article.

Model: Ethical Decision Making Plan

Source: United States Department of Defense

1. Define the problem (state the problem in general terms and decisions to be made)

2. Identify the goals (short and long term goals)

3. List the appropriate laws or regulations4. List the ethical values at stake

5. Name all the stakeholders (identify persons who are likely to be affected by a decision and what is at stake for each person)

6. Gather additional information (take time, ask questions, demand proof when appropriate, check your assumptions)

7. State all feasible solutions (list solutions that have already surfaced, produce additional solutions by brain storming with associates, note how stakeholders can be affected by each solution)

8. Eliminate unethical options (eliminate solutions clearly unethical, eliminate solutions with short-term advantages but long-term problems)

9. Rank the remaining options according to how close they bring you to your goal, and solve the problem

10. Commit to and implement the best ethical solution

According to Martin and Bush (2008), Knapp and VandeCreek identified 5 common steps after reviewing several Ethical Decision Making Models:1. Identification of the problem2. Development of alternatives3. Evaluation of alternatives4. Implementation of the best option5. Evaluation of the results

Anderson, Gail (1997). Women & Therapy. Introduction: Children, Adolescents and Their Powerholders in Therapy Settings, 20, 2, 1-6.

Bersoff, D.N. (2008). Ethical Conflicts in Psychology, Fourth Edition. American Psychological Association: Washington D.C.

Bush, S.S., Connell, M.A., & Denney, R.L. (2006). Ethical Issues in Forensic Psychology: A Systematic Model for Decision Making. Washington D.C.: American Psychological Association

Kish-Gephart, J.J., Harrison, D.A. & Trevino, L.K. (2010). Journal of Applied Psychology. Bad Apples, Base Cases, and Bad Barrels: Meta-Analytic Evidence About Sources of Unethical Decisions at Work, 95, 1, 1-31.

Koocher, G.P. & Keith-Spiegel, P. (2008). Ethics in Psychology and the Mental Health Professions: Standards and Cases. Oxford University Press: New York. (Chapter 2: Making Ethical Decisions and Taking Action, written by Edmund Burke, pages 20-40).

Martin, T.A. & Bush, S.S. (2008). NeuroRehabilitation. Ethical considerations in geriatric neuropsychology, 23, 447-454.

HIPAA: U.S. Department of Health & Human Services: http://www.hhs.gov/ocr/privacy/

Illinois General Assembly: School Code: http://www.ilga.gov/legislation/ilcs/ilcs4.asp?DocName=010500050HArt%2E+27&ActID=1005&ChapterID=17&SeqStart=149700000&SeqEnd=156200000

Mental Health and Developmental Disabilities Code: http://www.ilga.gov/legislation/ilcs/ilcs5.asp?ActID=1496&ChapAct=405%26nbsp%3BILCS%26nbsp%3B5%2F&ChapterID=34&ChapterName=MENTAL+HEALTH&ActName=Mental+Health+and+Developmental+Disabilities+Code%2E

National Conference of State Legislatures on Cyber-harassment (720 ILCS 135/1‑2): http://www.ilga.gov/legislation/ilcs/documents/072001350k1-2.htm

State laws: Illinois Mental Health Confidentiality Act: http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=2043&ChapterID=57

United States Department of Defense: Ethical Decision Making Plan: http://www.ryerson.ca/ethicsnetwork/downloads/model_I.pdf

U.S. Department of Health & Human Services on HIPAA: http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html

Know your Ethics Code Know what the law requires of therapists Take the “higher road” Do what minimizes harm to clients and

others, and to your person ethical values Think clearly Document your thinking process and use of

an Ethical Decision Making Model If there are any questions, consult consult

consult!