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In this essay, based on a case study and ethical dilemma (see appendix); I will demonstrate the process of ethical decision making and justify a course of action. I will discuss the ethical issues from the dilemma; critically examine competing BACP ethical principles and guidelines, issues of difference, organisational issues and legal implications and evaluating the outcome. To conclude I will discuss the therapeutic relationship. To maintain confidentiality and client anonymity, all personal details have been amended within this academic essay and case study.
Impacts upon the problem and issues to consider
An impact upon the problem is, if I breach confidentiality, I will be damaging the trusting relationship formed with Raj, leaving her feeling isolated, further vulnerable and let down. This could affect not only her trust in future relationships and prevent her from seeking help in the future but also her therapeutic progress.
If I breached confidentiality it could lead to my client experiencing further threats from her husband. Raj is fearful of going to the police when this happens as in the past he manipulated the police into believing she was abusing her husband which led to him having custody of their son. Furthermore, it could cause the father to be angry with Aaron and could lead to him experiencing further abuse.
However, as a member of the BACP I have a duty of care towards my client and a statutory and common law duty to safeguard vulnerable children as recognised by the Children’s Act (2004) (Jenkins, 2004). Further impacting the situation is the organisations policies regarding confidentiality and child protection, which require me to breach confidentiality and report such concerns to my line manager and make a safeguarding alert to social services. Additionally, when contracting in our initial counselling session, I explained that in circumstances of child protection and where my client or others are at risk of harm, confidentiality would be breached, which Raj agreed too, thus she was aware of this when she disclosed child abuse to me.
Furthermore, if I was to breach confidentiality without Raj’s consent, she would not want to continue our counselling sessions due to trust being broken. It could also seem disrespectful of Raj’s choices and concerns and that I do not understand her frame of reference.
Further issues to consider include the client’s culture, my own morals and standpoint, what action needs to be taken to ensure a good quality of practice, the ethical, legal and professional implications for any decision made as well as considering will breaching confidentiality be for the greater good and whose interests will be met. While also considering Raj’s interests and rights to be free of harm, autonomous living, justice and good quality of therapy, I must also consider the consequences for myself and my own self-respect and needs (BACP, 2010).
Whose dilemma is it?
It is Raj’s dilemma as she is fearful of her ex-husband finding out that Aaron told her about the incident, fearing this will lead to Aaron being further abused. The decision affects Raj as I have been trusted with personal, confidential information, therefore Raj will feel neglected and betrayed if confidentiality is breached, leaving her isolated (Welfel, 2006, pp 67). Her vulnerability will further due to feelings of abandonment as presently I am her only support besides the collectivist family unit.
It is also my problem as I am being asked to keep confidence despite feeling wary and uncomfortable in doing so. While I have no legal obligation to report child abuse, I have an ethical obligation to report the disclosure as I have a duty of care towards protecting a child at risk and a vulnerable adult as well as acting in the best interests of the client. Furthermore it would be morally wrong of me to not report the incident and especially if something else happens causing further harm to Aaron and/or Raj, which seems likely as the ex-husband has a history of abuse and aggressive behaviour. I will need to act quickly in order to prevent possible further harm to Aaron.
Raj has specifically asked for confidentiality to be maintained, so if I breached confidentiality, this will be untrustworthy and going against my client’s wishes. However, confidentiality can be breached in cases of child protection and if someone is at risk of harm; in this case Aaron. Due to Raj’s vulnerability and fear resulting from domestic violence, her thought process may be irrational and anxiety provoked. As a counsellor I need to act in the best interests of my client and to protect her from harm.
By breaching confidence, I do not want to create further problems for my client or do anything that will cause harm to her or her son. I have an obligation to Raj, BACP and the organisation to put my own feelings aside in order to follow the best interests of my client and what causes the least harm to her whilst also having an ethical obligation to protect Aaron against harm.
In my job description, it is not stated that I will solely liable for damages; therefore, it is the organisations problem because as my employer they could face legal implications if confidentiality is breached, i.e. if Raj sued the organisation. BACP (2010) state “respecting client confidentiality is a fundamental requirement for keeping trust”. I am a member of the BACP so I would be going against their guidelines by breaching confidence without consent.
Ethical Principles and Values, Organisation Policies and Legal Issues
By law, I am required to maintain confidentiality so long as the client or anyone else is not at risk of harm and when confidentiality is assumed or requested, , I would be lying to Raj and betraying her trust and their relationship is this information was disclosed to a third party (Welfel, 2006). However, while in cases of child protection informed consent is not required due to having a statutory duty to report, I can be honest and open with Raj about what I plan on doing to ensure congruence and maintain the therapeutic relationship.
There are many possible conflicts between ethical principles and the law. The law states confidentiality must be abided so long as no one is at harm, however the BACP ethical principles of justice and self-respect ensure that not only does the professional consider the clients best interest, without causing harm to themselves. However, by adhering to confidentiality about something I am morally against I would not be appropriately applying the ethical principles as entitlements for myself. While I have a main responsibility to keep Raj from harm, I also must consider the Aarons right for safety. While Raj has a human right to choice, I have an ethical and professional obligation to ensure I provide Raj with necessary information to ensure the decision made is the best possible decision for Raj and Aaron and would cause the least harm.
By attending clinical supervision and line management supervision I will be able to receive guidance on dealing with dilemma, gain a differing perspective on the situation. Reflection will also help me understand the situation more clearly.
I have established an effective therapeutic relationship based on trust, congruence, safety, UPR and warmth with Raj. It would be untrustworthy of me to breach confidentiality as Raj trusts me. However as I am required by the BACP and organisation to report child protection, I will need to be honest with Raj and explain that I will need to report the incident however it would be better if she gave her consent and explaining why this matter needs to be reported.
Throughout the counselling process, I have valued Raj’s autonomy through choice and offering power to make decisions within therapy. I must respect her decision by keeping her material confidential and her right to be self-governing and make choices independently without hindrance (Gillon, 1985). However by helping Raj consider the situation and consequences thoroughly, through all perspectives, she will be able to make an informed decision. By gaining informed consent I will be abiding by BACP guidelines as well as respecting my client’s right to choice and accurate information and being client-centred. By explaining my ethical obligations in the contracting process and reiterating this and my requirements in safeguarding children when Raj made the disclosure, I am informing her of foreseeable conflicts as soon as possible.
Raj is vulnerable, confused, scared and distressed, therefore is it not sure if she is able to recognise her best interest. She may not be acting rationally due to her fear of her ex-husband and worry over her son. By explaining why it would be in her best interests and Aarons best interests to disclose child abuse, I am showing a commitment to promoting her well-being as well as being concrete and honest.
The action that would cause the least amount of harm to Raj is to make the safeguarding alert without disclosing where I gained the information. While this will limit the action social services can take against her husband and to protect her son, it will ensure that her husband will not find out that she or Aaron disclosed the abuse. If I was to not make the safeguarding alert, Raj would remain distressed and fearing for her son’s safety which would cause her further emotional harm.
Raj has human rights to freedom and choice over her decision and the support she receives and the right to respect for private and family life, however she and Aaron have a right to prohibition of torture. The fairest decision for both Raj and Aaron is to make the safeguarding alert with informed consent. By honouring her right to information I am being fair by assisting her to make an informed decision. I am also being fair to myself in abiding by BACP ethics, the law and organisational policies.
I am being asked to go against my own beliefs and morals as well statutory law and BACP ethical guidelines, thus conflicting with my right to beneficence, autonomy, non-maleficence, justice and my human rights.
BACP state informed consent should be sought before breaching confidentiality, however the organisations policies state that clients do not need to be informed when breaching confidentiality for child protection matters, which would be dishonest of me and affect the therapeutic relationship. This causes conflicts within what is being asked of me, professionally, ethically, legally and morally what I feel is right. To work through these conflicts I attended clinical supervision and discussed the dilemma with my line manager.
Possible Courses of Action
As a member of the BACP I am required to maintain confidence at Raj’s request. By providing a rationale as to why confidentiality needs to be breached, I could work within the boundaries of my job and BACP ethical guidelines by helping Raj to understand that this disclosure would assist in ensuring Aarons safety in the future as procedures would be put into place to prevent further harm to Aaron and a safety plan can be formed to ensure Raj is safe from harm from her ex-husband. I could explain to her that when I make the disclosure to social services, I don’t have to disclose her personal details and she can remain anonymous thus her ex-husband will not know that she has reported the incident. I can also explain to social services that Aaron is at risk of further harm so procedures will be put into place to protect him should the incident be investigated. This will hopefully put Raj at ease. Raj would need to give written informed consent for me to share her information with a third party (Welfel, 2006), providing she is “fully informed of all the facts to make that choice” (Gerch and Dhomhnaill (2005). This would ensure I am abiding by the Data Protection Act (1998). By giving a rationale, offering a different perspective and accurate and necessary information, Raj will be able to make an informed decision. Raj is more likely to give me informed consent to make the disclosure if I show her that she can trust me to consider her best interests and ensure her safety as far as possible. I will allow Raj time to make up her mind, and ask questions to ensure she does not feel pressured (McLeod, 2010).
The other option is to breach confidentiality without Raj’s consent as a child is at risk of harm. This would mean the disclosure could be made sooner as I would not need to speak to Raj thus action to ensure Aaron’s safety could be taken sooner. However, in doing so I will damage the therapeutic relationship, breaking her trust and causing more psychological harm as she I would then be another person in her life whom she trusted but let her down, which will then make her more vulnerable and cause trust issues within future relationships. Furthermore, Raj could take legal action against me or the organisation (Jenkins, 2007). By choosing this course of action I will be going against BACP ethical guidelines, the organisations ethos and my own values and morals as an integrative practitioner as well as safeguarding legislations. To ensure Raj’s safety I still could keep Raj’s personal details confidential when making the safeguarding alert.
Course of Action
Having referred to the Children’s Act (1989, 2004) and it’s supporting guidance for safeguarding children (HM Government, 2006, 2010). I will explain to Raj that due to ethical guidelines, the organisations policies regarding child protection and statutory and common law as well as my moral duty of care towards Aaron, I need to breach confidentiality as stated in the counselling contract. I will explain to her that this safeguarding alert will assist in ensuring her son’s safety in the future as there will be a record made and that social services will do whatever they can to prevent further harm to Aaron. I will explain to Raj that when I raise this alert to social services, if she prefers, I will not disclose her personal details, I will maintain her anonymity in accordance to the data protection act (1998) (Jenkins, 2007) and I will not disclose where I got this information from thus her husband will not know that she has reported the incident. However I will also explain to Raj that should she give me permission to disclose where I got this information from it will be further help as the more evidence I can provide, the better chance there is of social services acting upon the disclosure. I will explain that this is completely her choice and I will respect whatever decision she make, but I am professionally, ethically and legally required to breach confidentiality, thus enabling her to make an informed choice. Thus Raj would feel more confident and knowledgeable about her decision and she will have a choice in her decision (BMAED, 2004, pp. 74), thus respecting her autonomy and Human Rights (Bond, 2010).
I will also explain that due to my respect for Raj I would like her permission to make this disclosure and to agree upon what information will be shared as well as abiding by BACP guidelines and the law. By explaining to Raj why this action must be taken, how I will ensure her and Aarons safety is maintained as much as possible and explaining each step I will take and the information to be shared, I am showing Raj that I value her and her opinion, I have her best interests at heart and that protecting Aaron and maintaining her safety is key within the work that I am doing. Ultimately I am exemplifying she can trust me and providing her with a safe environment, free from punishment.
By also offering alternative perspectives such as explaining the possible consequences of not making the safeguarding alert would also allow Raj to make an informed choice (BACP, 2010). It is important that I am honest with Raj and that I give her the necessary information as this would exemplify fidelity, client autonomy, respect, and equality. I will reassure Raj that I will support her, listen to her and that as an Asian counsellor I can understand her concerns regarding family honour and confidentiality thus I will maintain her anonymity it she feels that it what she wants to do.
By choosing this course of action I show that I have considered universality, publicity and justice (Bond, 2010, Gabriel and Casemore, 2010) and the ethical, legal and professional implications, whereby I am abiding by the BACP ethical framework, the organisations policies on child protection and statutory law regarding data protection, confidentiality, and child protection and safeguarding vulnerable adults. Furthermore, I have considered the consequences of this action within supervision, considering the effect on the therapeutic relationship, my own rights and legal implications if informed consent is not sought.
Evaluation of the outcome
The outcome was that after the fourth session, with informed consent I made a safeguarding alert whilst also maintaining Raj’s anonymity, which led to social services checking on Aaron and a record being made. Raj attended a further where she reflected upon her therapeutic progress, her self-esteem and shared her decision to apply for sole custody of Aaron.
I would take this action again for other clients and feel I made the right decision as I was honest, gave the necessary information, respected Raj’s autonomy, beneficence, maleficence and ensured that the decision was fair for everyone involved, prevented further harm to Raj, Aaron and abided by ethical and legal guidelines (Bond, 2010, Gabriel and Casemore, 2010). Furthermore, I considered the client’s culture and presenting issues which were relevant to ensuring her safety. Over all, I promoted the clients well-being and protected her from harm.
When clients are able to see us as genuinely concerned for them, that we are not putting on a professional façade, they will feel safe with us because we are reliable (Merry, 2002). By being honest about what I was intending to do and explaining I was congruent yet mindful of the client’s frame of reference and experience I highlighted I was sincere in offering help.
Beyond the physical scars, domestic violence has profound effects on a women’s self-worth. Lewis (2003) stated an abused woman needs to regain power and control over her life by making independent choices and decisions. Carl Rogers (1951) highlighted that we all have the capacity to be fully functioning if our power is given recognition. Through a client centred approach based on respect, acceptance and choice, I helped Raj to recognise her worth and power within the therapeutic relationship and thus empowering her. Roger’s core conditions (1951) encourage women to develop power from inside them in order to attain improved self-awareness and to take control. Thus by allowing Raj to take control over what was happening in therapy, I was helping her become autonomous, and take control over the choices she wanted in life, whilst also protecting her from harm and understanding her cultural needs through empathy and UPR. The increase in self-esteem would enable further self-awareness, which would later help achieve successful therapy outcomes from changes in personality and behaviour (Rogers, 1951). These points highlight that I had provided a good quality of care and maintained a good therapeutic relationship (BACP, 2010). It must be considered, it is due to the effective relationship that Raj felt comfortable to make the disclosure and through offering her power and autonomy and being honest, she felt comfortable with giving her consent as I was able to exemplify that her and Aaron’s safety was paramount.
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