Running head: ETHICAL DECISION MAKING 1

Ethical Decision Making Exercise John Laing University of Calgary APSY 603 Dr. Irene Estay

ETHICIAL DECISION MAKING 2 Identification of the Individuals and Groups Potentially Affected by the Decision Those affected by the decision I make are likely to be the 11-year old aboriginal boy, his grandmother, as well as school staff, including his teachers. A decision to begin counselling or not will likely affect the boy because treatment could help reduce his potential feelings of loneliness and isolation, thus increasing his level of engagement in social and academic activities. However, if the boy is experiencing psychiatric distress such as auditory hallucinations, then a decision to have him first assessed to rule out such a query is of great value to the intervention process. The situation is further complicated by the lack of insight I have pertaining to the Aboriginal culture and their spiritual beliefs. Hearing such voices could be rooted in cultural and spiritual beliefs. Lacking cultural insight could lead one to insult the family by suggesting the boy has a psychiatric problem. Furthermore, the nearest assessment clinic is a significant distance away making such an assessment difficult to undertake for the boy and his grandmother. As a psychologist I must look out for the best interests of the boy based on my clinical judgement. As such, withholding counselling until the boy is assessed could have negative consequences for him. However, not encouraging the family to undergo a psychological assessment could lead to even more deleterious consequences should the boy in fact suffer from pathological auditory hallucinations. Furthermore, although the referral was made on behalf of the boy, the grandmother has opened up and has disclosed some distress in her life as well. As such, the grandmother would be affected if such issues were not addressed with her. Lastly, because the school is privy to the situation and will be affected by the decision I make, I would try and involve them in the collaborative intervention process as well. Identification of Ethically Relevant Issues and Practices, Including the Interests, Rights, and Any Relevant Characteristics of the Individuals and Groups Involved and of the System or Circumstances in Which the Ethical Problem Arose

ETHICIAL DECISION MAKING 3 Based on the ethical standards contained within the Canadian Code of Ethics for Psychologists 3rd edition, (Sinclair & Pettifor, 2001), I identified 14 standards that I believe warrant further evaluation including: three under Respect for the Dignity of Persons; eight under Responsible Caring; two under Integrity in Relationships; and one under Responsibility to Society (Sinclair & Pettifor, 2001). They are indentified by each of the overall principles presented in the following sections Principle I: Respect for the Dignity of Persons Value: General Respect - Demonstrate respect for the knowledge, insight, experience, and areas of expertise by others (I.1). Considering that I do not know a lot about the Aboriginal population and their spiritual beliefs, I must be open to listening to the boys perspective, his grandmothers perspective, as well as other community members who can provide insight into the issue of hearing voices in particular. I need to show respect through active listening and consideration of their values, beliefs and culture. The grandmother and the boy will have knowledge and experience that will be crucial to my decision to undertake counselling or not. Interacting with the family and the school will be paramount to ethical work with the family. Value: Informed Consent Seek as full and active participation as possible from others in decisions that affect them, respecting, and integrating as much as possible their opinions and wishes (I.16); Provide, in obtaining informed consent, as much information as reasonable or prudent persons would want to know before making a decision or consenting to the activity. The psychologist would relay this information in a language that the persons understand and would take whatever reasonable steps are needed to ensure the information was, in fact, understood (I.23). When considering these two values it is important to include the grandmother and boy in the decision making process. It is important to include them when deciding if counselling is warranted and also to help make the decision about referring the boy for a psychological assessment. When discussing

ETHICIAL DECISION MAKING 4 informed consent, I would be clear and explicit about my opinion regarding the potential benefit of a psychological assessment. I would also convey the potential risks of having such an assessment completed. I would want both the boy and the grandmother to be aware of why I thought counselling could be helpful and how such an assessment could benefit the boy and the intervention process before they made a decision to begin either service. Furthermore, because the school is privy to the situation, at least to some extent, I would attempt to involve them in the process. Principle II: Responsible Caring Value: General Caring Protect and promote the welfare of clients, research participants, employees, supervisees, students, colleagues and others (II.1); Avoid doing harm to clients, research participants, employees, supervisees, students, trainees, colleague and others (II.2). These two standards are of particular interest. I must consider, in the protection of the boys welfare, whether it is in his best interests for me to refrain from beginning counselling until a full psychological assessment has been completed. Furthermore, to what degree do I encourage the boy to be assessed if I strongly believe it is warranted, even though he and his grandmother may not agree? I must consider whether I will cause more harm by insisting an assessment be completed and potentially alienating the family, or potentially allowing serious psychiatric symptoms to go untreated. I also need to decide whether or not I am competent enough to evaluate the severity of his potential symptoms and monitor them for sometime before deciding if a referral for assessment is needed. Value: Competence and Self-Knowledge - Take immediate steps to obtain consultation or to refer a client to a colleague or other appropriate professional, whichever is more likely to result in providing the client with competent service, if it becomes apparent a clients problems are beyond their competence (II. 8). Although I would consider myself competent to address issues related to loneliness, isolation and social withdrawal, I feel far less knowledgeable regarding Aboriginal populations and their

ETHICIAL DECISION MAKING 5 cultural/spiritual beliefs. I would need to immediately consult a colleague who was more knowledgeable in the area to highlight how the boys culture could affect my understanding of the issue, as well as the treatment process. I would also refer the boy to another professional if I deemed the voices he often hears to be problematic and psychological/psychiatric in nature. As I do not have expertise working with people who experience hallucinations I would ensure he receives competent care by making an appropriate referral to someone more qualified. Value: Risk/benefit analysis Assess the individuals, families, groups, and communities involved in their activities adequately enough to ensure that they will be able to discern what will benefit and not harm the persons involved (II.13); Be sufficiently sensitive to and knowledgeable about individual, group, community and cultural differences and vulnerabilities to discern what will benefit and not harm person involved in their activities (II.14). It would be important for me to look closely at both of these principles. Developing a better understanding of the family and the culture would help me assess whether the family and community are overlooking or minimizing serious psychiatric problems. Developing such an understanding would also help me decide if my initial reactions pertaining to the boy hearing voices were misguided. Being sensitive to potential cultural differences would help develop an appropriate case analysis of the problem and help direct appropriate interventions that are culturally appropriate. Before making a decision about making a referral for psychological assessment prior to starting counselling, I would ask many more questions and get to know the boy and his grandmother better. Value: Maximize Benefit - Strive to provide and/or obtain the best possible service for those needing and seeking psychological service. This may include, but is not limited to: selecting interventions that are relevant to the needs and characteristics of the client and that have reasonable theoretical or empirically-support efficacy in light of those needs and characteristics; consulting with, or

ETHICIAL DECISION MAKING 6 including in service delivery, persons relevant to the culture or belief systems of those served; advocating on behalf of the client, and, recommending professionals other the psychologists when appropriate (II.21). This principle is important to analyze for several reasons. First, the grandmother seems to be in need of supportive/psychological services as well. The grandmother is not eating nor sleeping well and just lost her husband. Furthermore the grandmother has residual feelings related to her past and experience in residential schools. Although the grandmother is not seeking service per se, my duty as a psychologist is to promote the welfare of all human beings (Sinclair & Pettifor, 2001). As I see her as someone in need of supportive services I would attempt to work with the grandmother to identify possible services that could be helpful to her, including my services if appropriate. This particular value is also of great importance because it provides me direction to ensure I seek treatment interventions that are culturally appropriate and effective with similar populations. Furthermore, I must consider and involve other members of the aboriginal community, if appropriate and warranted, including Elders etc. Although this may not be a possibility, I would intend to explore the idea with the boy and his grandmother. Value: Minimize Harm Give reasonable assistance to secure needed psychological services or activities, if personally unable to meet requests for needed psychological services or activities (II-31); Maintain appropriate contact, support, and responsibility for caring until a colleague or other professional begins service, if referring a client to a colleague or other professional (II.33). In the event that the grandmother consents and wishes to take her grandson for a psychological assessment, I must ensure that I assist her in finding a way to receive the service. As the proximity of the clinic is problematic I would work with the grandmother, the boys school, the staff at the clinic, and other appropriate community members on ways of making the assessment a possibility. Helping to create a team approach would provide more opportunities to overcome barriers in the way of accessing services that far away. For example, I would explore options such as the school helping to pay for it, identifying a community member who can give the family a ride, and/or advocating to the clinic to provide such

ETHICIAL DECISION MAKING 7 needed services to the community on an established regular basis or at least for this circumstance. However, in the event that such services are not a possibility or are not going to occur in a timely manner, and/or if I made a referral to someone who I felt was more competent to work with the boy, I would continue to support the family until such time someone more competent could take over the client care. Principle III: Integrity in Relationships Value: Accuracy/honesty Acknowledge the limitation of their own and their colleagues knowledge, methods, findings, interventions, and views (III.8). It would be critically important for a psychologist to have a sufficient understanding of the community and the different cultures within the community they work in. However, if they lacked certain knowledge it is important that they identify this and acknowledge it. In this case, and at this point in my career, I must acknowledge my lack of insight into Aboriginal communities/people and would therefore, have views that are limited, misguided and erroneous. By acknowledging this limitation I ensure the family can make the best informed decision possible about the services I can delivery. I would be honest about my capability around working with children with similar issues, but also acknowledge my lack of experience working with Aboriginal youth and youth who experience spiritual or psychiatric/pathological hallucinations. Value: Objectivity/lack of bias Evaluate how their personal experiences, attitudes, values, social context, individual differences, stresses, and specific training influence their activities and thinking, integrating this awareness into all attempts to be objective and unbiased in their research, service, and other activities (III.10). As someone who lacks insight into Aboriginal spirituality and culture and has been recently trained in child psychology, I am quick to think that hearing voices is pathological in nature and a full psychological assessment is warranted. However, when examining my own experiences, beliefs, and professional training, I soon discover that my first inclination may be incorrect. I must take the time to

ETHICIAL DECISION MAKING 8 evaluate my own lenses to ensure I give the boy and his grandmother an unbiased platform to present their problems and seek support. Without understanding my own background and how this could impact how I work with others I would be quick to pass judgment that could have a negative effect on the boy and his grandmother. Principle IV: Responsibility to Society Value: Respect for Society Acquire an adequate knowledge of the culture, social structure, and customs of a community before beginning any major work there (IV.15). If in fact I worked in an Aboriginal community, where the boy and his grandmother potentially live in the case example used for this paper, I would most certainly be in violation of this value. Before taking a position in such a community I would spend a considerable amount of time educating myself both personally and professionally regarding norms, customs, beliefs, and best-practices for such a population of people. Consideration of How Personal Biases, Stresses, or Self-Interest Might Influence the Development of or Choice Between Courses of Action As a white male, who grew up in a small middle-class town, to middle-class working parents, I most certainly have personal biases that could influence the professional decisions I make. I have not experienced many of the injustices many of the Aboriginal people have. Having such a different childhood, family, and cultural experience could make it difficult for me to see and understand how some Aboriginal people have developed certain coping skills. Because of the difference in experiences I could overlook how both the boys and the grandmothers experiences have shaped their current behaviours, thus not spending enough time to hear their point of view. Furthermore, because of such a bias in my upbringing, my education in psychology, and my lack of insight into this particularly familys spirituality, I would run the risk of blindly insisting on a full psychiatric/psychological assessment without adopting the familys point of view.

ETHICIAL DECISION MAKING 9 Development of Alternative Courses of Action and Their Possible Consequences The first alternative is to begin counselling and assume the issues that made me first question the need for a psychological assessment are culturally based and not for me to explore. In this case I would work with the child around his social isolation and withdrawal, grief and possible loss. I would also work with him around his issues of abandonment that could be related to why he now lives with his grandmother. This course of action would ensure I do not unwittingly insult the familys spiritual practices/beliefs; however, without further exploration of the voices he hears the boy could continue to experience severe psychological symptoms without the proper treatment. The second alternative is to refrain from counselling until the boy has undergone a full psychiatric/psychological assessment to rule out or confirm auditory hallucinations. The benefit would be that the voices could be definitively confirmed or ruled out as a psychiatric disorder. However, this would leave the boy vulnerable and his psychological well-being would be unmanaged unless I referred him to another counsellor who felt comfortable beginning services without an assessment. The third alternative would be to refuse to work with the boy entirely and refer him on to another counsellor. This would ensure the boy receives some form of care and would free me from the anxiety related to making such a decision. However, this course of action does not ensure the boy is properly cared for and does not lend to my professional development and growth. The fourth alternative is to begin working with the boy and his grandmother to address issues that they see as relevant and impacting their life. By gaining insight into their beliefs and familys functioning I would gain the information necessary to make my own assessment of whether a full psychological assessment is warranted. If, based on my professional judgement and after assessing the family and the community, I felt that the voices were concerning I would then work with the family to educate them on the need for further assessment. This could be time consuming; however, the decision for further assessment would be based on evidence and professional judgment after considerable consultation with

ETHICIAL DECISION MAKING 10 the family and possible other stakeholders. This would ensure the boys and grandmothers immediate concerns are being mitigated while possible long term plans for assessment and intervention are addressed through collaboration with the family. Choice of Course of Action after Conscientious Application of Existing Principles, Values, and Standards Although both the third and fourth alternatives of action could be seen as ethical, I would choose the fourth alternative. The fourth alternative fits into the role of a psychologist as a genuinely inquisitive professional who provides services to others in need of support. I would explore with the boy and his grandmother the issue they deemed problematic and I would help the family delineate an appropriate course of action. I would respect their right of self-determinism and choice during our consultations and would work with them in collaboration as to what the best course of action is. Part of my role would be to develop an understanding of their beliefs, values and culture at the same time as educating them on issues related to why social isolation and withdrawal are problematic and why a psychological assessment could be useful if warranted. This alternative is likely to lead to a beneficial outcome, whereas alternative three would merely avoid the potential of doing harm. Alternative four provides support to the family while addressing other concerns and is a straight forward and honest approach that ensures Respect for the Dignity of others and provides Responsible Caring of both the boy and his grandmother. Action with a Commitment to Assume Responsibility for the Consequences of the Action I will carry out the fourth alternative. I need to ensure that I closely monitor the boy and his grandmother to ensure they are capable of addressing the concerns and can meet their own needs. While providing support I must monitor the manifestation and context of the voices and make immediate and appropriate referrals for further intervention if the boy or others are in danger. If through the course of my own assessment while working with the family collaboratively, I feel that I am no longer competent to address their needs, I will help the family identify a service provider that can.

ETHICIAL DECISION MAKING 11 Evaluation of the Results of the Course of Action To evaluate my decision I would constantly check in with the grandmother, the boy, and school staff to monitor possible improvements or setback regarding the boys feelings of loneliness and social isolation. I would also continue to work with the grandmother around her feelings related to her past and the loss of her husband. I would monitor whether she felt working with me was beneficial and/or helping her make desired changes in her life. Lastly, if the voices were deemed to be concerning I would immediately consult with a more qualified practitioner and make an immediate referral for further assessment and intervention. To do this I need to monitor how the voices manifest themselves and understand the context in which the boy experiences them. Assumption of Responsibility for the Consequences of Action, Including Correction and of Negative Consequences If I cannot meet the needs of the boy or his grandmother I would help them identify someone more appropriate to meet their needs. If the boys voices were pathological in nature I would work with the grandmother and the boy around education and the need to be further assessed. If the boy became dangerous to himself or others the proper authorities would be notified including the police and the hospital. The latter would be addressed through the informed consent process. Appropriate Actions as Warranted and Feasible, to Prevent Future Occurrences of the Dilemma It would be important to clearly define what my role is as a professional who provides counselling services in the community. It should be understood by those who seek my services, or provide referrals for my services ,that I cannot address psychiatric issues such as hallucinations and that such concerns should be referred to a more appropriate professional. Furthermore, it would be necessary for me to further develop my expertise in the area of working with Aboriginal youth and children who

ETHICIAL DECISION MAKING 12 experience spiritual or pathological hallucinations. Clearly stating my competence and further developing my expertise to other areas would help avoid such a dilemma in the future. Conclusion and Critical Evaluation After working through the Decision making Model I would begin counselling the boy. I believe I am able to provide adequate care the meets the ethical principals outlined by the Canadian Code of Ethics for Psychologists. Working through the model allowed me to consider and address ethic standards/values that I may have otherwise overlooked particularly in the Responsible Caring domain. I feel confident, after reviewing the standards, that I could provide adequate care so long that I am open with the family about my limitations and work to establish a collaborative relationship during the informed consent process. Furthermore, understanding my own limitation and potential biases will allow me to ensure I meet the standards outlined in the Responsible Caring section of the code. After review of this section I feel that I am able to ethically begin counselling. However, it should be noted that at any point through the collaborative process that I deemed the familys needs outweighed my competencies, a referral would be made to a more qualified professional. I would begin counselling without a psychological assessment; however, I would inquire about the nature of the voices and their significance and make a clinical judgment about the need for further assessment and intervention after my initial assessment. Furthermore, I would seek to learn as much as possible about the family and their beliefs and help provide education around the benefits of further intervention and assessment if it was warranted. Beginning counselling and allowing the family to make an informed decision about the assessment and treatment process is in the best interests of the family based on the initial referral information. It should also be noted that if, after the initiation of counselling services, the situation changes based on my initial assessment, working through the Decision Making Model again would be beneficial.

ETHICIAL DECISION MAKING 13 References Sinclair, C., & Pettifor, J. (Eds.). (2001). Companion manual to the Canadian code of ethics for psychologists (3rd ed.). Ottawa, ON: Canadian Psychological Association