Course:PSYC537/2010WT1/Vignette1

VIGNETTE 1

You are the psychologist director of an organization providing psychological services to people with developmental disabilities. Leslie receives services from your organization. Leslie's only sibling is his legal guardian. Leslie is extremely close to his sibling and relies on his sibling for both emotional and instrumental support. Your staff has found Leslie to be quite capable of making sound decisions and of living independently. However, Leslie's sibling insists that Leslie needs 24-hour care, citing 10 year old examples of bad decisions that Leslie has made. When you suggest that Leslie may have developed better decision-making skills since that time, Leslie's sibling produces the guardianship order to "remind" you that Leslie cannot make decisions on his own. What do you do?

STEP 1: Who are the people potentially affected by decision? Mainly Leslie and Leslie's sibling. Also yourself, and other staff at the care facility. (HM)

STEP 2: What are the relevant ethical issues/laws? Which ethical values/laws are in conflict? Depending on how old Leslie is, the Infant's Act may come into play, although the Adult Guardianship Act may be more appropriate. There are issues of informed consent intertwined in this issue. In this case it seems as though Leslie would be capable of giving informed consent although it is not completely clear. It may also depend on what actions you or Leslie may want to take (i.e., does Leslie need support or assistance from our organization?), in which case we would need to decide who Leslie's representative would be to carry out any further actions (KA)

In any ethical situation, we have the greatest responsibility toward those who are in the most vulnerable position, namely Leslie in this case. An important issue to consider is whether living independently is going to serve Leslie's best interests; if living independently in and of itself is an important treatment goal/objective as outlined in the informed consent, or is an essential component of a treatment plan that aims for higher levels of functioning and independence, it is our ethical responsibility to clearly explain to Leslie and his guardian the potential benefits versus risks of their decision on the therapeutic outcome. While we are striving to provide the best care possible for Leslie, at the same time, from a legal standpoint, his sibling/guardian's decision must also be respected, unless new evidence suggests the necessity of such guardianship has been called into question by the judge or other legal experts. (CC)

STEP 3: How do personal biases, stresses or self-interest affect my choice of action? I grew up in an individualistic culture where independence is highly valued. When I first read this vignette, I realized that my value in independence biased me to want to advocate for more independence for Leslie. However, it is not readily apparent from the vignette that Leslie himself wants more independence at this stage of his personal growth nor is it clear what goals propelled him to seek psychological services from the organization in the first place. It is possible that at this time Leslie would be happier with 24-hour care and that Leslie never sought psychological services with the intention to gain more independence to begin with. As a psychologist, I wouldn’t want to assume my value in independence is shared by Leslie and follow a course of action according to this bias.(SC)

I agree with Sabrina. While Leslie's personal wishes must be taken into account, the psychologist's theoretical orientation and his/her underlying assumptions about the mechanism of change might also play a role in this decision. For instance, a psychologist of psychoanalytic orientation might argue against Leslie's sibling's decision to keep him home, because the dependency inherent in their relationship might be seen as causing or maintaining delays in Leslie's development. Whereas, a psychologist of humanistic or interpersonal orientation might show less concern about the sibling's decision, as they may interpret Leslie's relationship with his sibling as a major source of comfort and support for Leslie, and will continue to be so, regardless of Leslie's current developmental abilities. (CC)

STEP 4: Consult with colleagues.

STEP 5: Develop alternative courses of action.

- Take steps to update the guardianship order and further suggest that Leslie start to live independently.
- Allow the sibling dynamics to continue as is, i.e., keeping the current sibling living situation as is with Leslie’s sibling providing continuous care and support to Leslie.
- Suggesting that the change of Leslie’s living situation be made gradual. Providing services to both Leslie and the sibling in allowing them to get adjusted and comfortable with his gradual independence and in providing care and support when necessary, as well as indicating community resources to be used (besides your organization). & Explaining to both Leslie and his sibling that they can still support each other while living independently and that their closeness can continue in a different form. Further revisit progress and living situation at a later date.
(JK)

-Additionally, another option might be to suggest that Leslie's guardian/sibling seek counseling/support through their agency or another agency as well; this might help the guardian deal with the stresses inherent in having this type of relationship, as well as potentially determine what he or she gains out of the guardianship (a sense of purpose, authority over Leslie, etc). (SV)

STEP 6: Analyze likely short-term, ongoing and long term risks and benefits of each.

1. "Take steps to update the guardianship order and further suggest that Leslie start to live independently." Risks: - If the psychologist insists on review of the guardianship order, the sibling may become offended or upset and transfer Leslie to another organization, which could disrupt Leslie's normal routine and potentially cause him emotional distress. - Should Leslie begin living independently, he may feel more isolated without the contact with his care workers. - Should Leslie begin living independently, his sibling may feel less inclined to provide as much emotional and instrumental support, which would severely impact Leslie as his sibling is currently his major source of support. - Should Leslie begin living independently and later be found incapable of caring for himself, the sibling may take legal action.

Benefits: - Should Leslie begin living independently, it may give him a greater sense of control over his life and possibly increase his quality of life. - Should Leslie begin living independently, the costs associated with his 24-hour care would be decreased or eliminated - potentially benefiting the sibling who is currently supporting him. - Should Leslie begin living independently, the organization could re-allocate their resources to other individuals with more serious needs. (AH)

2. Allow the situation to continue as is. Risks: Leslie may not be allowed the independence he has a right to; Leslie may come to resent his sibling, which could cause conflict between them; additional costs may be incurred by provision of care Leslie does not need. Benefits: The relationship between Leslie and his sibling may remain intact, which provides social support for Leslie; Leslie can be assured continuous care; the relationship between the sibling and the practitioner can remain strong, which means Leslie can stay in treatment through the program. (SV)

3. Suggest the changes be gradual. Risks: The guardian may not agree, causing friction in the relationship. Additional costs might be incurred during the transition that are unnecessary. Leslie might decide he does not want a change in the relationship and supervision level. Benefits: The transition may be easier for Leslie to handle, and if the practitioner is wrong about Leslie being able to handle less supervision, this would be determined in a less stressful way. (SV)

STEP 7: Choose course of action after conscientious application of principles.

After careful consideration of all the options, to me, it seems to make the most sense to chose option #3: "Suggest the changes be made gradually". Although it does risk causing some friction in the relationship between you and the guardian, as long as Leslie has an interest in this option, then his wellbeing should be prioritized. By gradually easing him into a new program with reduced levels of care, it helps facilitate the transition, instead of overwhelming Leslie all at once. It also keeps the door open to ease him back to his original level of care should the reduced care not be adequate. Therefore, although this option may temporarily hurt the rapport between you and Leslie's guardian, the gradual pace and the trial nature of the changes might make him more open to the idea. Furthermore, by choosing this course of action, the relationship between you and Leslie's brother would be much less negatively impacted than if option 1 ("take steps to update the guardianship order and further suggest that Leslie start to live independently") was implemented. In terms of additional costs, it is likely that reduced care would be cheaper. If this was not the case, then referrals to cheap or free community resources for both Leslie and his brother would be necessary. This option is preferable to the second suggestion (allowing the situation to continue as is) because it would likely be much cheaper than continual care. Secondly, it gives Leslie the opportunity to explore his autonomy and potentially experience the empowering feeling of mastery. Although Leslie's brother may not desire to have less responsibility in caring for his brother at the moment, after experiencing some freedom for the first time, he might enjoy the change. One final benefit of option 3 is that it opens up the care facility's resources to others who need the services more. Therefore, I feel that option 3 is the best compromise and offers the most benefits with the least risks. (AA)

STEP 8: Act with commitment to assume responsibility for consequences.

STEP 9: Evaluate results of course of action.

STEP 10: Assume responsibility for consequences, including corrections or re-entry into decision making process if still unresolved.

STEP 11: Take action, as warranted, to prevent future occurrences. In the future take extra care to keep the legal guardian aware of the care being provided to the client and the progress that client is making. If possible meet regularly with the guardian so they have an up to date idea of how the client is doing. Perhaps if Leslie's sibling had been able to witness evidence of Leslie's increased independence more gradually this would be less shocking for the sibling and as a result he/ she may have been more accepting of the idea of a new living arrangement. It may also be helpful to broach the topic of reducing care early on so the guardian can think this over and maybe begin to increase independence in small steps. (HM)