Course:PSYC537/2010WT1/Vignette4

VIGNETTE 4

You are the only psychologist living in a small rural community. Your primary area of practice is treatment of children with externalizing disorders. In working with one of your clients, you get to know the child’s father and discover that he suffers from an alcohol addiction. The father says he is aware that his addiction is harming his family and asks if you would be willing to work with him to help him “kick the habit”. You have no experience with treating addictions and already have his son as a client, but you are concerned about the consequences of not helping this man.

STEP 1: Who are the people potentially affected by decision? -Me (the psychologist) -My child client -My client's father -My Client's other family members (CC)

-Possibly also other people struggling with alcoholism/addictions in the community (AH)

- The community as a whole, since it is a small rural area, and it is likely that everyone knows everyone (or almost). So each person’s well-being could impact the well-being and functioning of the community at a global level. (JK)

STEP 2: What are the relevant ethical issues/laws? Which ethical values/laws are in conflict?
Principle II of the CPA Code of Ethics: Responsible Caring
-There exists an obligation to protect the welfare of those in the most vulnerable position; in this case, that could be the child or the father. Care must be taken to ensure that adequate service provision is made for all parties in need. (SV)

Ethical Standards of Competence (Principle II.6 of the CPA Code of Ethics, CPBC Code of Conduct Section 3.0)
-There is a prohibition against the practice of psychology outside of one's area of competence, except under situations of extreme urgency or need, where no other options are available. (SV)

Respect for Dignity of Persons (CPA Code of Ethics, Principle I)
-If both father and son are accepted as clients, care must be taken to ensure that confidential information revealed by one party is not shared with the other, that dual relationships are disclosed, and that informed consent is obtained or assent is renewed once this information is provided. (SV)

STEP 3: How do personal biases, stresses or self-interest affect my choice of action?
Possible biases which may affect the psychologist:
- Personal attitudes toward or previous experiences with addictions/addicts, especially those involving alcohol.
- Their initial impression of the father.
- Their relationship with the child client (how much they like/dislike the child; what the child has told them about the father, and his/her relationship to the father; how much they feel that helping the father will help the child; etc.,).
- How isolated they feel as professionally as a psychologist in this rural setting.
- How much they have a tendency to feel protective/solely responsible for the mental health of the individuals in the community.

If I was the psychologist in this situation:
I would probably have feelings of loyalty to the child client, and so I would have to be careful not to only see this person as 'the alcoholic father of my client', and make sure to take the time to consider what is best for him as an individual, as well as a part of his family. Previous experiences with family members with addictions would definitely make me emotionally reactive to the whole situation, and I would have to continually be double-checking that I am weighing all the options rationally. I would also have to be very aware of how I interact with the father, to make sure that I do not respond to him in an emotional, or judgmental way. (AH)

Personally, I have an old close friend that works in a rural community as a GP and I have heard her perception of it. As possibly the only (or almost) mental health professional in the area and that everyone knows you through some community capacity, both or either professionally or personally, there may be a perception to live up to everyone’s needs and to feel solely responsible for their psychological well-being. I’ve also heard from my friend that is it quite difficult to get an outside professional come in to service someone in such rural communities. I would have to be careful of stepping out of my comfort zone for the wrong reasons and carefully gage what I am (or can become) competent at and in what ways I can seek assistance from other professionals.

The psychologist may also be biased by their perception of the level of alcoholism in the community, in deciding whether to gain competency with this population. Same goes for perceptions of the gain for the community in acquiring competency in family-therapy. (JK)

STEP 4: Consult with colleagues.

STEP 5: Develop alternative courses of action. 1. Providing treatment for the client's father 2. Decline treatment for the client's father 3. Refer the client's father to another psychologist who specializes in treatment for alcohol addiction. 4. Gain competency in assessment and treatment of adult alcohol addiction through attending workshops, supervision, and only provide treatment for the client's father after adequate competency has been achieved. 5. If the psychologist has developed competency working with families, he/she can offer services for the client's family first until he/she has acquired competency in treating alcohol addiction.(CC)

6. Begin treating the father right while continuously seeking guidance and consulting with colleagues who do specialize in this area, and gaining knowledge through other immediate sources such as journals and books. Warn the father by letting him know this is not your area of expertise. you could also Try and get a psychologist who is proficient in this area to come in and supervise you for a session or two.

7. See if the father is willing/ able to leave this remote area and get treatment elsewhere

8. Try and convince another psychologist who is proficient in this area to move there and treat this patient (a bit of a stretch you never know)

9. Potentially just treat the father or just treat the child if you are primarily concerned with possible threats to confidentiality. (HM)

10. You can suggest sources of help other than seeing a psychologist for alcohol addiction that are available in the community, such as AA.

11. You can decide to accept the father as a client but restrict your therapeutic techniques with him to ones that you are competent in. This may ‘only’ include active listening and providing emotional support. If later on you decide to acquire full competency with treating adult alcohol addiction, you can expand your repertoire of skills used.(SC)

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

Option 1 -

Risks: 1) You are unable to provide adequate and responsible care to the father because of insufficient competency. 2) As a result of 1), you are not able to help the father or worse, are harming him and his chances of recovery. 3) As a result of 1) and 2), the father ends up with a negative perception of psychologists in general and becomes less likely to seek help in the future for his addiction. He may also pull his child out of therapy as a result (if he was the legal guardian giving consent to treatment). Furthermore, the father may convince others living in the town of his negative appraisal of psychologists and deter them from seeking necessary psychological services. 4) As a result of 1) and 2), the entire family, including the child client, is harmed and suffers distress. The same may apply to anyone else the father can have a significant impact on, such as his close friends and relatives. 5) As a result of 1) and 2), you face disciplinary action for practicing outside your area of competency and/or are sued by the father.

Benefits: 1) Despite your limited competency, you are still able to provide helpful service to the father and have success with treating his alcohol addiction. 2) As a result of 1), you help the father, and this then create further positive changes in the family, including with the child client. Such changes may also be observed with anyone else who can be impacted by the father, such as his close friends and relatives. 3) Agreeing to help the father may be therapeutic on its own as he may perceive this as an increase in social support and perhaps this alone can help lessen his drinking problem. (SC)

Option 2 -

Risks: 1) Without any intervention at all, the father’s addiction problem worsens 2) Because of 1), your child client’s wellbeing declines. The same change may be observed in the other family members, the father’s friends and relatives. 3) The father does not understand why you declined his request for your service (despite your best effort at explaining the issue of insufficient competency) and forms a negative perception of psychologists. This may then deter him from seeking future help from psychologists (he thinks they will reject his request too) and may prompt him to take his child out of your care (if he was the legal guardian giving consent). Moreover, the father may be able to convince other residents in the small town of his negative appraisal of psychologists and deter them from seeking necessary psychological services.

Benefits: 1) Not being able to obtain service from you prompts the father to search for a psychologist competent in treating adult alcohol addiction. This then allows him to receive competent care. 2) The father was not harmed as a result of your practicing beyond your competency. (SC)

Option 3 - Risks: There may not be another psychologist in the area and the father may not be willing to move. Depending on his understanding of the work psychologists do and your explanation, he may not understand why you are not able to treat you and form a negative perception, lead him to not seek help, and similar negative outcomes will occur as listed in Option 2.

Benefits: If this is a viable option, the father will be able to seek help from a competent party while you are still able to treat the child without problems of confidentiality or practicing beyond your competency.

Option 4 - Risks: 1) You may run into problems with the dual relationship you are holding with both child and father. Depending on the information disclosed by either party, you may also run into problems with your Duty to Protect the vulnerable party if the father's alcoholism is threatening the well-being of the child. The father may leave your services and again, form negative perceptions of psychologists which he may share with the rest of the town. It could also potentially lead to a lawsuit. 2) Obtaining adequate training to treat alcohol addiction can be a lengthy process and you may not be able to treat the father for a while. In the mean time, he may decline rapidly leading to similar risks listed in previous options.

Benefits: You are able to adequately help the father without violating ethical standards of competence and, if you are able to help the father improve, may result in positive outcomes for the child as well.

Option 5 - Risks: You may run into similar problems of confidentiality even in a family therapy setting (especially if you still see the family members separately). A family/group setting for therapy may not necessarily be beneficial for the child or father, depending on the type of treatment they were receiving before. Similar to Option 4, if you are not able to address the father's problems with alcohol as soon as possible, he may decline rapidly, even with therapy for other issues. It may be hard to avoid the topic of alcohol abuse and you may step outside the boundaries of your competence unintentionally. Benefits: You are able to help the father within your boundaries of competence and at least help him with the family problems until you are able to treat him more specifically. Treating the whole family can also possibly bring about positive outcomes for all members instead of just the father. (KA)

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

After thinking through all the options and their corresponding benefits and risks, it seems that the best course of action would involve combining a few of the options so that their pros and cons could balance each other out. Specifically, I suggest the first step would be option #7: See if the father is willing/able to leave this remote area and get treatment elsewhere. If the father is ok with this option, then I would also implement option #3: Refer the client's father to another psychologist who specializes in treatment for alcohol addiction. This way, the father receives the best treatment possible and most immediately.

However, if the father is not willing or able to leave the remote area to seek help from someone who specializes in alcohol addiction, then another course of action should be followed. I believe that since it is important for the well-being of both your child client and his father that his father to get treatment, it is important that you take him on as a client in the limited capacity suggested in option #11: You can decide to accept the father as a client but restrict your therapeutic techniques with him to ones that you are competent in. This may ‘only’ include active listening and providing emotional support. If later on you decide to acquire full competency with treating adult alcohol addiction, you can expand your repertoire of skills used. I also think it is important that you simultaneously follow option #4: Gain competency in assessment and treatment of adult alcohol addiction through attending workshops, supervision, and only provide treatment for the client's father after adequate competency has been achieved. To clarify the last sentence, I think that treatment can be provided to the father in the mean time, but only treatment that you are competent in (as referenced in option #11). To supplement the fact that you are not necessarily treating the addiction, I think an excellent concurrent option for the father would be option #10: You can suggest sources of help other than seeing a psychologist for alcohol addiction that are available in the community, such as AA. Finally, if relevant, I believe another concurrent option for the child client and his family is option #5: If the psychologist has developed competency working with families, he/she can offer services for the client's family first until he/she has acquired competency in treating alcohol addiction. By combining all of these options, it maximizes the help received by both the child client, his father, and their family, while attempting to limit the psychological services provided by the therapist to just those that they are currently competent in. (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.