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C H A P T E R 6

Conflict: The Reality of “Being Ethical” Within the Real World

Ms. Wicks: Hi, Tom it is me again.

Mr. Harolds: Hey, how are you? Did you get that information from the state association?

Ms. Wicks: Not yet. They are supposed to call me. But, things are getting more confusing . . .

Mr. Harolds: Really?

Ms. Wicks: Ms. Armstrong, the principal at the school, informed me that it is understood in the district that we are not to counsel students regarding sexual issues. She said it is not a formal policy, just something that “we” all know not to do. So, I’m not sure if I broke a law or violated a code of ethics or may have stepped over the line in terms of my job definition. I am so confused!

W hen working with a client, a helper needs to be aware of and sensitive to the many individual issues and concerns presented by the client. In addition, the helper also needs to be fully cog-

nizant of the ethical and legal implications of his or her own professional

Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from capella on 2021-07-26 23:33:47.

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decisions in relationship to these client concerns. Now, to complicate mat- ters even more for those practitioners working within an organization or a system, be it a school, a hospital, an agency, or a company, individual prac- tice decisions must also reflect and be congruent with policies, procedures, and informal standards and values operating within that system.

The current chapter looks at the ethical culture of social systems and the influence it exerts on the practice decisions of those helpers working within that system. The chapter will discuss the impact of working for and within an organization. Further, in this chapter we will look at situations in which conflicts arise when what the professionals feel is best for the indi- vidual client falls outside of or even runs contrary to policies, procedures, or values of the organization. Under these conditions, what’s a practitioner to do?

● OBJECTIVES

The chapter will review the process and implications of making ethical practice decisions within an organizational or system context. Attempting to balance the needs of the individual client with the requirements of the employing organization and other interested parties (e.g., managed care organizations) is not an easy or clear-cut process. After reading this chapter you should be able to do the following:

• Define what is meant by “system culture.” • Discuss the impact of system culture on ethical decision-making. • Identify possible points of ethical conflict when working in a man-

aged care environment.

• Identify possible points of ethical conflict when working with third- party payees.

● SERVING THE INDIVIDUAL WITHIN A SYSTEM

Professional practice does not occur within a vacuum. At a minimum, pro- fessional practice occurs within the social context of a client and a helper. But for those working within an organization, professional practice and ethical decision-making occurs not only within this dyadic system but also within the context of the larger system or organization in which the helper works. Ethical problems in professional practice are often the result of the confluence of context, setting, and standards of practice. Practitioners who

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work in schools, clinics, or hospitals, and/or those who serve as providers for managed care can find themselves in conflict with these competing cli- ent systems (see Case Illustration 6.1).

Case Illustration 6.1

A Diagnostic Dilemma

Linda Alfreds is a new school psychologist, the first ever employed by the Hallstead School District. Linda’s job involves performing all psycho-educational assessments, especially those required for special education placement. Linda was informed, however, that with the excep- tion of a few “slower” children, the district really didn’t have children with special needs, which according to the superintendent was a blessing, since they have very limited monies for providing such services.

Linda was asked to see Marquis, a transfer student, who was reported as having difficulty keeping up with the work in a number of his classes. The test data presented Marquis as an impulsive child, with a significant receptive language problem. From her work at a previous school district, Linda knew that Marquis would benefit from placement in a resource room with a special education teacher trained in learning disabilities and language disorders.

Linda discussed the situation with her department chairperson and was told that the district did not have resource room personnel. However, the other middle school in the district did provide a classroom for “slow learners.” The chairperson directed Linda to record Marquis as being retarded rather than as having a language disability, since this would at least get him some special services. It was clear to Linda that the data would not support this diagnosis, but identifying the child with a language disability might fail to provide any special teaming assistance to Marquis.

Certainly the school psychologist presented in Case Illustration 6.1 is confronted with a serious ethical and potentially legal dilemma. As in this case, practice decisions must clearly reflect not only the needs of the client as well as the characteristics and orientation of the helper but also the unique characteristics and demands of the context or organization in which the helping occurs. Balancing all of these unique needs is not always easy or clear-cut. The ethical practitioner needs to be aware of the system and the subtle and often times not so subtle influences that a system can exert. Such an awareness begins with an understanding of the nature of systems.

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As used here, a system is “an entity made up of interconnected parts with recognizable relationships that are systematically arranged to serve a per- ceived purpose” (Kurpius, 1985, p. 369). As one of the interconnected parts within a work setting, the human service provider needs to fully understand the roles enacted, the relationship that exist, the values and assumptions that support these relationships, and the degree to which all of these exert pres- sure on the performance of one’s duties. One cannot be an ethical-effective provider of service without full awareness of the system and system dynamics in which he works

It is not unexpected that when working in a system with multiple con- stituents that conflict in performance of one’s duties may emerge. This may occur in a situation of a school counselor who feels that what is best for the student may be contrary to the policy or procedures of the school, for whom they work. Or it is possible that one working in an employee assistance pro- gram (EAP) might experience the pressure of a divided loyalty. When under contract to provide employees services, one might feel a strain between the desire to maintain employee confidentiality while understanding that the contract exists with the employee’s place of business, and there may be a legitimate need to know on the part of that employee’s manager. Under these conditions, information regarding the client’s treatment as related to job performance may be within the need to know and thus conflicts with the client’s right of privacy and confidentiality. The practitioner, while respect- ing the confidentiality of the information gathered, needs to be sensitive to the obligations agreed to in contracts with the organization. The EAP coun- selor described in Case Illustration 6.2 appears to have developed a plan for balancing the needs of the organization with the rights of the client.

Case Illustration 6.2

Balancing the Needs of the System and the Client: A Case of Confidentiality

Hanna Johannsen was a private practicing mental health counselor who was certified as an EAP counselor. In addition to seeing clients for a fee, Hanna provided EAP services to the members of a local school district. In this EAP capacity, Hanna received a contracted fee and was to provide three to five sessions free of charge to any school district employee who desired such counseling. In addition, should additional counseling be desired or required, Hanna would make a referral to another provider, and the employee would then be responsible to con- tinue on a fee-for-service basis.

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ETHICAL CULTURE OF SOCIAL SYSTEMS ●

As part of the contract with the school superintendent, the EAP counselor was to provide monthly reports that included (a) the number of people seen, (b) the specific school in which the employee worked, (c) the job class (i.e., teacher, administrator, staff, etc.), (d) the type of problem presented, (e) the number of sessions utilized, and (f) and evaluation of the outcome. While the specific names of clients and any details of the nature of the problem presented were not to be disclosed, Hanna felt that the information requested was such that it could jeopardize the confidentiality of those who utilized this EAP service.

Hanna worked out a compromise with school administration so that all first sessions could be made completely confidential. In that first session, as part of setting the boundaries of confidentiality, Hanna explained to each client the types of data she would reveal to the superintendent and asked the client for their informed consent before making additional appointments. If the client would not give that consent, Hanna would provide a referral list and share no information about the contact with the central office.

Organizations—or for that matter, any social system (e.g., families)—develop their own values or standards that guide decision-making and practice within that system. These values, which may take form explicitly in an organization’s value statement or implicitly as behavior guiding day-to-day decisions, serve as a core to what has been described as systems culture (Schein, 2010). Schein described system culture as a “pattern of shared basic assumptions that the group learned as it solved its problems of external adaptation and internal inte- gration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way you perceive, think, and feel in relation to those problems” (Schein, 2010, p. 18). The assumptions that serve as the base for the development and maintenance of a system’s culture form the unquestioned, non-debatable truths and reality of people within the system. These develop when a solution or procedure works repeatedly. As a result, those involved begin to take it for granted to the point where what was once only a hunch or possibility starts to get viewed and treated as a reality. These basic assumptions then serve as the foundation from which the system defines structures and processes to guide its operations. This is an important concept for the ethical practitioner to grasp, because when members of an organization embrace these assumptions, they in turn shape what the mem- bers value and the form these values take (see Exercise 6.1).

Chapter 6. Conflict–●–133

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The cultural values of a system become enacted in the way mem- bers prioritize and function-shaping policies, decision-making, and other operations. Practice decisions, therefore, may begin to reflect institutional values and organizational ethics more than they represent “best practice” or codes of professional conduct. While it is possible that organizational ethics can parallel those of the profession, in view of the fact that the purpose of an organization may be different than the purpose of any one helping relationship, the organizational ethics may not only be conflictual but may act to undermine the values and ethics of the practitioner (see Exercise 6.2).

While it is clear that the ethical practitioner must be aware of the often- times subtle influence of a system’s culture on his or her practice decision,

Exercise 6.1

Making Culturally Compatible Choices

Directions: Below is a table that provides a social context, a focus for a practitioner, and two practice decision options. Along with a col- league, select the options that you feel would most likely be encour- aged and/or supported by that particular social context and provide your rationale for your selection.

Social- Organizational Cultural Context

Focus for Practice Decision

Practice Decision Options

Selection and Rationale

(sample) Catholic High School

Increased evi- dence of stu- dent pregnancy

1. Guidance unit on sex- ual behavior, safe sex, and sexually transmitted diseases

2. Guidance unit on self- esteem and value of abstinence

Option 2, given the school’s belief that sex outside of marriage is unaccept- able and immoral

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Social- Organizational Cultural Context

Focus for Practice Decision

Practice Decision Options

Selection and Rationale

A free-standing clinic that is funded primar- ily through managed care contracts

A client diag- nosed as depressed, with the possibility of having an early history of sexual abuse

1. Referral for anti-depres- sant medica- tion

2. Contract for long term, “recovered memories’’ therapy

A military industrial com- plex, making “sensitive’’ technical equipment

A personnel director who is approached by an upper level manager experi- encing extreme financial pres- sures and who has had fantasies of “selling tech- nology” to other governments

1. Respect the confidential- ity of the rela- tionship and work with the employee on stress reduc- tion

2. Report the fantasies to his supervisor

A public school, with limited spe- cial education facilities and funding

A school psy- chologist who believes a student is in serious need of ongoing indi- vidual psycho- therapy

1. Recommend therapy to his family as part of an Individual Education Program

2. Suggest that his family may find it useful to con- tact an out- side therapist

Chapter 6. Conflict–●–135

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Exercise 6.2

Goals: Values and Decisions

Directions: As noted within the chapter, decisions are made that not only reflect the values held, but the goals desired. Below you will find a scenario, system and practitioner goals, and decision options. Your task is to identify the decisions preferred by the system along with those preferred by the practitioner. Next identify the situations in which these are parallel or in conflict.

Scenario System Goals

Practitioner Goal

Decision Preferred by System

Decision Preferred by Practitioner

Parallel or Conflict

1. (sample) Star football player has a very bad sprained ankle.

Win the big game

Rest the ankle

Allow the student to play

Sideline the student for one game

Conflict

2. The top salesman for a corporation has embraced his alcoholism and is committed to a treatment program.

Maintain sales

Maintain salesman’s health

Adjust sales region to allow salesman to attend meetings while continuing sales

Encourage and support in attending meetings

3. A social worker noted that a fifth grade teacher who is approach- ing retirement has a number of physical prob- lems, has been falling asleep in class, and often verbally abuses the children for making noise.

Educate children in fulfil- ment of the schools mission

Protect children from verbal abuse and show concern for an aging teacher with ill health

Try not to make too public for the remain- der of the semester and then provide the teacher with an early retire- ment pack- age

Work with the teacher in develop- ing some cooperative learning units while providing supportive counseling around the benefits of retirement

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Scenario System Goals

Practitioner Goal

Decision Preferred by System

Decision Preferred by Practitioner

Parallel or Conflict

4. A residential setting for individuals with severe emotional problems

To provide therapy while at the same time reducing patient disruption

To provide therapy geared at empower- ing individ- uals to take responsi- bility for their own actions

Reliance on medication including sedatives

Using the minimum amount of medication in order to support the client’s development of cognitive/ behavioral methods of control

the question remains: “If enculturated, how does one identify the operating assumptions, values, and culture?” It has been suggested that the use of inter- pretation of the artifacts and values reveals basic assumptions (Schein, 2010). Artifacts would include the visible, tangible, or concrete manifestations, be they the physical surroundings and their appointments, the stories or oral histories still shared, and even the rituals and ceremonies practiced, whereas a system’s values are revealed in what the system views as important in terms of goals, activities, relationships, and feelings (Schein, 2010)). By review- ing the way those within the system traditionally and continually address specific problems posed by the situations they face in common, the ethical practitioner can begin to understand the system’s values.

WHO IS THE CLIENT? ●

One seminal question that needs to be addressed when working within an organization is “Who is the client?” While this at first may appear to be a simple question to answer, balancing a practitioner’s responsibility to the employing organization while at the same time servicing the individual helper seeker is not always that clear-cut or easy. The various professional organizations are aware of this potential confusion and area of conflict and have attempted to provide practitioners with guidelines for their practice decisions (see Table 6.1).

Chapter 6. Conflict–●–137

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Table 6.1 Ethics of Practice Serving Client and Organization

Professional Ethical Standards Statement on Serving Client and Organization

American Counseling Association (2014)

C.2.g. Counselors monitor themselves for signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when impaired. They seek assistance for problems that reach the level of professional impairment, and, if necessary, they limit, suspend, or terminate their professional responsibilities until it is determined that they may safely resume their work. Counselors assist colleagues or supervisors in recognizing their own professional impairment and provide consultation and assistance when warranted with colleagues or supervisors showing signs of impairment and intervene as appropriate to prevent imminent harm to clients.

American Psychological Association (2010)

1.03. If the demands of an organization with which psychologists are affiliated or for whom they are working are in conflict with this Ethics Code, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and take reasonable steps to resolve the conflict with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights.

National Association of Social Workers (2008)

3.09.a. Social workers generally should adhere to commitments made to employers and employing organizations.

3.09.b. Social workers should work to improve employing agencies’ policies and procedures and the efficiency and effectiveness of their services.

3.09.c. Social workers should take reasonable steps to ensure that employers are aware of social workers’ ethical obligations as set forth in the NASW Code of Ethics and of the implications of those obligations for social work practice.

3.09.d. Social workers should not allow an employing organization’s policies, procedures, regulations or administrative orders to interfere with their ethical practice of social work. Social workers should take reasonable steps to ensure that their employing organizations’ practices are consistent with the NASW Code of Ethics.

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Although the various professional organizations address the issue of serving individuals and organizations, it is still for the individual practitioner to resolve questions such as, does the ethical practitioner, when working with individual members of an organization, make decisions that are best suited for the goals and objectives of the institution, even if not in the best interest of the individual care seeker? Or does the individual and the indi- vidual’s well-being take primacy? (See Case Illustration 6.3.)

Case Illustration 6.3

Who Is the Client?

Col. R. J. Wipps was a clinical psychologist working in service of the U.S. Army’s Special Service Division. Col. Wipps provided testing and individual counseling to those involved with Special Services.

Col. Wipps was approached by D. L. Kingsley, an officer in charge of a highly sensitive military project. D. L. came to Col. Wipps because of what he reported to be extreme stress as a result of financial difficulties that he was currently experiencing. D. L. noted that he was concerned that his wife would leave him if something didn’t happen soon to improve their lifestyle. When asked what he was attempting to do to resolve the financial problems, D. L. was quick to note that “nothing short of something illegal” could help. When confronted directly about whether he had considered illegal activities, D. L. stated: “Of course not . . . but I’ve been drinking a lot lately and God only knows what I could do if I get drunk!”

Col. Wipps recommended that D. L. take a medical leave while he went into a treatment program for the alcohol and also received some individual and marital counseling. D. L. said he would think about it but really did not feel that was necessary. D. L. asked if he would be able to see Col. Wipps for some counseling during this really stressful time. D. L. also wanted to be sure that the relationship would be confidential.

For Col. Wipps (see Case Illustration 6.3), questions existed about whether individual confidentiality should be respected or whether this individual posed a significant security risk and thus should be identified to appropriate personnel. In part, the answer to this question rested on whom Col. Wipps identified as his client, D. L. Kingsley or the U.S. Army. Most guidelines, like that of the American Counseling Association (ACA) (see

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Table 6.1) indicate that the client is the primary concern for the ethical helper and the institution secondary. But it could be argued that accepting a position within an organization is a tacit agreement to serve as its agent and to embrace its values and standards of practice. In fact, the ACA Code of Ethics (2014) advised that acceptance of employment is essentially an agree- ment with the principles and policies of the institution, and that “counselors strive to reach agreement with employers regarding acceptable standards of client care and professional conduct . . . ” (ACA, 2014, Principle D.1.g).

It would appear, therefore, that the ethical practitioner needs to be account- able and responsive to both the system of employment and the individual clients served within that system. As such, it is essential that the practitioner not only understand but also commit to the mission of the organization as well as the specific values underlying that mission and the ways it becomes manifested in the procedures, policies, and decision-making processes. This does not mean to suggest a blind allegiance to the organization at the cost of the individual. In fact, it can be argued that the ethical helper will attempt to change organizational policies and procedures that are not healthy for those within the system. For example, the ACA Code of Ethics states: “Counselors alert their employers of inappropriate policies and practices. They attempt to effect changes in such policies through constructive action within the organization. When such polices are potentially disruptive or damaging to clients or may limit the effectiveness of services provided and change can- not be affected, counselors take appropriate further action” (ACA, 2014, D.l.h). In a similar vein the American Psychological Association (APA) directs its members that “if the demands of an organization with which psycholo- gists are affiliated or for whom they are working are in conflict with this Ethics Code, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and take reasonable steps to resolve the conflict with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights” (APA, 2010). The significance of this responsibility to confront organizational policies and practices that are deemed damag- ing to clients or in some way forcing practitioner unethical behavior is high- lighted by the ACA directive that if there is an irreconcilable conflict between the institution’s practices and those standards established by the code, resig- nation from employment should be considered (ACA, 2014, Principle D.1.h).

Thus, while some practitioners find themselves feeling responsible for championing the client’s right to confidentiality in the face of the organi- zation’s rules and regulations, in some situations, this is neither legal nor ethical. For example, in the military, confidentiality is guided by federal statutes, Department of Defense regulations, and the specific service (i.e., Army, Navy, Air Force) regulations, a point that needs to be considered

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by Col. Wipps (see Case Illustration 6.3). While supporting respect for the privacy of the individuals, these directives also mandate access to confidential materials by federal employees on a “need to know” basis (Neuhauser, 2011).

An ethical practitioner attempts to resolve conflicts between organiza- tional need and individual need in a way that not only reflects the desire of the practitioner to be supportive of his or her organization but also upholds the professional code of ethics. Thus, when confronted by the desire to protect the care seeker’s privacy while abiding by the rules and reg- ulations of the organization in which one is employed, the use of advanced warning on the limits of confidentiality would be essential as a means of serving both the organization of employment and the care seeker.

When There Are Multiple Masters

Ethical practitioners will not only know the mission, objectives, and val- ues of the organizations within which they work, but will also make known to their employers the nature of their own professional ethical commit- ments. Beyond this, it appears that an ethical practitioner will also share with his or her clients the obligations of fidelity and conditions of employment and how these may flavor the helping relationships and the practitioner’s decisions. This is especially important when an organization’s disclosure policy places additional limits on the confidentiality between client and helper (see Case Illustration 6.2).

Recently, the issue of multiple clients or conflicts between the needs of an employing organization with those of the client has taken on a new dimen- sion with the introduction of managed care. Managed care is a term applied to a widespread set of attempts to contain health care costs. The term has been used to describe “any type of intervention in the delivery and financing of health care that is intended to eliminate unnecessary and inappropriate care and to reduce costs” (Langwell, 1992, p. 22). Under managed care, third- party payers review requests for the initial delivery of services, determine the volume of services to be provided, and review any subsequent requests for service. Given the level of involvement in the professional decision process, it could be argued in managed care situations the practitioner has in fact two clients, the primary client being the person seeking assistance and the second- ary client being the managed care company. The potential for conflict can arise in that the needs and goals of these two clients may not always be congruent.

Managed care is essentially an economic strategy designed to provide care of or better quality for less money. While the concept of cost contain- ment is noble, the reality is that the goals of managed care can be in conflict

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with those of the practitioner (Meyers, 1999). Metzl (2012), for example, argues that managed care’s desire to create a homogenous cost effective product or template for treatment planning, while perhaps working with the administration of EKGs to patients with chest pain are not applicable to the nonhomogenous client base presenting with depression, personality disorders, or other form of mental health conditions.

Under these conditions, the question that can arise is, at what point does the cost containment interfere with the client’s needs and the helper’s ethical practice?

Managed care may challenge the practitioner’s ability to provide ethical practice. Managed care stresses time-limited interventions, cost-effective treat- ment, toward preventive rather than remedial processes (Metzl, 2012). Profes- sional literature raises several concerns about the impact of managed care on the effectiveness of treatment provided (Roberts & Hurley, 2012). As noted by these authors (Roberts & Hurley, 2012), managed care could result in clients receiving undertreatment, in that they may go underdiagnosed, experience restricted referral, and have insufficient follow-up. Thus, the policies of man- aged care may conflict with the practitioner, especially when utilization review decisions are contrary to professional judgment or when short-term or limited interventions are inadequate forms of treatments. Ethical rules and standards are often incongruent with the realities of treatment situations. In a managed care environment with restrictions to the number of sessions allowed, adher- ing to professional guidelines for risk management and standard of care service may simply be unrealistic.

In addition to potentially restricting treatment choice, the third party review can also compromise client privacy. Given these potential areas of conflict, what is the ethical practitioner to do?

At a minimum, the ethical practitioner needs to inform clients how their delivery of services may be influenced by managed care policies and restric- tions. Our professional codes have addressed this concern by directing clinicians to provide clients information needed to understand the potential conflict and the limits imposed on practice. For example, APA directs its members as follows:

When psychologists agree to provide services to a person or entity at the request of a third party, psychologists attempt to clarify at the outset of the service the nature of the relationship with all individuals or organizations involved. This clarification includes the role of the psychologist (e.g., therapist, consultant, diagnostician, or expert wit- ness), an identification of who is the client, the probable uses of the services provided or the information obtained, and the fact that there may be limits to confidentiality. (APA, 2010, Principle 3.07)

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A point echoed in the codes of ethics presented by the American Asso- ciation for Marriage and Family Therapy (AAMFT, 2015, Principle 1.13), beyond informing clients of the third-party relationship, practitioners are directed to gain client permission prior to any disclosure to that third party (e.g., ACA, 2014, B.3.d; AMHCA, 2010, 2.q; NASW, 2008, 1.07.h).

Another concern that can arise when working within a managed system is that of balancing the requirements of managed care’s cost containment principle with the ethical concern of providing quality of care, when such care requires extending services beyond that sanctioned by the managed care agency. How it is accomplished is truly the dilemma faced by all man- aged care providers. Do therapists continue pro bono? Do they challenge the managed care gatekeepers about artificial limits to needed care?

While the limitations to the number of sessions to be paid by insurance may make good economic and business sense for the insuring body, the question remains: What happens to the client once these limits are reached? Should the client continue to need care, the helper is ethically bound not to abandon him or her. The helper could refer the client needing additional treatment or provide pro bono services. Both strategies invite complication. How does one refer if referral sources are limited? How does one provide pro bono services to so many and survive financially? The answer may lie in the decisions an ethical practitioner makes before engaging in managed care service. Haas and Cummings (1995) advise therapists to consider the question of how to provide service to the client and how to avoid abandon- ing clients without going bankrupt before one joins a managed care plan. Understanding the nature of the managed care contract and resolving areas of professional standards of practice and care with those of economic neces- sity is a must for the ethical helper (see Exercise 6.3).

Exercise 6.3

Serving Clients in a Managed Care Environment

Directions: Contact two private practitioners who provide clinical services and are part of a managed care organization. Ask the practi- tioners each of the following questions:

• What are the limits to the types and/or length of services you can provide to your managed care clients?

• Are there are any unique limitations to the confidentiality of your records when working with managed care clients?

(Continued)

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● BEYOND PROFESSIONAL STANDARDS: A PERSONAL MORAL RESPONSE

• What, if any, avenues of appeal do you have regarding the deci- sions made by the managed care utilization review boards?

• How do you inform your clients of the special conditions regard- ing type and length of service, utilization review, confidentiality, and so forth, that may exist by the nature of providing managed care services?

• Have you turned down any opportunities to join a particular managed care group because you found it too restrictive?

• Have you been able to change any policies, procedures, or requirements in the managed care organization of which you are a part as a way of better servicing your clients?

• As a provider in managed care, what do you find to be the most challenging factor to your ability to provide ethical, professional care for your clients?

(Continued)

While it is easy to grasp and comprehend the dilemmas one may face as the varying demands, needs, and responsibilities of client, profession, and system of employment converge on a practitioner, positioning oneself to make the ethical decision may be quite another story. The existence and potential impact of these forces is not a simple intellectual or academic issue. It is a real-life dilemma that has the potential to impact the client, the practitioner, and the therapeutic relationship. Restrictions of modes and duration of treatment not only have the potential to undermine effective- ness but also can erode the professional’s personal and professional values. The limited autonomy on professional decision-making may increase the stress experienced in practice and contribute to conditions of burnout and empathy fatigue (See Chapter 14). Confronted with these conditions, the ethical practitioner may find herself confronted by a conflict between the institution’s practices and the standards established by her professional code. Such conflicts will require ethical practitioners to clarify and resolve these conflicts in a way that maximizes adherence to ethical dictates of

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their profession. This can be facilitated by establishing a preplan of resolv- ing potential conflicts between organization and professional ethics and values, including adjusting contracts and contract demands so that they are in line with system goals AND professional standards. When this is not pos- sible, then it is the contention of these authors that the ethical practitioner should consider resignation. Exercise 6.4 is provided as a stimulus for your own development of such a preplan.

Exercise 6.4

Recontracting or Resigning

Directions: Part 1: Below you will find a number of organizational poli- cies or procedures that a practitioner would need to follow. Identify those you find objectionable. How would you attempt to rework these policies/procedures before you would resign your post?

Organizational Directive (Policies/ Procedures) Rework or Recontract Resign?

All clinical records, including notes, are open to inspection by anyone identified as an executive administrator within the organization.

Attempt to specify the specific types of data open for review and tie each level of data to a specific administrator with a “need to know.” Further, all clients would be informed as to the access to records.

Yes, if not modified

Allowed only to utilize a brief therapy form of service. Therapy restricted to eight sessions maximum.

(Continued)

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Organizational Directive (Policies/ Procedures) Rework or Recontract Resign?

Prior to providing ser- vice, all intake infor- mation must be shared with a review board in order to achieve per- mission to continue. Further, a specific treatment plan and progress reports must be completed after every four sessions.

As an employee, you are required to provide service, in-house, for all the clients you see, regardless of their needs and your level of training.

You are required to acquire a minimum of 30 continuing education credits in your professional field every 2 years.

Part 2: Ask an individual care provider who is a member of a managed care program to show you his or her contract and statement of responsibilities, policies, and procedures governing service delivery. Review this contract and identify areas that you feel may potentially compromise your ability to provide ethical practice.

(Continued)

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CONCLUDING CASE ILLUSTRATION ●

Returning to the scene with which we opened the chapter, we find Ms. Wicks (Maria’s counselor) expressing her felt conflict among the informal values and rules of conduct held within the system in which she works, her concern for her client, and her understanding of her professional code of ethics. As you read the continuing dialogue, try to identify some of the values and/or under- lying assumptions existing within that school’s culture and begin to identify where and how these may conflict with this particular counselor’s under- standing of her professional code of conduct. The questions in the reflection section that follows the exchange should help you in this process.

Ms. Wicks: Hi, Tom, it is me again.

Mr. Harolds: Hey, how are you? Did you get that information from the state association?

Ms. Wicks: Not yet, they are supposed to call me. But, things are getting more confusing . . .

Mr. Harolds: Really?

Ms. Wicks: Ms. Armstrong, the principal at the school, informed me that it is understood in the district that we are not to counsel students regarding sexual issues. She said it is not a formal policy, just something that “we” all know not to do. So now I’m not sure if I broke a law, or violated a code of ethics, or may have stepped over the line in terms of my job definition. I am so confused!

Mr. Harolds: Well, Michelle, this is a very conservative community, and the truth is that with so many of our students having Latino back- grounds, we rea1ly don’t want to impose mainstream cultural values where they don’t belong.

Ms. Wicks: But, Tom, it is not like I’m going to promote a particular position here. I am just very concerned that she is making some decisions that could prove harmful and even potentially lethal to her.

Mr. Harolds: It is clear you are concerned about your client, but you need to understand something. In the past, we attempted to help the students make what we thought were value decisions. In fact, in health class we used to have a unit on sexuality and sexually transmitted diseases. Well, 5 years ago a parent group took the

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health teacher, the principal, and the school superintendent all to court for supposedly “imposing moral values” on their children. As a result, we removed health from our curriculum, replaced it with something on career choices, and created a parent supervisor board for the school that reviews curriculum decisions. So the superintendent is likely to be extremely sensi- tive about anything that may be interpreted as promoting a set of values or beliefs. I guess Ms. Armstrong is simply trying to avoid pressure from the central office. No sense rocking the boat.

Reflections

1. Assuming that Mr. Harolds’s depiction of the way the system operates is accurate, what would be the primary value or motive driving deci- sions around controversial topics?

2. When it comes to decision-making, which of the following would you suspect takes primacy in the culture of that school: Do what’s expedient? Avoid conflict at all costs? Be politically correct? Do what is best for the students?

3. Could you identify an artifact that reflects the operating values and assumptions within that school?

4. What do you feel Ms. Wicks should do? In relationship to her client? Future clients? Her principal? Her job definition and contract?

● COOPERATIVE LEARNING EXERCISE

Directions: With a colleague, review each of the following scenarios and

• Identify potential areas of conflict • Decide if the behavior of the practitioner is ethical • Identify decision options available for the practitioner • Discuss possible preplan options that could have been implemented

to reduce the potential of conflict.

Scenario 1: High School Counselor

A high school counselor has been working with a student athlete who was self-referred, because of his concern about his tendency to attend under- age drinking parties on the weekends and become intoxicated. The student expressed genuine concern over these tendencies and appeared willing to

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work with the counselor in order to curtail both the desires and the actions. He is particularly concerned with changing his behaviors, as the basketball season has just begun and he is the starting center for the team. There is a zero-tolerance policy for student athletes engaging in illegal activities, such as underage drinking. The counselor feels that he should warn the basketball coach about the student’s tendencies toward attending parties and drinking on the weekends.

Scenario 2: An Employee Assistance Provider (EAP)

Dr. Livingston is a licensed social worker working in private practice. Dr. Livingston also provides short-term counseling to employees of a local manufacturing plant. In this capacity as an employee assistance counselor, she has agreed to provide short-term (maximum of five visits) counseling to all employees and offers referral services for those needing more extended care. Further, her contract calls for her to consult with managers in order to increase their effectiveness when working with their employees.

In working with Helen, Dr. Livingston discovered that Helen and her coworkers have been punching in and out for one another and, as a result, have developed a system where they can cut approximately 8 hours a week off their actual work while recording and receiving pay for a full 40-hour week. Helen is a little troubled by this procedure but reports this is what everybody does. Dr. Livingston feels that she should report this information to Mr. Hansen, the owner of the company, since it is he with whom she has a contract.

SUMMARY ●

• Practice decisions made must reflect not only the needs of the client and characteristics and orientation of the helper but also the unique characteristics and demands of the context or organization in which the helping occurs.

• A professional role as well as the expectations of professional behav- ior is shaped in response to the organization’s expectations and needs; therefore, these expectations are incorporated as standards and guides for practice decisions.

• System culture is a pattern of basic assumptions invented, discovered, or developed by a given group as it learns to cope with its problems of external adaptation and internal integration. The pattern has worked well enough to be considered valid and is taught to new members as

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the correct way to perceive, think, and feel, in relationship to those problems.

• Once enculturated within a system, it is easy for the cultural values to become enacted in the way members prioritize and function— shaping policies, decision-making, and other operations. As such, practice decisions may begin to reflect institutional values and organizational ethics more than they represent “best practice” or codes of professional conduct.

• Most guidelines, like that of the ACA, indicate that the client is the primary concern for the ethical helper and the institution secondary. But it could be argued that accepting a position within an organiza- tion is a tacit agreement to serve as its agent and to embrace its values and standards of practice.

• The ethical practitioner needs to be accountable and responsive to both the system of employment and the individual clients served within that system.

• Ethical practitioners will share with their clients the obligations of fidelity, conditions of employment, and how these may flavor the helping relationships and the practitioners’ decisions. One special situation in which it is clear there may be more than one client is in the case of managed care.

• Managed care is essentially an economic strategy designed to provide care of equal or better quality for less money. The policies of managed care may conflict with the decisions of an ethical practitioner, espe- cially when utilization review decisions are contrary to professional judgment or when short-term or limited interventions are inadequate forms of treatments.

• Understanding the nature of the managed care contract and resolv- ing areas of professional standards of practice and care with those of economic necessity is a must for the ethical helper.

• Acceptance of employment is essentially an agreement with the prin- ciples and policies of the institution. When conflict exists between the institution’s practices and the standards established by the code, the ethical practitioner needs to clarify and resolve conflicts in a way that maximizes adherences to ethical dictates of his or her profession. This can be facilitated by establishing a preplan of resolving potential con- flicts between organization and professional ethics and values, including adjusting contracts and contract demands so that they are in line with system goals AND professional standards. When this is not possible, then it is the contention of these authors that the ethical practitioner will consider resignation.

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IMPORTANT TERMS ●

artifacts managed care

basic assumptions need to know

client organizational ethics

cultural values preplan

ethical culture of social systems system

limits of confidentiality utilization review

ADDITIONAL RESOURCES ●

Houser, R., Wilczenski, F. L., & Ham, M. (2006). Culturally relevant ethical decision- making in counseling. Thousand Oaks, CA: Sage.

Sperry, L. (2007). The ethical and professional practice of counseling and psycho- therapy. New York, NY: Pearson.

Thompson, R. (2012). Professional school counseling: Best practices for working in the schools. New York, NY: Taylor & Francis.

Web-Based

Daniels, J. A. (2001). Managed care, ethics, and counseling. Journal of Counseling and Development, 79, 119–122. doi: 10.1002/j.1556-6676.2001.tb01950.x

Glosoff, H. L., & Pate, R. H., Jr. (2002). Privacy and confidentiality in school counsel- ing. Professional School Counseling, 6(1), 20–27.

Kremer, T. G., & Gesten, E. L. (1998). Confidentiality limits of managed care and cli- ents’ willingness to self-disclose. Professional Psychology: Research and Practice, 29(6), 553–558. Retrieved from http://dx.doi.org/10.1037/0735-7028.29.6.553

Mappes, D. C., Robb. G. P., & Engels, D. W. (1985). Conflicts in ethics and law in counseling and psychotherapy, Journal of Counseling and Devel- opment, 64(4), 246–252. Retrieved from http://onlinelibrary.wiley.com/ doi/10.1002/j.1556-6676.1985.tb01094.x/abstract

Reamer, F. G. (2008). When ethics and the law collide, Social Work Today, 8(5). Retrieved from http://www.socialworktoday.com/archive/EoESepOct08.shtml

Stone, C. (2006, January). Confidentiality and the need to know. ASCA school- counselor. Retrieved from http://schoolcounselor.org/magazine/blogs/ january-february-2006/confidentiality-and-the-need-to-know

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● REFERENCES

American Association for Marriage and Family Therapy. (2015). Code of ethics. Retrieved from https://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/ Code_of_Ethics.aspx

American Counseling Association. (2014). Code of ethics. Retrieved from http:// www.counseling.org/resources/aca-code-of-ethics.pdf

American Mental Health Counselors Association. (2010). Code of ethics. Retrieved from http://c.ymcdn.com/sites/www.amhca.org/resource/resmgr/Docs/ AMHCA_Code_of_Ethics_2010_up.pdf

American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from http://www.apa.org/ethics/code/principles.pdf

Haas, L. J., & Cummings, N. A. (1995). Managed outpatient mental health plans: Clinical, ethical and practical guidelines for participation. In D. N. Bersoff (Ed.), Ethical conflicts in psychology. Washington, DC: American Psychological Association.

Kurusu, D. J. (1985). Consultation interventions: Successes, failures and proposals. The Counseling Psychologists, 13, 368–389.

Langwell, K. M. (1992). The effects of managed care on use and costs of health services. (Staff memorandum). Washington, DC: Congressional Budget Office.

Metzl, J. M. (2012). Managed mental health care: An oxymoron of ethics? Jefferson Journal of Psychiatry, 35–42.

Meyers, C. (1999). Managed care and ethical conflicts: Anything new? Journal of Medical Ethics, 25(5), 382–387.

National Association of Social Workers (Rev. ed., 2008). Code of ethics. Retrieved from http://www.socialworkers.org/pubs/code/code.asp

Neuhauser, J. A. (2011). Lives of quiet desperation: The conflict between military necessity and confidentiality. Creighton Law Review, 44, 1003–1044.

Roberts, M. C., & Hurley, L. K. (2012). Managing managed care. New York, NY: Springer.

Schein, E. (2010). Organizational culture and leadership (4th ed.). San Francisco, CA: Jossey-Bass.

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