4.7 Case Studies

Amara is a licensed professional counselor working at a private practice. Her client, Daniel, is a 24-year-old man struggling with depression and social anxiety. During their most recent session, Daniel disclosed that he has been feeling intensely angry toward a former coworker, Greg, who bullied him at a previous job. Daniel mentions that he has been following Greg on social media and has fantasized about hurting him as a way to “get even.”

Amara remains calm and explores Daniel’s statements further. When she asks if he has specific plans to harm Greg, Daniel hesitates before revealing that he has thought about “teaching Greg a lesson” but insists that he is only venting and has no real intention of following through. Despite his reassurances, Daniel’s tone and body language make Amara uneasy, and she is concerned that he might be minimizing the seriousness of his thoughts.

Amara knows she must balance her ethical duty to maintain client confidentiality with her duty to warn and protect potential victims if there is a credible threat of harm.

Apply the Nine-Stage Ethical Decision-Making Model to this case study. As a reminder, the steps to the Nine-Stage model include:

Step 1: Define the situation

Step 2: Determine who will be impacted

Step 3: Refer to ethical codes and principles

Step 4: Refer to laws, regulations, and organizational policy relevant to the dilemma

Step 5: Reflect on personal feelings, reactions, and competencies

Step 6: Consult with trusted, honest, and competent colleagues

Step 7: Determine alternative courses of action

Step 8: Consider potential outcomes

Step 9: Decide on a course of action and monitor outcomes

Discussion Questions

1. How should Amara interpret Daniel’s disclosure? What specific language or behaviors in the session might indicate whether his statements pose a credible threat?
2. Which sections of the ACA Code of Ethics are most relevant to this case, and how should they guide Amara’s decision-making?
3. How might breaching confidentiality affect Amara’s therapeutic relationship with Daniel? How could she address these potential consequences with him?
4. How might consultation help Amara balance her ethical and legal responsibilities?

Stepwise Overview

Step 1: Define the Situation

Daniel has disclosed strong feelings of anger towards a past coworker, Greg. Though he has not acted on these feelings, Daniel has disclosed that he has been following Greg’s social media presence and implied that he has thought of “teaching Greg a lesson.” Based on the information present, Amara’s professional experience has made her wary of Greg’s presentation, and she is wondering if it warrants a mandated report.

The primary ethical dilemma is the duty to respect client confidentiality vs. to warn potential victims if a credible threat of harm is identified. Amara must also consider her obligations to the various stakeholders involved at this point in the decision-making process.

Step 2: Determine who will be impacted

The primary stakeholders involved in this case are Amara, Daniel, and Greg. The secondary stakeholders include the private practice Amara is affiliated with and the families/significant others of all primary stakeholders. Amara’s primary professional obligation to herself is to behave ethically while also ensuring her safety. Her primary professional obligations to Daniel in this situation are to respect the confidentiality of his disclosures, promote the therapeutic relationship, and avoid causing harm to Daniel through her practice. Amara’s key professional obligation to Greg is to warn him if a credible threat of harm to his safety exists. Amara has the right to ensure her safety by exploring the primary stakeholders’ rights. In contrast, Daniel has the right to the confidentiality of his presentation for counseling, provided there is no imminent danger to himself or others. Greg has the right to be warned if credible harm to his safety exists.

Considering the possibility of harm, a few key areas emerge. The first area of potential harm would arise if Daniel followed through on his thoughts about “teaching Greg a lesson.” Not only would Greg experience physical harm, but Daniel would likely also be harmed by the consequences of his actions. Additionally, if this occurred while Amara knew of Daniel’s thoughts about harming Greg, Amara could be at risk for professional sanctions or a malpractice lawsuit. The second potential area for harm would occur if Amara were to breach confidentiality by warning Greg. This would likely result in emotional harm to Daniel and a degradation of the counseling relationship, in addition to potential legal system involvement (albeit to a lesser extent than the former possibility). Greg would most likely experience psychological distress arising from fear for his safety, and Amara may be at risk of a similar malpractice lawsuit from Daniel for breaching confidentiality.

Step 3: Refer to ethical codes and principles

The core ethical values most applicable to Amara’s situation are autonomy, beneficence, nonmaleficence, veracity, and fidelity. Whether or not to report what Daniel has disclosed involves discerning which option best promotes these values. Choosing to disclose Daniel’s threats to Greg (and potentially emergency services, depending on the jurisdiction) may represent a violation of fidelity, the promise to keep therapeutic content confidential, as well as Daniel’s autonomy to resolve the situation appropriately himself. However, it may also represent an opportunity to promote both autonomy and veracity for Greg, allowing him to keep himself safe in light of the present information. Additionally, beneficence and nonmaleficence are at odds. Disclosure would minimize the possibility of serious harm to Greg. However, it would come with legal and emotional consequences for Daniel.

The most applicable ethical standards to the present situation are Standard B.2.a of the ACA (2014) code and Standard II-8 of the NAADAC (2021) code, as provided below.

And

In light of the codes’ recommendations, a few suggestions are relevant to Amara’s dilemma.

1. Whether or not to report depends on whether “serious and foreseeable harm” (ACA, 2014, Section B.2.a) exists or whether “clear and imminent danger” (NAADAC, 2021, Section II-8) towards Greg is present. The interpretation chosen will likely depend on the legal statutes relevant to Amara’s municipality.
2. Amara must consult with others if she is questioning the case and document their recommendations.

Step 4: Refer to laws, regulations, and organizational policy relevant to the dilemma

Amara must familiarize herself with legal statutes in her place of residence regarding standards used for mandated reporting and apply them to the present case. Furthermore, if her private practice has established policies for such situations, she must consult and utilize the recommended course of action in informing her decision. If Amara is still unsure of the legal ramifications of her decision, consultation with a legal professional may be necessary.

Step 5: Reflect on personal feelings, reactions, and competencies

At this stage, Amara must reflect on the reactions the present situation evokes for her. How is the situation making her feel? Is any countertransference present that might be influencing things? Would either of these factors impair her ability to make an objective decision? We need more information to answer these questions appropriately based on the vignette alone. However, a counselor in this situation would be wise to reflect on the salience of these factors.

Amara must also consider her competence in dealing with the present situation in the context of past education and experience. As Amara is a licensed counselor in private practice, it is a safe assumption that she has had various diverse experiences within the counseling field that she can rely on to inform her final decision. Debates regarding mandated reporting are not uncommon in counseling practice, and thus, Amara has likely been exposed to similar past situations in some capacity. Though there may be nuances in Amara’s situation outside of the information presented in the vignette, Amara is most likely competent to address this situation based on present information.

Step 6: Consult with trusted, honest, and competent colleagues

At this stage, Amara must consult with one or more of her colleagues who embody the core tenets of the ethics codes and, she trusts, can remain objective and impartial in providing feedback. Using the previous steps of the decision-making model, she should prepare a brief presentation for her consultant(s) and document any suggestions they provide.

Step 7: Determine alternative courses of action

Based on the previous analysis. Amara decides that a few potential options emerge.

Option 1: She breaches confidentiality and reports the information shared in counseling to Greg and local law enforcement, as required in her state. She also calls Daniel shortly afterward to inform him of recent developments. This option is feasible in light of the present situation. As identified in step three, this option violates a few key ethical tenets while promoting others. However, it does align well with the code’s stance and legal requirements regarding mandated reporting. The legal strength of this option, however, would depend on whether Amara’s state uses the standard of  “serious and foreseeable harm” (ACA, 2014, Section B.2.a) or “clear and imminent danger” (NAADAC, 2021, Section II-8). The latter would require more evidence of Daniel representing a risk of harm than is available in the present case.

Option 2: She decides not to breach confidentiality and waits to discuss the matter in greater depth during her next session with Daniel. This option avoids breaching any ethical duties to Daniel, though it may represent a failed opportunity to promote autonomy, beneficence, and nonmaleficence for Greg. Amara may also be held to greater legal scrutiny without further action were Daniel to harm Greg in light of her present knowledge.

Option 3: She decides to call Daniel before their next session to discuss Daniel’s feelings towards Greg in greater detail. She voices her concern for Daniel and the legal implications that may befall him if he harms Greg. She invites Daniel for a partial session in which they conduct some crisis planning work surrounding Daniel’s animosity towards Greg. This option allows Amara to uphold her ethical duties to Daniel while demonstrating a greater degree of diligence in this case that may not meet the requirements for mandated reporting.

Step 8: Consider potential outcomes

Option 1: This option would likely damage the therapeutic relationship between Daniel and Amara as it requires Amara to breach multiple ethical duties to Daniel to protect Greg. Furthermore, Daniel may be subject to legal sanctions that would negatively impact multiple domains of his well-being. There is also a chance Amara may receive a complaint or lawsuit alleging malpractice if Daniel disagrees with her decision. This option takes more of a risk-management approach in satisfying legal obligations at the cost of ethical practice with Daniel. However, doing so may be necessary depending on the statutes Amara must abide by.

Option 2: The primary risk inherent in this option is that Daniel will harm Greg between sessions despite Amara’s knowledge that she could have allowed her to intervene. Though she does not directly violate any ethical principles for Greg, she may fail to promote beneficence and nonmaleficence by not taking further steps to address Daniel’s thoughts. Furthermore, a plausible argument could be made that the ethics codes necessitate further action to protect Greg, whether through mandated disclosure or further intervention with Daniel. In the identified worst-case scenario of harm to Greg, Amara would be at greater risk of malpractice-related consequences as identifiable physical harm has befallen another person. Given the nuance of this case, doing nothing until the next session appears to take a “hands-off” approach that may border on unprofessional. It seems that ethical and legal obligations are improperly satisfied through a lack of further intervention with Daniel and/or failure to take further steps to protect Greg.

Option 3: The primary risks of this option are that Daniel may feel alienated by being called back for crisis counseling or refuse Amara’s request. Furthermore, though crisis planning is feasible to reduce the risk of harm to Greg, it does not eliminate the possibility. This option, however, does afford Daniel a greater degree of autonomy and attempts to resolve the situation more informally, reducing the chance of harm for both Greg and Daniel. Using an approach that attempts to find a middle ground between the two previous extremes also balances Amara’s ethical obligations while reflecting a sensitivity towards legal standards that could insulate Amara from allegations of malpractice in a crisis.

Step 9: Decide on a course of action and monitor outcomes

Amara decided on Option 3 as the best course of action based on the ethical decision-making process. She feels that, while concerning, Daniel’s disclosure does not meet the standards of “serious and foreseeable harm” (ACA, 2014, Section B.2.a) or “clear and imminent danger” (NAADAC, 2021, Section II-8) put forth by the ethics codes for breaking confidentiality. Amara is still uncomfortable about not intervening further before her next session with Daniel. Amara calls Daniel, and though her request for an additional session slightly takes him aback, he agrees once Amara voices her concern for the legal consequences of the actions he disclosed.

Maria is a licensed mental health counselor in a community counseling center serving a diverse clientele. Her client, Darnell, is a 29-year-old African American man who has been in therapy for six weeks to address symptoms of depression and anxiety. During their latest session, Darnell disclosed that he has been experiencing significant conflict with his family, particularly his parents.

Darnell explains that his parents expect him to take on a caregiving role for his younger siblings and financially support the family, even though he is already struggling to maintain his job. While Darnell loves his family deeply and values their strong cultural emphasis on collectivism and familial responsibility, he feels overwhelmed and resentful.

Maria, who identifies as a White American, encourages Darnell to set boundaries with his parents to prioritize his mental health. However, Darnell appears uncomfortable with this suggestion, explaining that such boundaries would feel disrespectful and could lead to significant tension within his family. Maria begins to wonder if her cultural lens influences her advice and whether it aligns with Darnell’s values and lived experience.

Apply the multicultural ethical decision-making model to the case study. As a reminder, the steps of the multicultural ethical decision-making model are:

Step 1: Define the situation and identify the ethical dilemma(s)

Step 2: Explore the role of power and privilege

Step 3: Consider degrees of acculturation and racial identity development

Step 4: Consult with trusted, culturally competent colleagues

Step 5: Consider alternative courses of action

Step 6: Make a decision

Step 7: Evaluate the decision made

Discussion Questions

1. How might Maria’s cultural background influence her initial advice to Darnell?
2. What steps can Maria take to better understand and integrate Darnell’s cultural values into the counseling process?
3. How can Maria balance her ethical obligation to respect Darnell’s autonomy while honoring his cultural beliefs?
4. How might Maria’s actions impact her therapeutic relationship with Darnell?

Stepwise Overview

Step 1: Define the situation and identify the ethical dilemma(s)

Before beginning this decision-making process, it is important to note that given the brief nature of this vignette, assessments regarding the influence of power, privilege, and culture within Maria and Darnell’s lives are general at best and as such, cannot reflect the lived experiences and nuance inherent in the lives of our clients. We provide the following analysis as a primer for your work with the decision-making process and hope the salient factors identified can serve as inspiration when working with real clients.

The primary ethical dilemma is a difference in worldviews between a more individualist orientation (Maria) and a more collectivist orientation (Darnell). Viewing this through the lens of the core ethical principles in counseling, principles of autonomy, nonmaleficence, and justice are most salient. Maria must work to ensure Darnell receives culturally competent treatment that considers his values and worldview rather than imposing her own, thus promoting justice while respecting Darnell’s autonomy. Maria must also ensure that the guidance and exploration she provides in counseling does not harm Darnell, thus promoting nonmaleficence.

It is also important to note that the present counseling encounter is occurring in the context of centuries of racism, systemic discrimination, and oppression perpetrated by White Americans against African Americans. The healthcare/social service system that Darnell is entering has historically (and currently) contributed to ongoing healthcare and psychosocial disparities within the black community in addition to perpetrating horrific injustices such as the Tuskegee Syphilis and Cincinnati Radiation Experiments.

Regarding counselor and client thoughts concerning the present dilemma, Darnell has voiced discomfort with Maria’s suggestions thus far, and Maria is also beginning to question whether her initial suggestions were inappropriately culture-bound.

Step 2: Explore the role of power and privilege

In her role as a counselor in America, Maria is afforded a significant degree of power. In addition to the status afforded by completion of higher education and a professional career within American society, Maria can act as a broker with numerous social services and can make reports that hold significant legal value. As a white woman in America, Maria is afforded a moderate amount of privilege owing to her racial background. However, she also must contend with systemic sexism and gender-based discrimination as a woman.

Darnell is afforded moderate power as a client in a non-mandated counseling relationship. Recent trends towards person-centered counseling have begun to equalize client-counselor power imbalances, and an increasing emphasis on consumer choice in healthcare has made it easier for clients to find alternative sources of care or file grievances against incompetent professionals (Schaufeli et al., 2009). This being said, contemporary dynamics generally afford the counselor greater power in the counselor-client dyad.

As an African American man, Darnell is afforded a lesser degree of privilege than Maria in American society. While Darnell is less likely to have experienced discrimination on account of his gender, he resides in a society where both systemic and overt racism against African Americans and historical trauma owing to the history of slavery in America are salient forces that impact his daily life.

As a power differential is present between Maria and Darnell, Maria must be especially sensitive to the possibility that she may be imposing her values onto Darnell. Future work with Darnell should involve creatively exploring the dilemma in the context of Darnell’s culture and worldview. At the same time, Maria brackets the influence of her own culture on the decision-making process.

Step 3: Consider degrees of acculturation and racial identity development

Though information about acculturation is scarce within this vignette, a few key inferences can be made. Maria’s inclination towards individualistic coping mechanisms (suggesting Darnell put his mental health above the needs of his family) is characteristic of Western culture (Sue et al., 2022). The lack of information relating to other cultural influences for Maria also suggests that she primarily operates from a Western perspective, given her identification as a White American.

Darnell shares that he strongly values his culture’s emphasis on collectivism and family responsibility. He is also highly aware of the negative impact of acting against those cultural values on his family. These pieces of information suggest that Darnell’s culture is an essential aspect of his life and familial functioning, and the influence of culture is a very salient force for Darnell.

Considering any steps Maria must take to adapt her practice for Darnell, counseling Darnell from a perspective that respects the importance of his culture requires Maria to adopt a perspective of cultural humility and sensitivity, which represents an opportunity for personal and professional growth rather than a departure from traditional practice.

Step 4: Consult with trusted, culturally competent colleagues

At this stage, Amara must consult with colleagues who demonstrate strong cultural competence and knowledge of her ethical duties as a counselor. Furthermore, Amara should seek consultants from diverse backgrounds and lived experiences to ensure a diversity of perspectives when approaching her dilemma. She should also consider how her consultant’s backgrounds may influence the suggestions they provide as part of the exploration process.

Step 5: Consider alternative courses of action

Based on the information gained in the previous steps of the decision-making process, continuing to suggest that Darnell cope with his difficulties by distancing himself from his family would not be an appropriate option. While Darnell may reduce his level of job and caretaking-related stress, the strain his distance would put on his family would likely be just as harmful, if not more so. Furthermore, Maria continues suggesting that this option would be a form of value imposition upon Darnell, which is prohibited by the ACA (2014) and NAADAC (2021) codes.

Keeping this in mind, a few options emerge:

Option 1: Maria could talk to Darnell about her ethical dilemma, sharing that she feels her past suggestions may have been inappropriate. After engaging Darnell regarding the ethical dilemma, Maria and Darnell could actively collaborate on a creative solution that he feels comfortable with while ensuring his cultural values remain respected. In this approach, Maria takes accountability for what may have been experienced by Darnell as countertherapeutic while also attempting to equalize the power imbalance present in the counseling relationship.

Option 2: Maria could choose not to discuss the dilemma at hand openly. Instead, begin with the previously discussed brainstorming session. While this approach engages Darnell as an active collaborator in treatment, it ignores the role Maria’s power and privilege may have played in the previous session and, in doing so, minimizes the effect this may have had upon Darnell.

Option 3: Maria could educate herself regarding culturally sensitive situations that have been approached in the past and come to Darnell with a few more appropriate suggestions during their next session. In the context of the decision-making process, while it may appear to resolve the dilemma on the surface, this approach does little to equalize power and privilege imbalances within the counseling relationship. Furthermore, while education relating to culture and diversity is always a beneficial tool for professionals, considering that such education qualifies one to make the best decisions for clients without collaborative input is incorrect. It may be stereotyping or offensive at worst.

Step 6: Make a decision

In light of the present options, Maria chooses option one as she feels it best equalizes the dynamics of power and privilege while also minimizing any harm done by her previous suggestions. Furthermore, the chosen option ensures Darnell is an active participant in the treatment process and informs him of her motivations for directing treatment as she is. At this point, Maria would also explore any potential critiques of her decision and assess her feelings about proceeding with this course of action.

Step 7: Evaluate the decision made

This course of action honored the ethics codes by avoiding the imposition of values and attempting to repair any potential harm from Maria’s culture-bound suggestions. Maria also structured the decision-making process around reducing the imbalance in power and privilege between herself and Darnell by moving forward with a collaborative approach to counseling.

Additional factors Maria might consider as she concludes the decision-making process are how her own culture and values may have shaped the decision reached, how others would feel about the decision she reached, her personal feelings on the decision she arrived at, and finally, anything that she learned from the decision-making process itself.