“There is nothing more useless than a merely well informed [person]” Alfred North Whitehead.
Abstract
Clinical training in ethical decision making processes has relied heavily on teaching students to apply ethical codes and legal statutes to written scenarios using ethical decision making models. While an excellent academic exercise, this approach tends to remain abstract and does not prepare students for the complexities of making decisions during the process of therapy. Recently, experts in the field have called for reforms in ethical training, believing current models must move beyond cognitive exercises that detach students from the humanity of their clients and themselves. The described pedagogical approach bridges the gap by using a modified Objective Structured Clinical Exam to provide a safe context for students to practice ethical decision making and receive feedback before entering actual clinical practice.
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Dr. Bobbi Miller currently serves on the Editorial Board of Contemporary Family Therapy Journal. Dr. Paul Springer has no conflicts to report.
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Appendices
Appendix 1: Example Scenario and Scripts
Scenario
The scenario deals with a divorcing couple who share custody of one child and have been seeking therapy. The initial goal was to work on the relationship and has since shifted to adjusting to the reality of the divorce and the impact on the child. This scenario involves child abuse in the context of a contentious divorce.
Scripts
Therapist
You have been working with a family for about one year; Partner 1 (39), Partner 2 (38), and Child (11). The initial goal was to save the relationship/marriage, but the couple decided to separate/divorce during therapy. The family has remained in family therapy with you. The goal has changed to managing the transition to their new status as a divorced family effectively. You have been seeing the family together and seeing the child some individually as well. The divorce process has been very contentious. You are attempting to work with them on how to co-parent throughout this transition, but you have begun to notice that their interactions are getting more and more hostile. You have also noticed that you are beginning to feel more frustrated and reactive toward partner 2. You believe that many of their demands on their partner and child are unreasonable. One afternoon between sessions you receive a phone call from partner 1. They tell you that they are concerned about something that they found out and does not know what to do. They report to you that their child came back from staying with partner 2 and is refusing to go back. Partner 1 tells you that the child won’t tell them what happened, but seems to “indicate” that partner 2 hurt them somehow. Partner 1 says that they are very concerned and does not want to ‘make” their child go to the house of partner 2 again.
Partner 1
You have been seeing a therapist for about one year. First the goal was to try and save your marriage/relationship. However, you and your partner have decided to get divorced. You have continued to engage in therapy in an attempt to work on co-parenting your child even after the separation/divorce. You believe that your partner is being uncooperative with the plan and you recently found out that they have been dating someone. You are very angry about this and have been venting to friends, sometimes around your child. A couple of nights ago, your child came home from your partner’s house very upset. Your child refused to tell you what happened, but reported to you that they would not go to your partner’s house again. You have seen your ex-partner get very angry and lose their temper and you are concerned about what they might have done. You call your therapist to report your concerns that your partner may have abused your child.
Partner 2
You have been seeing a therapist for about one year. First the goal was to try and save your marriage/relationship. However, you and your partner have decided to get divorced. You have continued to engage in therapy in an attempt to work on co-parenting your child even after the separation/divorce. You believe that your partner is talking behind your back to your child and have noticed more and more of an attitude from your child when they stay with you. You find yourself getting really frustrated your child. The last time they visited, you got very angry, grabbed them by the hair and slapped them across the face. You are appalled that you did this and apologized profusely, but your child refused to talk to you for the rest of the trip. You have never done anything like this before. You do not say anything to anyone about what happened. You are very concerned about what this might mean for your ability to keep your child.
Child (11)
You have been seeing a therapist for about six months. First the goal was to try and save your parents’ marriage/relationship. However, they have decided to get divorced. Now therapy sometimes involves you. Sometimes you speak with the therapist with your parents and sometime you talk to the therapist alone. You are feeling very torn between your parents. Parent 1 is very angry with parent 2 and always talking about what an awful person they are and how it is their fault the two got divorced. Parent 2 has also started to date someone and this makes you angry. You have been sulking more and giving parent 2 more attitude. Parent 2 has been more frustrated with you. At your last visit, you and parent 2 got into a fight and they grabbed you by the hair and slapped you across the face. You are very angry with parent 2 and do not want to go to their house again. You go home and tell your parent 1 that you do not want to return to parent 2′s house. However, you love parent 2 and don’t want them to get into trouble, so you don’t tell parent 1 what happened. Parent 1 has been so angry at parent 2, you are not sure what they would do if you did tell them. (If the therapist asks you what happened, go ahead and tell the therapist- but insist that they do not tell anyone- including your parents).
Supervisor
Your supervisee has encountered a dilemma that they are going to come and talk to you about. Your team and the supervisee have been working together for about 6 months. You have noticed that the therapist seems especially bonded with the child and at times has a difficult time connecting with parent 2. (You will need to provide some feedback to your supervisee about how to proceed with their dilemma; you can also provide suggestions about where your supervisee could go for more information. Feel free to ask your supervisee any questions that you need to).
Observer (Therapist)
Your role is to follow the therapist throughout the entire activity. Think about the choices that you would make in their role. Focus on what you would do similar and what you might do different. Also focus on why you might do some things similarly or in a different way? Do not intrude on the process. Your job is simply to observe. You will be sharing some of your observations at the end of the activity, so I would encourage to you to take notes.
Appendix 2: Debriefing Guide-Step One
As we debrief today, please describe your experiences to the extend you feel safe to do so. If you need extra time to debrief anything sensitive that you are not able to share with the group, please let me know and we can meet privately.
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1.
Describe the experience of being part of this therapy session. What feelings came up for you?
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2.
Were there experiences that were particularly triggering for you? If so, what were they and what make them difficult.
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3.
What was your role in the activity and how did your role shape your perspective of the decisions made in therapy?
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4.
For those with a professional role:
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a.
Was there anything specific to the context that made it hard for you to do your job? If so, what?
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b.
Would you have changed anything that happened? If so, what and why?
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c.
Did you find yourself stuck at any point about how to proceed? If so, at what point and why?
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a.
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5.
For the clients:
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a.
How did you feel about your relationship with the therapist throughout the session? At the end of the session?
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b.
Would you come back to therapy? Why or why not?
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c.
What made you feel cared for in this interaction? How could you have experienced more care?
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a.
Appendix 3: De-Briefing Guide Stage Two: Reflection/Evaluation Paper Directions and Grading Rubric
Overview: This paper should describe your experience as the therapist, supervisor, consultant, or observer during the role play. You are expected to demonstrate your ability to identify, seek out additional information, and make a decision about the ethical dilemma that you are presented with. This decision should reflect an understanding of the stakeholders involved and their perspectives, as well as the complexity of the issues involved.
Your paper should discuss the following issues: (1) what was your role in the activity and how did your role shape your perspective of the decision made; (2) if you were the therapist- identify the ethical dilemma and the decision that you ultimately made; if you were the supervisor/consultant- identify the ethical dilemma and the guidance that you provided to your supervisee/colleague; if you were an observer- identify the ethical dilemma, the decision that the therapist made and whether you would have made the same decision (3) using the ethical principles AND codes support the decision that you made, guidance that you gave, or decision you would have made, (4) identify the key stakeholders in this scenario and the process that you took (or would have taken) to consider their needs in making your decision, (5) briefly review the process that you took to make your decision and anything that you would have changed about your process after receiving feedback from the individuals involved.
Your paper should be between three to five pages. It will be graded on its clarity and how well you address the issues described above. In addition, organization, quality of writing (sentences are well formed, varied in length and style, effective use of paragraphs), Use of APA style: professionalism (12 pt font, times and roman, 1-inch margins), mechanics (free of spelling, typographical and grammatical errors), and use of headings.
Values Paper Grading Rubric.
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Attended session on time and fully participated in activity/85
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Clearly identified own role and influence of the role on decision making process/7
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Clearly and correctly identified ethical dilemma(s) present/8
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Supported decision using both ethical codes AND Principles; use of codes and principles demonstrated familiarity with both/20
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Identified key stakeholders in scenario and reflected on how they were included in the decision-making process/15
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Clearly articulated process of making the decision and any changes s/he would make next time/15
150 Points: Points will be taken off for any problems with organization, quality of writing and use of APA (American Psychological Association Publication Manual).
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Miller, B.J., Springer, P. Ethics-Based Training for Clinicians: Moving Beyond Ethical Decision Making Models. Contemp Fam Ther 42, 370–380 (2020). https://doi.org/10.1007/s10591-020-09537-7
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DOI: https://doi.org/10.1007/s10591-020-09537-7