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Article 54

Integrating Differentiation of Self Into Ethical Decision-Making

Counselor Training Method

Darren A. Wozny, Kimberly Hall, and Kirk Zinck

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Introduction

Counseling practice inevitably requires every counselor to address ethical dilemmas and to utilize an ethical decision-making model in order to choose the most ethical course of action. All ethical decision-making models have the common component of counselors consulting with their peers to help determine the best ethical course of action. However, it can be challenging for a counselor to advocate for an “unpopular” ethical course of action that goes against the “consensus view” of their peers. Thus, the aim of this article is to describe a counselor training method, “the ethical debate,” that can help counselors-in-training develop higher levels of differentiation of self and facilitate a stronger ethical decision-making process.

Ethical Issues in Counseling

A fundamental counselor obligation is to acquire the knowledge and decision- making skills that are necessary to utilize the code of ethics to guide competent professional practice. Ethical competence includes the following: a) knowledge of ethical standards; b) knowledge of commonly encountered ethical issues; c) development of ethical decision-making skills; and d) ability to apply one’s knowledge of ethics to professional activities. Given the importance of maintaining one’s ethical competence, this article integrates differentiation of self into the ethical decision-making process in order to better address contemporary and emerging ethical issues in counseling.

Within the professional literature, we identified the most common ethical dilemmas faced by counselors who practice in clinical, community, and school settings. The ethical dilemmas faced by counselors in clinical and community settings include: a) addressing value-based conflicts; b) ensuring ethical practice; c) strengthening the professional identity of counseling; d) determining boundaries of competence; and e) maintaining multicultural competency in an ever-changing social and professional context (Balkin, Watts, & Ali, 2014; Francis & Dugger, 2014; Herlihy & Dufrene, 2011 Kocet & Herlihy, 2014; Meyers, 2014). There are also some emergent issues evident in the contemporary literature that include: a) addressing social justice and diversity; b) being increasingly accountable for counseling outcomes; c) integrating medical advances into the knowledge base of counseling; d) and incorporating changes in how science, social, government, and business entities conceptualize mental health, which affects how diagnosis is utilized and how counseling is delivered (Bodenhorn 2006; Iyer & Baxter- MacGregor, 2010; Meyers, 2014).

School counselors share most of the same contemporary ethical issues faced by clinical and community counselors. However, maintaining student confidentiality is the most common and challenging issue within the context of schools (Bodenhorn, 2006; Iyer & Baxter-MacGregor, 2010). In the school system, the counselor is one component of a multifaceted approach to serving the academic, developmental, and emotional needs of students. As a participant in a team approach to the planning and delivery of services that will meet the individual educational needs of a student, a school counselor is accountable to the students who are their primary clients. Yet, the school counselor must work with parents, faculty members, administrators, and specialists who may also provide services to a student. Further, the Family Educational Rights and Privacy Act grants parents the right of privilege, a legal right to information about children under 18 years old. Iyer and Baxter-MacGregor (2010) emphasized that parents must understand certain issues in order to be of assistance to a child. Thus, school counselors continuously weigh the required and appropriate disclosure of pertinent information to parents and educators with maintaining the confidentiality to which students are entitled (American School Counselor Association, 2004). The ongoing struggle, “where a student’s right to confidentiality is weighed against others’ need to know” (Phillips, 2007, p. 41), infuses tension and uncertainty into the school counselor’s job. Other ethical dilemmas that commonly challenge school counselors include maintaining the confidentiality of student records, navigating the dual relationships with faculty, and awareness of a colleague’s breach of ethics (Bodenhorn, 2006).

Review of Ethical Decision-Making Models

The very nature of counseling puts counselors in unique positions that often lead to ethical dilemmas. We encounter a range of clients, situations, crises, and demands for our expertise in human emotions, thoughts, and behavior. While ethical codes are provided for us by numerous professional organizations (e.g., American Counseling Association [ACA], American School Counselor Association [ASCA], and others), these codes alone cannot account for our own personal and professional thoughts, feelings, and responses. These aspects of each of us impact every ethical decision that we make.

Ethical decision-making models seek to provide counselors with a general framework to help us examine the dilemma itself, possible courses of action, and consequences of those actions. If used appropriately, then these models can help us in the decision-making process to produce consistent, logical, and practical ethical decisions. While there are several ethical decision-making models in the literature, the most prominent models include Kitchener’s principle model (1984), Rest’s four-component model (Rest & Narvaez, 1994), the social constructivist model (Cottone, 2001, 2004), and Remley and Herlihy’s (2014) ethical decision-making model.

Perhaps the most well-known ethical decision-making model is Kitchener’s (1984) principle model. The premise of this model is that relying on personal value judgments is not sufficient and that clear ethical guidelines are necessary for decision- making. Kitchener identified five moral principles that are imperative during ethical decision-making: (a) autonomy; (b) nonmaleficence; (c) beneficence; (d) justice; and (e) fidelity. The principle of autonomy addresses the responsibility of the counselor to encourage clients to make their own decisions, facilitate self-determination, and empower clients in the process. Nonmaleficence requires counselors “to do no harm or least harm” and at least consider the intentional and unintentional ramifications of their chosen course of action on clients and others that come into contact with the client. Beneficence challenges counselors to be maximally effective with clients and “go the extra mile” to meet the clients’ best interests. Justice invites counselors to ensure that all interactions with clients emphasize fairness and equality and reflect a commitment to nondiscrimination in the distribution of clinical services to different client groups. The fidelity principle involves counselors “doing what you say you are going to do” and being faithful to your client, which establishes and maintains trust in the therapeutic relationship.

The four-component model (Rest & Narvaez, 1994) has been identified as one of the most empirically grounded approaches based on analyzing moral development. This model includes four components: (a) moral sensitivity, (b) moral judgment, (c) moral motivation, and (d) moral character (Johnson, 2012). Moral sensitivity is recognizing that there is an ethical dilemma. Once an ethical problem has been recognized, the counselor must then choose a course of action. Judgments about what is right and wrong play a role here when determining the best course of action. Moral motivation relates to a counselor’s follow-through on the course of action. Moral values may sometimes interfere with other concerns, such as job security. For example, a counselor may fear acting in a manner that is morally just to them but perhaps not what their superior wants them to do. Finally, moral character explores the ability of the counselor to execute the plan despite obstacles.

The social constructivist model of ethical decision-making takes all ethical decisions and views them in a social context (Cottone, 2001, 2004). This model views problems as opportunities for the client, the professional, and the community and places the ethical decision-making process out in the open to create dialogue. This model involves obtaining information from all those involved, assessing the nature of the relationship, consulting colleagues and literature, and responding in a way that offers a reasonable consensus by engaging all of the influential participants.

Remley and Herlihy’s (2014) ethical decision-making model involves an eight step process that includes: a) identify and define the ethical dilemma (what is the ethical dilemma?); b) consider the moral principles and relevant ACA ethical standards (which moral principles and ethical standards are primary in this ethical dilemma?); c) tune into your feelings (what are your feelings about this ethical dilemma? What is your gut feeling about your potential courses of action?); d) consult with professional colleagues and experts (what is the consensus view of how other counselors would handle the same ethical dilemma?); e) involve your client in the ethical decision-making process (what feedback did your client give you when you presented the multiple sides of the ethical dilemma?); f) identify desired outcomes (what is the best case scenario of how this ethical dilemma gets resolved?); g) consider possible actions (describe and justify at least two potential courses of action to resolve the ethical dilemma?); and h) choose and act on your choice (what was your chosen course of action and your rationale?).

Regardless of the specific ethical decision-making model that you follow, responsible practice requires that we (a) base our actions on informed, sound, and responsible judgment, (b) consult with colleagues and seek supervision, (c) keep knowledge and skills current, (d) engage in constant self-examination, and (e) remain open (Corey, Corey, & Haynes, 2014).

While the models mentioned previously all differ in their underlying approach to decision-making, they all possess similar steps to follow when analyzing a possible ethical dilemma. These steps are further outlined in A Practitioner’s Guide to Ethical Decision-Making, which outlines specific steps in the ethical decision making process (Forester-Miller & Davis, 1996). These steps include: identifying the problem; applying the ACA Code of Ethics; determining the nature of the dilemma; identifying potential courses of action and consequences; and finally selecting and implementing the course of action. When identifying the problem, the counselor needs to gather as much information as possible and consider the problem from multiple perspectives. Once the problem has been clarified, the counselor should refer to ethical codes regarding counseling behavior. Next, the counselor should determine the nature and dimensions of the ethical dilemma. This step involves examining the issue through the ethical decision-making model that the counselor follows. For example, if a counselor follows Kitchener’s (1984) model, then the moral principles of autonomy, nonmaleficence, beneficence, justice, and fidelity need to be considered. This step also includes reviewing related professional literature, consulting with experienced professional colleagues and/or supervisors, as well as consulting with state and national professional associations. According to ACA (2014), “counselors strive to resolve ethical dilemmas with direct and open communication among all parties involved, and seek consultation with colleagues and supervisors when necessary” (p. 19). The fourth step is to generate potential courses of action, which is a brainstorming phase. Once the counselor has considered a multitude of potential courses of action, he should consider consequences for each of those actions. The counselor should then determine the best possible course of action to take, evaluate whether or not this course of action will present any new ethical considerations, and ultimately implement the best chosen course of action.

Differentiation of Self: Bowen’s Core Concept

In Bowenian Family Therapy, the core concept of differentiation of self is at the heart of Bowen’s theory (Nichols, 2014). Bowen’s theory (Kerr & Bowen, 1988) focuses on how people manage conflict, or more specifically, both internal and external anxiety sources. Internal sources of anxiety include our emotional pulls due to our previous individual history. For example, an individual’s lack of experience in handling a particular situation (e.g., heated arguments) may influence the individual to experience a high level of anxiousness in a current interpersonal conflict. External sources of anxiety include any interpersonal conflict that challenges an individual to maintain the relationship without resorting to the emotional reactivity patterns of interaction.

A person’s level of differentiation of self is on a continuum from high (most desirable) to low (most problematic). An individual with high differentiation of self has the ability to manage both internal and external sources of anxiety by separating their thoughts from their emotions, being able to self-reflect to avoid the emotional reactivity patterns of fusion (closeness) and emotional cutoff (distance). A highly differentiated individual has the ability to advocate for their position, even if their position is not the popular viewpoint. High differentiation of self allows the person to be the “lone dissenting voice” and avoid the external anxiety pull of conforming to the group consensus. However, the highly differentiated individual balances advocating for their position, which helps the individual maintain their individual identity and personal/professional values, with maintaining the relationship with the conflicting individual(s). In other words, high differentiation of self means standing up for your views and values but doing so in a diplomatic and respectful manner in order to maintain the relationship.

In regards to external sources of anxiety, Bowen (Kerr & Bowen, 1988) emphasized that people with low differentiation of self tend to deal with conflict or anxiety in terms closeness or distance. Thus, low differentiation of self can result in a person handling conflict or anxiety by fusion or closeness, whereby the individual fuses to another person’s viewpoint or group consensus to decrease the anxiety level. The difficulty with the fusion pattern is that over time, as the individual concedes more and more to the viewpoints of others, they begin to lose their individual identity (inability to stand up for their own values and viewpoints) and take on the identity of another person’s or group’s viewpoints (and inherent values). Moreover, low differentiation of self can also result in a person handling conflict or anxiety by emotional cutoff or distance whereby the individual copes with the high levels of anxiety in a conflict with others by either discontinuing all further contact with the individual in question or limiting interaction to superficial interaction and benign topics of conversation with that individual.

Fortunately, an individual’s level of differentiation of self is not constant but can be changed with training and experience. Thus, counselor education programs ideally would like to recruit students with high levels of differentiation of self, though that is often not the case, and counselor education faculty need to find innovative methods to develop counseling students’ differentiation of self during their counselor education curriculum and training. To develop an innovative method, our counseling faculty thought of common sources of counselor anxiety or conflict, and we came up with the issues associated with ethical dilemmas and the ethical decision-making process that we use to address the ethical dilemmas. Our thinking was that counselors will encounter many ethical dilemmas during their professional careers and are already required to learn at least one ethical decision-making process to address ethical dilemmas. Thus, there is a natural opportunity to develop differentiation of self in counselors-in-training. In most ethical decision-making models, counselors are encouraged to pay attention to their emotional feelings in response to an ethical dilemma and also to consult other professionals in order to help delineate the most ethical course of action. Both of these ethical decision-making steps are closely associated with development of differentiation of self. The step of tuning into one’s emotional responses to an ethical dilemma helps counselors-in-training raise their awareness of internal sources of anxiety, which can be both helpful in some situations (where a gut feeling may keep a counselor-in-training searching for a more ethical course of action) and unhelpful in others (previous experience in conflict situations produced anxiety and a tendency to avoid conflict in future). The step of the counselor consulting with other colleagues when dealing with an ethical dilemma challenges the counselor to deal with external sources of anxiety whereby the counselor may feel pressure to abandon their initial ethical course of action and conform to their counseling colleagues’ group consensus (fusion). Conversely, a counselor may over-advocate for their ethical course of action and emotionally cut-off counselor colleagues in the process. The challenge is for the counselor to balance advocating for their ethical course of action while consulting with other peers who may hold alternative ethical courses of action. The goal is always for the counselor to find the most ethical course of action (either their own view or a peer’s view) and maintain their professional relationship in the process.

The Ethical Debate: A Counselor Training Method

The ethical debate is the counselor training method used to develop higher levels of differentiation of self among counselors-in-training. The premise behind the ethical debate is that it is an educational opportunity that creates both internal and external sources of anxiety among counselors-in-training whereby a counseling student has the experience of advocating for an ethical course of action against a professional consensus (several counseling student peers) advocating for an alternative course of action. The ethical debate puts a counselor-in-training in the position of being the “lone dissenting voice” and challenges the counseling student to argue their ethical course of action based on the moral principles (autonomy, nonmaleficence, beneficence, justice, and fidelity) as well as relevant ethical standards (ACA, 2014; ASCA, 2004) rather than resort to emotional reactivity patterns of fusion (conforming to the professional consensus and adopting their ethical course of action) or emotional cutoff (wanting to quit the ethical debate and distance themselves from their peers).

The ethical debate is implemented as part of a 5-hour workshop on ethical decision-making whereby counselors-in-training learn about each of the moral principles (autonomy, nonmaleficence, beneficence, justice, and fidelity) and become more familiar with the ACA (2014) and ASCA (2004) Codes of Ethics by practicing an ethical decision-making model in deciding ethical courses of action with case vignettes. In the first hour, counselors-in-training are introduced through discussion to the five moral principles (autonomy, nonmaleficence, beneficence, justice, and fidelity) and each of the eight steps of an ethical decision-making model (Remley & Herlihy, 2014) as the process that will be used develop an ethical course of action in each of the ethical dilemma case vignettes. For counselors and counselors-in-training that are well versed in the moral principles and familiar with the ACA and ASCA Codes of Ethics, the workshop can begin with a brief introduction followed by the presentation of the initial ethical dilemma case vignette. Each ethical dilemma case vignette round needs to include the following components:

1. Small group discussion (45 minutes) of the ethical dilemma case vignette whereby the small group follows the ethical decision-making process steps (identify the ethical dilemma; consider each of the moral principles and ethical standards; tune into your feelings; involve your client in the decision-making process; identify desired outcome; consider possible actions – minimum two courses of action; choose and act on your choice; Remley & Herlihy, 2014);

2. The chosen course of action from the small group discussion will be the position of the professional consensus (group ethical debate position) and the alternative course of action will be the ethical course of action that the counselor-in-training (lone position) will advocate for in the ethical debate against the professional consensus;

3. Choose ethical debate roles (lone position vs. group position) randomly in the first couple of vignettes then assign to ensure that all group members are given opportunity to be in the lone ethical debate role;

4. Ethical debate (20 minutes – 10 minutes per side or five 2-minute talking turns each) whereby group facilitator ensures that ethical debate rules (see below) are followed;

5. Ethical debate processing (10 minutes) whereby group facilitator processes with each person in the ethical debate their experience of the debate.

Depending on the familiarity with the moral principles and the ACA and ASCA Codes of Ethics, a 5-hour workshop should allow for three to four rounds (75 minutes per round) of different ethical dilemma case vignettes. The facilitator’s role (usually counselor education faculty) in the ethical decision-making workshop is the following:

1. Ensure the small group discussion follows the ethical decision-making process steps (caution the counselors-in-training from deciding prematurely how they will

   handle the ethical dilemma without first following the ethical decision-making steps);

2. Facilitate discussions on each of the moral principles, relevant ethical standards from ACA and ASCA Codes of Ethics, consider personal feelings, how to involve the client; and determine at least two courses of action for the ethical dilemma;

3. Ensure that counselors-in-training follow the ethical debate rules (see below);

4. Process each counselor-in-training’s experience of the ethical debate (both lone position and group position).

The rules of the ethical debate are as follows:

1. Only one person talks at a time;

2. Each person’s talking turn is no more than 2 minutes, though they can yield earlier;

3. Each debate side will take turns talking (no side will have consecutive talking turns);

4. Each side will have an opening argument response and a closing argument response;

5. All members of the group side must speak at least once;

6. Each side must present their ethical argument based minimally on moral principles and may cite relevant ACA and/or ASCA standards, if possible.

The Ethical Debate: Counselor Training Method Feedback

At the conclusion of the ethics workshop, counselors-in-training were asked to complete an ethics training workshop feedback form whereby they were to first identify their role in the ethics debate (lone position or group position); then they were asked to share their experience of participating in the ethics debate exercise. The two facilitators (counselor education faculty) were also asked to provide written feedback about their experience of facilitating the ethics debate in their assigned small group.

Counseling Students’ Training Method Feedback

Students in the group position role:

“I found it to be slightly challenging because of the side of the argument I was on. However, once the debate got started, it became easier. I enjoy ‘real-life’ situations like this because it gives us great practice.”

“I really enjoyed it. The debate made things seem real in a way, and it helped me see things from an opposite perspective. It was also humbling in a way, as I found myself alone with my own opinion.”

“It was a positive experience and a great idea. I didn’t get to choose on the side of the debate so that put my points at a disadvantage. I enjoyed the debate.”

“I found it hard to support or build an argument against something that I agree with. Other than that, it was a good exercise that brought out good points.”

“The ethical debate was an eye opener for me. To advocate for students, it is important that I be able to speak on what I know is right ethically. There will be others that have a different viewpoint from my own, but we can express our different views in a meaningful way. This debate was really helpful to me.”

“I think it was much easier as part of the group because you have others to back you up. However, not everyone shared the same viewpoint in the group so I could see where it could be easier to take on the viewpoint of others (from the lone position).”

Students in the lone position:

“My experience with the ethics debate was good. It helped me to look at one situation in many different ways. However, being by myself (in the ethics debate) made me feel like I had nobody to back me up in my (ethical) decision.”

“I felt completely confident defending my point of view. It was an interesting exercise.”

Faculty/Facilitators’ Training Method Feedback

“The exercise went well and I was quite surprised at how well my ‘lone’ counselor did! She is typically a quiet student so I was expecting that she would have a difficult time standing firm, but she did not. I think it would have been helpful if we had worked through one or two more cases and highlighted the ethical codes and moral principles more. I was disappointed that their arguments weren't very specific to the codes or principles but were more general. The exercise was very helpful in getting students to examine the multiple sides of an ethical dilemma and in getting them to really think through their own perspectives (based on the first ethical dilemma).”

“I thought the ethics debate experience was helpful in getting counseling students to ‘stand up for themselves even if the viewpoint is unpopular.’ However, based on my experience facilitating the ethics debate there are a couple of changes that I would implement next time: (1) I would remind or interject that student’s arguments need to be supported by one or more moral principles and for students to cite ethical standards from the code of ethics, if possible; (2) I would use less complicated ethical dilemmas in the first couple of rounds until counseling students were more familiar with the ethical debate process, moral principles, and ACA and/or ASCA Codes of Ethics; (3) I would remind all counseling students that regardless of position in the debate (lone vs. group) they are to build the best ethical argument even if it is not the ethical position that they would choose on their own.”

Discussion and Clinical Implications

Barriers/ Challenges – Potential Strategies

1. Inability to cite ethical standards by memory in ethical debate (potential solution – see ethical debate variations (#2).

2. Lack of familiarity with moral principles and how to use them to build an ethical argument (potential solution – see ethical debate variations (#2).

3. Inexperience participating in a debate process (fusing with contrary ethical viewpoint; potential solution – increase opportunities across the counseling curriculum to participate in ethical debate).

4. Counseling students that “freeze up” or want to prematurely “quit” in the debate process – emotional cutoff (potential solution – increase opportunities across the counseling curriculum to participate in ethical debate).

5. Lack of continuity or disjointed ethical argument on the group position of the ethical debate (potential solution – increase opportunities across the counseling curriculum to participate in ethical debate).

Variations on Ethical Debate

1. Permit all counselors-in-training in the ethical debate an opportunity to speak during each talking turn. Previously only one person on the group position (three people) could speak during the 2-minute talking turn. Therefore, each of the three counselors-in-training in the group position would talk consecutively for 2 minutes each (6 minutes total) and the counseling student in the lone position would have 6 minutes to respond during his/her talking turn. This would increase the anxiety level further in the lone position counselor-in-training because he/she would need to respond to more aspects of the group position’s ethical argument (presented by three people).

2. Facilitator could temporarily shorten talking turns by 1 minute if the counselors- in-training in either the group or lone positions do not present ethical arguments related to either one of the moral principles or cite an ethical standard from the ACA/ASCA Codes of Ethics.

3. For advanced counselors-in-training (those familiar with moral principles and ACA/ASCA Codes of Ethics), the small group ethical decision-making process could be omitted as the precursor to the ethics debate. Advanced counseling students could be presented an ethical dilemma case vignette “cold” and asked to argue one side of the ethical dilemma in the debate from either the group position (assigned position) or lone position (assigned position).

4. The ethical debate could be adapted to larger workshop groups whereby counselors could be subdivided into groups of five (lone position vs. group position with one participant as debate facilitator). Participants could then rotate roles.

5. The ethical debate could also be a one-on-one debate whereby a counselor-in- training debates a peer with superior ethical debating skills. This would be more efficient in giving more counselors-in-training an opportunity to be in the “lone position.”

Conclusion

Differentiation of self is a Bowenian Family Therapy core concept that reflects how an individual deals with anxiety or conflict. Those with higher levels of differentiation of self are able to resist the urge to be emotionally reactive when presented with internal and/or external sources of anxiety. Thus, ethical dilemmas can be sources of internal anxiety, and consulting with other counselors can present a source of external anxiety. Counselors dealing with ethical dilemmas need to avoid acting in an emotionally reactive way that results in emotional cutoff (distancing from colleagues that you disagree with) or fusion (giving up your strongly held viewpoints on the ethical dilemma for the sake of the relationship—results in loss of individual identity over time). The “ethical debate” is a counselor training method that has the potential to develop higher levels of differentiation of self in counselors-in-training as well as practicing counselors by encouraging them to advocate for their ethical positions in ethical dilemmas, even if they do not share the consensus viewpoint.