Issue One: Breaching Confidentiality in Counseling Minors
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Before we move into the topic, we want to explore the issue of confidentiality in counseling. This is applicable to not just minors but also all age groups, religions, cultures and genders. Remley (1985) stated that confidentiality is an ethical standard that is a rule of practice set forth by a profession. The American Counseling Association’s (ACA) Code of Ethics and Standards of Practice require that counselors respect their clients’ right to privacy and avoid illegal and unwarranted disclosures of confidential information. The ACA code lists the exceptions to confidentiality as when disclosure is required to prevent clear and imminent danger to the client or others or when legal requirements demand that confidential information be revealed. When counseling clients who are minors or individuals who are unable to give voluntary, informed consent, parents or guardians may be included in the counseling process as appropriate. Counselors act in the best interest of clients and take measures to safeguard confidentiality.
Confidentiality should exist for the benefit of the client be it whether the client is a minor or not. Should parents or guardians be involved in the counseling process, the counselor must act with exceedingly professional expertise when disclosing confidential information. There is an ethical responsibility to obtain the minor’s permission before releasing information. For counseling to be effective and to provide an environment in which the client feels free to share concerns, the counselor must be able to assure minor clients that personal information will be kept confidential to build trust between them.
There are vacillating priorities between the rights of the child, school policy, guardians’ rights, and dictates of laws and ethical codes (Glosoff & Pate, 2002; Lawrence & Kirpius, 2000). There is a tenuous balancing act among the parents who desire autonomy in raising their children, the governmental agencies safeguarding public welfare, and the minor who deserves both privacy and protection. The ACA Code of Ethics (1995) highlights the needs for the counselor to clarify client relationships in families to directly address any possible conflicts, and to promote flexibility in the decision to involve a guardian in the counseling process as long as confidentiality and the client’s best interests are safeguarded. Recognition of the need for a thorough understanding of ethical and legal requirements also applies to the issue of duty to warn. A counselor with a flexible orientation toward confidentiality will usually make an independent decision based on merits of each separate case that promotes the moral principle of fidelity in which the child’s trust is protected by keeping the promises inherent in confidentiality issues (Glosoff & Pate, 2002). An evaluation of what is in the child’s best interest will predominate, which underscores the moral principles of beneficence. This is seen as an ambiguous process that is influenced by the counselor’s cultural background and personal values and biases.
Conversely, no guarantee of confidentiality erodes the foundation of trust in therapy, leading to increased client resistance and premature termination. In this situation, from the outset an adolescent will be reluctant to enter a counseling relationship with a professional who apparently views the referring agency, court, school, or guardian as the real client rather than the teen. An attitude of flexibility toward confidentiality offers the ability to be adaptable to various situations, but throws the counselor into the nebulous area of trying to negotiate the balance of ethical and legal dictates. A more moderate stance embraces the advice of the ACA Code of Ethics regarding clarification of counseling relationships and can draw the adolescent into the decision-making process, which strengthens therapeutic rapport. Similarly, a counselor asking the child’s permission before disclosure gives the minor a sense of control and helps diminish damage to trust when sharing information is necessary.
In the course of work when working with minors, I sometimes can be unclear about my ethical obligations concerning confidentiality, especially with adolescents. When they mention activities such as shoplifting, alcoholism, drug experimentation and the most tricky case of sexual habits, it becomes a difficult issue. The question of confidentiality in ethics come into question and the counselor, or myself in this case, will struggle with building trust with the client and involving the parents in the counseling process. Let’s consider a case study.
Joseph’s parents divorced when he was 5 and he has been living with his mother since. His mother used to attend therapy with him when she noticed he was very withdrawn and didn’t communicate very much since the incident. The therapy went on for a year. Now at age 16, he has been sent to his counselor after his form teacher has noticed his constant late coming to school and also looking listless and distracted during lessons. His grades have also taken a sharp dip. His close friend, Kenneth, tells the teacher that Joseph has been attending all-night parties and has started to experiment with drugs and alcohol. Joseph doesn’t say much during the counselling sessions except mentioning that he has got a girlfriend now, who is 7 years his senior, and wants to move in with her. They met at a party and got sexually involved with each other and he now feels responsible for taking care of her. He insists the relationship is built out of love and that his parents should not hear or have a say in any of this.
His counsellor has shared her concerns with Joseph and is struggling with whether she has an obligation to disclose anything to his parents. It would be helpful to consider this case from three perspectives: that of law, clinical practice and ethics. The law generally states that minors cannot consent to treatment and a parent or guardian will consent on the minor’s behalf. The parent who consents on the minor’s behalf generally has the right to know the content of the child’s treatment until the minor reaches the legal age of (usually) 18. From a clinical perspective, the situation is more complex. An important aspect of treatment is to foster an individual’s autonomy, and a great pleasure of treating adolescents is to watch as they come to enjoy their growing independence. One aspect of independence is privacy. As a child grows into adolescence and adulthood, the surrounding zone of privacy should increase, thus making room for a more defined sense of self and a greater sense of autonomy.
A paradox thus arises: Good clinical treatment may require what the law generally refuses, that is, a zone of privacy. I feel that early in the relationship the counselor should make clear what relationship she will have to each of the parties (the minor and the parents/guardians). It should be accompanied by an explanation of how information-sharing will work, what information will be shared, with whom and when, in a manner appropriate to the minor’s age and understanding. As the child develops and grows up, the structure of the therapy may change for clinical reasons and this will have ethical implications. The minor’s greater sense of self and enhanced capacity for autonomy may require greater respect for the child’s need for privacy. The counselor will thus need to revisit earlier discussions and explain that, for clinical reasons, the structure of the therapy should change. Such boundary renegotiation is clinically and ethically indicated. However, a counselor cannot promise a minor that information will be kept from a parent who has legal custody. A parent with the legal right to treatment information may choose, however counterproductive in the counselor’s eyes, to exercise that right. Clinical judgement will also be able to indicate to what extent maintaining an adolescent’s privacy is central to the treatment. A counselor may conclude that an adolescent’s wish not to have information shared reflects an appropriate separation and so should be honored or he may also conclude that sharing certain information would be helpful.
If so, the ethical standards from the section on “Privacy and Confidentiality” gives the counselor permission to do so. Nonetheless, regardless of whether an adolescent assents to have information disclosed to a parent, it makes both clinical and ethical sense to tell the adolescent beforehand, what information will be shared, and when. Ideally, the adolescent would be part of such conversations. There may also be times when a counselor will be mandated to disclose information. Serious threats of harm, neglect and abuse falls under mandatory reporting laws and must be disclosed in many states. Adolescents should be told that serious threats of harm to self or others will also not be kept confidential. A counselor may feel strongly that revealing information to a parent could harm the minor or be destructive to the treatment. Refusal to disclose in such a case, even in the face of a parent’s request, may be legally supportable. A counselor in this position should seek both legal counsel and consultation from colleagues. Joseph’s therapist revisited the issue of confidentiality when Joseph expressed a wish that she not speak with his mother.
A compromise was reached whereby the therapist would speak to Joseph’s mother only with Joseph present. The issue of confidentiality became more complicated when the therapist felt that certain information should be shared and Joseph refused. The therapist should gently explore with Joseph the reasons behind this refusal. During some sessions, the therapist should be direct with Joseph about her discomfort with his behavior, especially the illegal activities, and point out the kinds of risks he was taking. Hopefully, over time, they would agree that Joseph himself would begin to speak to his mother about these issues, and that the therapist could follow up with a phone call. It is important to discuss each and every contact between the therapist and mother thoroughly with Michael, as well as to support his independent use of psychotherapy. Issue Two: Transcultural Issues in Counseling
As a counselor, we will be working with clients from various cultures. In order to work effectively with culturally diverse individuals and groups, it is important to know what culture means in people’s lives and to recognise differences that might be culturally-based. The idea of culture is interesting and important, but can be very hard to define and understand. Culture is a set of meanings that provides a sort of blueprint for how we should think, feel, and behave in order to be a part of a group. It includes patterns of traditions, beliefs, values, expectations, and symbols; in fact, every aspect of who we are that isn’t biological in origin. Often people are part of more than one culture; for example, we may belong to a professional group, a religious group, and social groups each of which has its own way of speaking, dressing, and behaving. Often we don’t recognise aspects of our culture until we encounter cultural ideas or practices that are different from ours. Knowing our own culture is an important aspect of self-awareness, however, because we need to be able to recognise culturally-based differences.
Some cultural differences that affect counselling relationships include communication styles, for example the way words and phrases are used, the degree of importance given to non-verbal communication, and the appropriate degree of assertiveness in communicating. Different attitudes toward conflict, for example whether conflict is positive or should be avoided, whether conflict should be resolved in face-to-face meetings. Different approaches to completing tasks, for example whether or not it is important to build a relationship with another person in order to work with him or her on completing a task. Different styles of decision-making, for example majority rule or consensus. Different attitudes about open emotion and personal matters. Different approaches to knowing, for example through symbolic imagery and rhythm, library research, visiting people who have had similar challenges. As a counsellor, we will be working with children and families from various cultural backgrounds.
One of the most important things to remember is not to assume that another person has the same values, beliefs, and practices that you do. We have to use our observation, listening, and questioning skills to learn what is important to the other person and how they see the world. We need to be open to learning about other ways of seeing and living in the world.
Counselors need to be aware of their own ethnicity and how it influences their interactions with other cultural groups. Problems need to be understood within the context of the person’s ethnicity. We learn from our culture, appropriate ways of responding to illness. For example, one group of people may tend to complain about their physical problems, while another may deny having any pain and see it as a form of punishment. Attitudes towards seeking help also vary from one ethnic group to another. It is important to clearly spell out the tasks of the first session to all family members and explain in detail the client-counselor relationship. The expectations the family may have about the encounter might be based on its experience with the medical profession. The family may expect the counselor to take charge and provide advice. By being direct, active and using a structured approach, the counselor establishes rapport with the family. The ethnic group may perceive the family as the primary source of support for its members. If this is the case, the family may be experiencing shame and guilt for not being able to solve its own problems. For example, an individual may turn to the family for support and seek our outsiders for support as a last resort. In some cultures, it is not acceptable to express personal concerns with a stranger; therefore, the clients adopt the counselor into their family. There may be fears and embarrassment about not being able to speak the language of the dominant culture well enough to express difficulties. As a result the counselor may view the client as passive and resistant.
Culture influences the family’s orientation toward being internally or externally controlled. An internally oriented family has the belief that their achievements, or lack of achievements, are determined by their own actions, thus shaping their destiny. On the other hand, an externally oriented family has the belief that achievements and non achievements occur independently of their actions and that the future is predicated on chance. An externally oriented family may be interpreted by an internally focused counselor as procrastinators. Another important dimension when working with the people who are from cultures different than our own is the locus of responsibility. Locus of responsibility assesses the amount of responsibility or blame given to the client or the clients system. Determining if the individual or the system is the cause of the behavior is important when making an assessment and determining interventions. In Canadian culture often the individual is seen as being responsible for his/her actions. Racial and ethnic minorities whose behaviors deviate from the middle class are labeled as deviant.
Be aware of ethno cultural roles and hierarchy. If the father is considered the authority figure, make sure you address him, first showing respect for his cultural positions. In attempting to seek information from the children, it is important to acquire permission before proceeding with the interview. Inquire about issues that may be specific to a particular ethnic group. Family members are often delighted to teach counselors about the key “insults” of their cultural group. If you experience resistance, check to see if you have violated a culture norm. We need to take note when the counselor becomes overly concerned about the family’s ethnicity to the point where one loses perspective as to their reason for seeking help.
A major assumption for culturally sensitive counseling is that counselors can acknowledge their own tendencies and the limit of their cultures on other people. Thus, it is essential for counselors to understand their cultures and their worldviews before helping and assisting other people. According to Padilla, Boxley, and Wagner (1973), there is increasing evidence that the trained counselor is not prepared to deal with individuals who are culturally different from them. Cultural sensitivity remains as one of the important characteristics of effective counseling. Padilla et al’s writing also shows that one of the characteristics of an effective counselor is the ability to recognize diversity and cultural differences. It is undeniable that the need to attend multicultural diversity of clients is more obvious when counselors and clients have different cultural backgrounds.
Culture is the core of internal ways in which human beings develop their sense of self, including values, beliefs, thought patterns, perceptions, and worldviews. All these qualities help determine and shape one’s external culture – the ways in which one establishes and maintains a relationship with the environment and others through implicit norms, language, traditions, rituals, and loyalties that influence attitudes, behaviors, and customs (Gushue, 1993). While it is true that Singapore is a mix of different ethnic groups, each group has retained much of its individual unique cultural character. This is because Singapore’s policy has always been geared towards multiculturalism, where every ethnic group is allowed to preserve its own culture while peacefully interacting with others. In the light of this, counselling and intervention is always presented within the cultural context and constraints inherent in our cosmopolitan society. The understanding of a client’s unique culture is necessary in order for a counsellor to effectively help the former behave and feel differently in a trusting relationship so as to achieve their goals. Psychological judgments are never free from the influence of therapist’s own cultural values. In intervention, counsellors need to be knowledgeable of the culture of their clients because each culture holds different ideas about what constitutes problems in living.
As we have grown up in a cosmopolitan environment, we are immersed in various orientations of different ethnic groups. Our awareness of our own culture only increases when we go to places where our culture is not the norm. Similarly in a counselling room, when we are with our client from a different culture, our awareness of our own culture tends to increase too. We are aware too of the diversity existing within the same culture as people may communicate and interact in a whole range of ways. Our worldviews as ethnic majority are highly correlated with cultural upbringing and life experiences. There is a tendency to take for granted that the ethnic minority has full knowledge of our culture since it is pervasive in the society. On the other hand, some of us harbor tinted views of the ethnic minority that cause us to unwittingly impose upon them stereotypes and preconceived notions. In my opinion, sensitivity includes respect and acceptance of who they are, the way they are and their beliefs.
People of the minority race should be treated fairly and equally. There isn’t a need to treat them with sympathy; otherwise, it would only remind them that they are being differentiated. I learned from my Indian and Malay friends at school about their feelings as minority races in Singapore and that they prefer to be seen as equals. To be more effective counsellors, we have to first examine ourselves or be aware of our personal values, beliefs, prejudices and motives for helping people. For instance, my own cultural beliefs that men should be stronger and be able to take on the world and solve their problems rationally and efficiently make me more sympathetic toward my female clients. The curiosity to explore the deeper meaning of our own cultural behavior will certainly enlighten and make us more sensitive to the differences or similarities existing in different cultural groups. A wise counsellor would always try to transcend such barriers and enter into the frame of reference of his client and operate from there.
The clients we see include students from as young as 6 years old, elderly patients at Nursing Homes/hospital. We also have couples with marital, family and financial issues. Their age group ranges from early 20s to the 70s. They are a mix of Singaporean Chinese, Malay, Indian and some immigrants. Our clients are mainly from low to average income group with basic education. English and Mandarin are the main languages used. Dialects are used when counselling the elderly folks.
Each member in the group shared both common and unique cultural issues they face in counselling. The sexism issue Annie regularly encounters involves female victims of domestic violence in Indian family whose men predominate in positions of power. Most oppressed Indian women inevitably choose not to react for fear of being ostracized by their own family and community. According to Yeo (1989), Asian derives their identity from membership in a family and a community and focusing on the individual might well alienate the person from the family.
Peter and Juliet shared about the common gender issue where parents think they must stay with sons only, while conflicts with daughters-in-law are common issues too. Some parents choose to stay on their own to avoid humiliating their sons. Medical and emotional problems may result from loneliness, poor self care and diet.
Jennifer related her early experience:
I’ve encountered difficulties on many occasions with clients of a different race, particularly Malay clients, in dealing with issues on pregnancy crisis. My early impression was that they were either not willing to share nor receptive to explore other options and alternatives pertaining to their decision to terminate their pregnancy. The session became more fruitful only after I acquired greater understanding of the Malay culture.
For Magdalene, while she is competent in conversational skills with some dialects, attempting to apply counselling techniques or skills present a real challenge. Majority of the counselling approaches are western in origin. The concepts and explanation are all in English. It is easy to miss the deeper nuances when she attempts to apply or translate them into dialect or language which she is not fully competent in.
Both Magdalene and Ruth observed that it is culturally the norm of the older generation to attribute crisis to some external causes and to seek help from temple mediums. The words of the mediums will then be accepted as truth. It can be a real challenge to counsellors from a different faith.
Ruth, the youngest member in our group, perceives age as a stumbling block to effective counselling when her clients are much older. In the Asian context, age is a sign of maturity and wisdom. With elderly clients, we are expected to show respect and humility, not as someone to solve their problems.
Annie faced the social-economic issue when she encountered Singaporean men who resorted to increase their socio-economic status by taking wives from the poorer ASEAN countries. The wives function more as domestic helpers or
care providers to the elderly/invalid parents or young nephews and nieces within the extended family. The relationship is further strained by language barrier and other cultural issues.
Western Counselling Models in Singaporean Context
The group is pragmatic in our counselling approach, integrating different therapy models to meet the client’s unique needs. With cross-cultural interaction comes the possibility that the client’s intentions and actions may be misperceived, misinterpreted, and misjudged notably, when we employ the western counselling models on culturally different clients. We are aware that some of these models may not even fit people from western cultures due to within-culture diversity and other diversity factors beyond culture. (Egan, 2005)
The second theme that emerged was the need to understand the worldview of culturally different clients in order to know how best to integrate the western counselling models in our counselling work.
Magdalene commented that the concept of individuation in Bowen Theory is culturally not in tandem with many elderly Chinese clients, who come from an environment where the family, community, or clan takes precedent over self; hence differentiation of self can be alien to them.
A person’s identity is formed and continually influenced by his or her context. Working effectively with clients requires an understanding of how the individual is embedded in the family, which in turn requires an understanding of how the family is affected by its place in a pluralistic culture. (Sue, Ivey & Pedersen, 1996).
Bowen Theory encourages the therapist to look into the Family of Origin to examine the interlocking relationships. This can present itself negatively as in-laws or family members may not be forthcoming when it comes to talking about sensitive and conflicting issues inflicting the family. Juliet presumed Bowen Theory will be better understood and accepted by the English-educated clients, but she found out to her dismay that some concepts contradict their cultural beliefs.
Peter found Rational-Emotive Behavioral Therapy (REBT) to be too confrontational in style. Telling a client that he is “horriblising” and “catastrophising” his life issues when he is seeking understanding from a counsellor in his moments of anxiety is not going to be welcomed. Asians generally seek familial help when they have problems. The concept of going to a counsellor who is a stranger is already a major deviation from their social norms. Facing a challenging counsellor may pose as a humiliating experience for some.
Solution-focused Brief Therapy (SFBT) focuses on what clients want to achieve through therapy rather than on the problem(s) that made them seek help. The approach does not focus on the past, but on the present and future instead. This goes down well with the clients she sees who are pragmatic and time-conscious.
However, Magdalene observed that asking the miracle question to a pragmatic elderly client may pose a challenge. Some of them have mindsets that have been deeply entrenched in their being; they do not see the need to change. Similarly, to challenge the Irrational Beliefs (Cognitive Behavioral Therapy) of the elderly whose sense of self has been conditioned to adopt a resigned disposition can be an uphill task.
The use of `hot-seat’ fantasy technique to help clients express their feelings where there is unfinished business may not be favored by the more ‘conservative and traditional’ clients as unleashing negative emotions towards the deceased is considered a taboo.
Magdalene related her encounter:
Using Gestalt approach, I encouraged him to imagine that the mother was present at the moment, and for him to tell her what was on his mind. He responded, ‘she is already dead, what is there to say?’ I realized later
that while he might be bad mouthing and blaming her for his current plight, it was culturally not appropriate for him to confront her.
Ruth felt incompetent when she encountered elderly people who often interrupted her during conversation to correct her. Her age and lack of knowledge in dialects made it difficult for her to express herself aptly. But she found Carl Roger’s Person-Centered therapy useful when working with clients who question her abilities.
The challenges we face as counsellors in a multicultural environment require that we know and understand the client’s culture so as to be congruent with the frame of the world that the client is in during counselling, i.e., individuals are best understood by taking into consideration salient cultural and environmental variables. Regardless of the therapist’s orientation, it is crucial to listen to the clients and determine why they are seeking help and how best to deliver the help that is appropriate for them. (Corey, 1996) In this pluralistic and post-modern age, no one helping approach has all the answers for the clients we see due to the complexity of human beings, as expressed by Sue, Ivey and Pedersen (1996).
The third theme that emerged was the need for therapists to create therapeutic strategies that are congruent with the range of values and behaviours that are characteristic of a pluralistic society.
Jennifer had this to say:
Without a deeper understanding of the Malay culture and religion, my counselling sessions with the Malays would certainly be unfruitful. There are family and social pressure to learn within the context of religion and culture. The Malay clients who are pregnant out of wedlock find themselves opting for abortion as the only way to avoid violating family tradition. I have to work on interventions that are congruent with the values of the clients.
It is a sign of respect that counsellor refrains from deciding what behaviour should be changed. Through skilful questioning on the counsellor’s part, ethnic minority clients can be helped.
The process of internalizing a new culture is an on-going undertaking. Generally the group is willing to be exposed to all kinds of clients so as to open up our own world views of the different cultures in our society. This includes interacting with people of different races at social events and festive celebrations. We recognized that with the culturally-constraint client we have to go slow during the first counselling session. The clients can be invited to teach the therapists about the significant parts of their cultural identity.
We all acknowledged the importance of supervision and guidance when we are unsure and need clarification. We also will be seen as more professional if we master the basic terminologies of counselling approaches in other languages/dialects.
Having an enquiring and inquisitive mind about the different cultures will help broaden our perspectives. Formal education on the multicultural aspects of counselling will help to hone our skills. We can also gain insights by reading articles and books related to multicultural counselling. There are hefty handbooks offering the theoretical background, practical knowledge, and training strategies needed to achieve multicultural competence. (Pope-Davis, Coleman, Liu, & Toporek, 2004). In addition, there are highly detailed research studies offering further insights in multicultural competence. (Darcy, Lee, & Tracey, 2004). The greater our depth and breadth of knowledge of culturally diverse groups, the more we can be effective practitioners (Corey, 2001).
In summary, the qualitative inquiry has promoted self-awareness of our own personal culture as we develop a sense of the world. Courage, openness and humility are some important elements we identified to secure trust and
acceptance by our clients of different cultures. Our group will certainly strive to integrate appropriate counselling approaches to create therapeutic strategies that are congruent with the client’s range of values and behaviours, without abdicating our own deepest beliefs and values.