See attached.
129
CHAPTER 6
Conflict: The Reality
of “Being Ethical” Within
the Real World
Ms. Wicks: Hi, Tom it is me again.
Mr. Harolds: Hey, how are you? Did you get that information from the
state association?
Ms. Wicks: Not yet. They are supposed to call me. But, things are getting
more confusing . . .
Mr. Harolds: Really?
Ms. Wicks: Ms. Armstrong, the principal at the school, informed
me that it is understood in the district that we are not to counsel
students regarding sexual issues. She said it is not a formal policy, just
something that “we” all know not to do. So, I’m not sure if I broke a
law or violated a code of ethics or may have stepped over the line in
terms of my job definition. I am so confused!
When working with a client, a helper needs to be aware of and
sensitive to the many individual issues and concerns presented
by the client. In addition, the helper also needs to be fully cog-
nizant of the ethical and legal implications of his or her own professional
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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130–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
decisions in relationship to these client concerns. Now, to complicate mat-
ters even more for those practitioners working within an organization or a
system, be it a school, a hospital, an agency, or a company, individual prac-
tice decisions must also reflect and be congruent with policies, procedures,
and informal standards and values operating within that system.
The current chapter looks at the ethical culture of social systems and
the influence it exerts on the practice decisions of those helpers working
within that system. The chapter will discuss the impact of working for and
within an organization. Further, in this chapter we will look at situations in
which conflicts arise when what the professionals feel is best for the indi-
vidual client falls outside of or even runs contrary to policies, procedures,
or values of the organization. Under these conditions, what’s a practitioner
to do?
● OBJECTIVES
The chapter will review the process and implications of making ethical
practice decisions within an organizational or system context. Attempting
to balance the needs of the individual client with the requirements of the
employing organization and other interested parties (e.g., managed care
organizations) is not an easy or clear-cut process. After reading this chapter
you should be able to do the following:
• Define what is meant by “system culture.”
• Discuss the impact of system culture on ethical decision-making.
• Identify possible points of ethical conflict when working in a man-
aged care environment.
• Identify possible points of ethical conflict when working with third-
party payees.
● SERVING THE INDIVIDUAL WITHIN A SYSTEM
Professional practice does not occur within a vacuum. At a minimum, pro-
fessional practice occurs within the social context of a client and a helper.
But for those working within an organization, professional practice and
ethical decision-making occurs not only within this dyadic system but also
within the context of the larger system or organization in which the helper
works. Ethical problems in professional practice are often the result of the
confluence of context, setting, and standards of practice. Practitioners who
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Chapter 6. Conflict–●–131
work in schools, clinics, or hospitals, and/or those who serve as providers
for managed care can find themselves in conflict with these competing cli-
ent systems (see Case Illustration 6.1).
Case Illustration 6.1
A Diagnostic Dilemma
Linda Alfreds is a new school psychologist, the first ever employed
by the Hallstead School District. Linda’s job involves performing all
psycho-educational assessments, especially those required for special
education placement. Linda was informed, however, that with the excep-
tion of a few “slower” children, the district really didn’t have children
with special needs, which according to the superintendent was a blessing,
since they have very limited monies for providing such services.
Linda was asked to see Marquis, a transfer student, who was
reported as having difficulty keeping up with the work in a number of
his classes. The test data presented Marquis as an impulsive child, with
a significant receptive language problem. From her work at a previous
school district, Linda knew that Marquis would benefit from placement
in a resource room with a special education teacher trained in learning
disabilities and language disorders.
Linda discussed the situation with her department chairperson and
was told that the district did not have resource room personnel. However,
the other middle school in the district did provide a classroom for “slow
learners.” The chairperson directed Linda to record Marquis as being
retarded rather than as having a language disability, since this would at
least get him some special services. It was clear to Linda that the data
would not support this diagnosis, but identifying the child with a language
disability might fail to provide any special teaming assistance to Marquis.
Certainly the school psychologist presented in Case Illustration 6.1 is
confronted with a serious ethical and potentially legal dilemma. As in this
case, practice decisions must clearly reflect not only the needs of the client
as well as the characteristics and orientation of the helper but also the
unique characteristics and demands of the context or organization in which
the helping occurs. Balancing all of these unique needs is not always easy or
clear-cut. The ethical practitioner needs to be aware of the system and the
subtle and often times not so subtle influences that a system can exert. Such
an awareness begins with an understanding of the nature of systems.
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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132–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
As used here, a system is “an entity made up of interconnected parts
with recognizable relationships that are systematically arranged to serve a per-
ceived purpose” (Kurpius, 1985, p. 369). As one of the interconnected parts
within a work setting, the human service provider needs to fully understand
the roles enacted, the relationship that exist, the values and assumptions that
support these relationships, and the degree to which all of these exert pres-
sure on the performance of one’s duties. One cannot be an ethical-effective
provider of service without full awareness of the system and system dynamics
in which he works
It is not unexpected that when working in a system with multiple con-
stituents that conflict in performance of one’s duties may emerge. This may
occur in a situation of a school counselor who feels that what is best for the
student may be contrary to the policy or procedures of the school, for whom
they work. Or it is possible that one working in an employee assistance pro-
gram (EAP) might experience the pressure of a divided loyalty. When under
contract to provide employees services, one might feel a strain between
the desire to maintain employee confidentiality while understanding that
the contract exists with the employee’s place of business, and there may be
a legitimate need to know on the part of that employee’s manager. Under
these conditions, information regarding the client’s treatment as related to
job performance may be within the need to know and thus conflicts with the
client’s right of privacy and confidentiality. The practitioner, while respect-
ing the confidentiality of the information gathered, needs to be sensitive to
the obligations agreed to in contracts with the organization. The EAP coun-
selor described in Case Illustration 6.2 appears to have developed a plan for
balancing the needs of the organization with the rights of the client.
Case Illustration 6.2
Balancing the Needs of the System and the Client:
A Case of Confidentiality
Hanna Johannsen was a private practicing mental health counselor
who was certified as an EAP counselor. In addition to seeing clients for
a fee, Hanna provided EAP services to the members of a local school
district. In this EAP capacity, Hanna received a contracted fee and was
to provide three to five sessions free of charge to any school district
employee who desired such counseling. In addition, should additional
counseling be desired or required, Hanna would make a referral to
another provider, and the employee would then be responsible to con-
tinue on a fee-for-service basis.
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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ETHICAL CULTURE OF SOCIAL SYSTEMS ●
As part of the contract with the school superintendent, the EAP
counselor was to provide monthly reports that included (a) the number
of people seen, (b) the specific school in which the employee worked,
(c) the job class (i.e., teacher, administrator, staff, etc.), (d) the type of
problem presented, (e) the number of sessions utilized, and (f) and
evaluation of the outcome. While the specific names of clients and any
details of the nature of the problem presented were not to be disclosed,
Hanna felt that the information requested was such that it could
jeopardize the confidentiality of those who utilized this EAP service.
Hanna worked out a compromise with school administration so
that all first sessions could be made completely confidential. In that
first session, as part of setting the boundaries of confidentiality, Hanna
explained to each client the types of data she would reveal to the
superintendent and asked the client for their informed consent before
making additional appointments. If the client would not give that
consent, Hanna would provide a referral list and share no information
about the contact with the central office.
Organizations—or for that matter, any social system (e.g., families)—develop
their own values or standards that guide decision-making and practice within
that system. These values, which may take form explicitly in an organization’s
value statement or implicitly as behavior guiding day-to-day decisions, serve as
a core to what has been described as systems culture (Schein, 2010). Schein
described system culture as a “pattern of shared basic assumptions that the
group learned as it solved its problems of external adaptation and internal inte-
gration, that has worked well enough to be considered valid and, therefore,
to be taught to new members as the correct way you perceive, think, and feel
in relation to those problems” (Schein, 2010, p. 18). The assumptions that
serve as the base for the development and maintenance of a system’s culture
form the unquestioned, non-debatable truths and reality of people within the
system. These develop when a solution or procedure works repeatedly. As a
result, those involved begin to take it for granted to the point where what was
once only a hunch or possibility starts to get viewed and treated as a reality.
These basic assumptions then serve as the foundation from which the system
defines structures and processes to guide its operations. This is an important
concept for the ethical practitioner to grasp, because when members of an
organization embrace these assumptions, they in turn shape what the mem-
bers value and the form these values take (see Exercise 6.1).
Chapter 6. Conflict–●–133
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134–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
The cultural values of a system become enacted in the way mem-
bers prioritize and function-shaping policies, decision-making, and other
operations. Practice decisions, therefore, may begin to reflect institutional
values and organizational ethics more than they represent “best practice”
or codes of professional conduct. While it is possible that organizational
ethics can parallel those of the profession, in view of the fact that the
purpose of an organization may be different than the purpose of any one
helping relationship, the organizational ethics may not only be conflictual
but may act to undermine the values and ethics of the practitioner (see
Exercise 6.2).
While it is clear that the ethical practitioner must be aware of the often-
times subtle influence of a system’s culture on his or her practice decision,
Exercise 6.1
Making Culturally Compatible Choices
Directions: Below is a table that provides a social context, a focus for
a practitioner, and two practice decision options. Along with a col-
league, select the options that you feel would most likely be encour-
aged and/or supported by that particular social context and provide
your rationale for your selection.
Social-
Organizational
Cultural
Context
Focus for
Practice
Decision
Practice
Decision
Options
Selection
and
Rationale
(sample)
Catholic High
School
Increased evi-
dence of stu-
dent
pregnancy
1. Guidance
unit on sex-
ual behavior,
safe sex,
and sexually
transmitted
diseases
2. Guidance
unit on self-
esteem and
value of
abstinence
Option 2,
given the
school’s
belief that
sex outside
of marriage
is unaccept-
able and
immoral
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Social-
Organizational
Cultural
Context
Focus for
Practice
Decision
Practice
Decision
Options
Selection
and
Rationale
A free-standing
clinic that is
funded primar-
ily through
managed care
contracts
A client diag-
nosed as
depressed, with
the possibility
of having an
early history of
sexual abuse
1. Referral for
anti-depres-
sant medica-
tion
2. Contract for
long term,
“recovered
memories’’
therapy
A military
industrial com-
plex, making
“sensitive’’
technical
equipment
A personnel
director who is
approached by
an upper level
manager experi-
encing extreme
financial pres-
sures and who
has had fantasies
of “selling tech-
nology” to other
governments
1. Respect the
confidential-
ity of the rela-
tionship and
work with the
employee on
stress reduc-
tion
2. Report the
fantasies to
his supervisor
A public
school, with
limited spe-
cial education
facilities and
funding
A school psy-
chologist who
believes a
student is in
serious need of
ongoing indi-
vidual psycho-
therapy
1. Recommend
therapy to
his family
as part of an
Individual
Education
Program
2. Suggest that
his family
may find it
useful to con-
tact an out-
side therapist
Chapter 6. Conflict–●–135
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136–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
Exercise 6.2
Goals: Values and Decisions
Directions: As noted within the chapter, decisions are made that not only reflect the values
held, but the goals desired. Below you will find a scenario, system and practitioner goals,
and decision options. Your task is to identify the decisions preferred by the system along
with those preferred by the practitioner. Next identify the situations in which these are
parallel or in conflict.
Scenario
System
Goals
Practitioner
Goal
Decision
Preferred
by System
Decision
Preferred by
Practitioner
Parallel or
Conflict
1. (sample) Star
football player
has a very bad
sprained ankle.
Win
the big
game
Rest the
ankle
Allow the
student to
play
Sideline the
student for
one game
Conflict
2. The top
salesman for a
corporation has
embraced his
alcoholism and
is committed
to a treatment
program.
Maintain
sales
Maintain
salesman’s
health
Adjust
sales region
to allow
salesman
to attend
meetings
while
continuing
sales
Encourage
and support
in attending
meetings
3. A social worker
noted that a fifth
grade teacher
who is approach-
ing retirement
has a number of
physical prob-
lems, has been
falling asleep in
class, and often
verbally abuses
the children for
making noise.
Educate
children
in fulfil-
ment
of the
schools
mission
Protect
children
from
verbal
abuse and
show
concern for
an aging
teacher
with ill
health
Try not to
make too
public for
the remain-
der of the
semester
and then
provide
the teacher
with an
early retire-
ment pack-
age
Work with
the teacher
in develop-
ing some
cooperative
learning
units while
providing
supportive
counseling
around the
benefits of
retirement
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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Scenario
System
Goals
Practitioner
Goal
Decision
Preferred by
System
Decision
Preferred by
Practitioner
Parallel or
Conflict
4. A residential
setting for
individuals
with severe
emotional
problems
To
provide
therapy
while at
the same
time
reducing
patient
disruption
To provide
therapy
geared at
empower-
ing individ-
uals to take
responsi-
bility for
their own
actions
Reliance on
medication
including
sedatives
Using the
minimum
amount of
medication
in order
to support
the client’s
development
of cognitive/
behavioral
methods of
control
the question remains: “If enculturated, how does one identify the operating
assumptions, values, and culture?” It has been suggested that the use of inter-
pretation of the artifacts and values reveals basic assumptions (Schein, 2010).
Artifacts would include the visible, tangible, or concrete manifestations, be
they the physical surroundings and their appointments, the stories or oral
histories still shared, and even the rituals and ceremonies practiced, whereas
a system’s values are revealed in what the system views as important in terms
of goals, activities, relationships, and feelings (Schein, 2010)). By review-
ing the way those within the system traditionally and continually address
specific problems posed by the situations they face in common, the ethical
practitioner can begin to understand the system’s values.
WHO IS THE CLIENT? ●
One seminal question that needs to be addressed when working within an
organization is “Who is the client?” While this at first may appear to be a simple
question to answer, balancing a practitioner’s responsibility to the employing
organization while at the same time servicing the individual helper seeker is not
always that clear-cut or easy. The various professional organizations are aware
of this potential confusion and area of conflict and have attempted to provide
practitioners with guidelines for their practice decisions (see Table 6.1).
Chapter 6. Conflict–●–137
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138–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
Table 6.1 Ethics of Practice Serving Client and Organization
Professional Ethical
Standards Statement on Serving Client and Organization
American Counseling
Association (2014)
C.2.g. Counselors monitor themselves for signs of impairment
from their own physical, mental, or emotional problems and
refrain from offering or providing professional services when
impaired. They seek assistance for problems that reach the
level of professional impairment, and, if necessary, they limit,
suspend, or terminate their professional responsibilities until it is
determined that they may safely resume their work. Counselors
assist colleagues or supervisors in recognizing their own
professional impairment and provide consultation and assistance
when warranted with colleagues or supervisors showing signs of
impairment and intervene as appropriate to prevent imminent
harm to clients.
American
Psychological
Association (2010)
1.03. If the demands of an organization with which psychologists
are affiliated or for whom they are working are in conflict
with this Ethics Code, psychologists clarify the nature of the
conflict, make known their commitment to the Ethics Code, and
take reasonable steps to resolve the conflict with the General
Principles and Ethical Standards of the Ethics Code. Under no
circumstances may this standard be used to justify or defend
violating human rights.
National Association of
Social Workers (2008)
3.09.a. Social workers generally should adhere to commitments
made to employers and employing organizations.
3.09.b. Social workers should work to improve employing
agencies’ policies and procedures and the efficiency and
effectiveness of their services.
3.09.c. Social workers should take reasonable steps to ensure that
employers are aware of social workers’ ethical obligations as set
forth in the NASW Code of Ethics and of the implications of those
obligations for social work practice.
3.09.d. Social workers should not allow an employing
organization’s policies, procedures, regulations or administrative
orders to interfere with their ethical practice of social work.
Social workers should take reasonable steps to ensure that their
employing organizations’ practices are consistent with the NASW
Code of Ethics.
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Although the various professional organizations address the issue of
serving individuals and organizations, it is still for the individual practitioner
to resolve questions such as, does the ethical practitioner, when working
with individual members of an organization, make decisions that are best
suited for the goals and objectives of the institution, even if not in the best
interest of the individual care seeker? Or does the individual and the indi-
vidual’s well-being take primacy? (See Case Illustration 6.3.)
Case Illustration 6.3
Who Is the Client?
Col. R. J. Wipps was a clinical psychologist working in service of the
U.S. Army’s Special Service Division. Col. Wipps provided testing and
individual counseling to those involved with Special Services.
Col. Wipps was approached by D. L. Kingsley, an officer in
charge of a highly sensitive military project. D. L. came to Col. Wipps
because of what he reported to be extreme stress as a result of financial
difficulties that he was currently experiencing. D. L. noted that he was
concerned that his wife would leave him if something didn’t happen
soon to improve their lifestyle. When asked what he was attempting
to do to resolve the financial problems, D. L. was quick to note that
“nothing short of something illegal” could help. When confronted
directly about whether he had considered illegal activities, D. L. stated:
“Of course not . . . but I’ve been drinking a lot lately and God only
knows what I could do if I get drunk!”
Col. Wipps recommended that D. L. take a medical leave while he
went into a treatment program for the alcohol and also received some
individual and marital counseling. D. L. said he would think about it but
really did not feel that was necessary. D. L. asked if he would be able
to see Col. Wipps for some counseling during this really stressful time.
D. L. also wanted to be sure that the relationship would be confidential.
For Col. Wipps (see Case Illustration 6.3), questions existed about
whether individual confidentiality should be respected or whether this
individual posed a significant security risk and thus should be identified to
appropriate personnel. In part, the answer to this question rested on whom
Col. Wipps identified as his client, D. L. Kingsley or the U.S. Army. Most
guidelines, like that of the American Counseling Association (ACA) (see
Chapter 6. Conflict–●–139
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140–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
Table 6.1) indicate that the client is the primary concern for the ethical
helper and the institution secondary. But it could be argued that accepting
a position within an organization is a tacit agreement to serve as its agent
and to embrace its values and standards of practice. In fact, the ACA Code of
Ethics (2014) advised that acceptance of employment is essentially an agree-
ment with the principles and policies of the institution, and that “counselors
strive to reach agreement with employers regarding acceptable standards
of client care and professional conduct . . . ” (ACA, 2014, Principle D.1.g).
It would appear, therefore, that the ethical practitioner needs to be account-
able and responsive to both the system of employment and the individual
clients served within that system. As such, it is essential that the practitioner
not only understand but also commit to the mission of the organization as
well as the specific values underlying that mission and the ways it becomes
manifested in the procedures, policies, and decision-making processes. This
does not mean to suggest a blind allegiance to the organization at the cost of
the individual. In fact, it can be argued that the ethical helper will attempt to
change organizational policies and procedures that are not healthy for those
within the system. For example, the ACA Code of Ethics states: “Counselors
alert their employers of inappropriate policies and practices. They attempt
to effect changes in such policies through constructive action within the
organization. When such polices are potentially disruptive or damaging to
clients or may limit the effectiveness of services provided and change can-
not be affected, counselors take appropriate further action” (ACA, 2014,
D.l.h). In a similar vein the American Psychological Association (APA) directs
its members that “if the demands of an organization with which psycholo-
gists are affiliated or for whom they are working are in conflict with this
Ethics Code, psychologists clarify the nature of the conflict, make known
their commitment to the Ethics Code, and take reasonable steps to resolve
the conflict with the General Principles and Ethical Standards of the Ethics
Code. Under no circumstances may this standard be used to justify or defend
violating human rights” (APA, 2010). The significance of this responsibility
to confront organizational policies and practices that are deemed damag-
ing to clients or in some way forcing practitioner unethical behavior is high-
lighted by the ACA directive that if there is an irreconcilable conflict between
the institution’s practices and those standards established by the code, resig-
nation from employment should be considered (ACA, 2014, Principle D.1.h).
Thus, while some practitioners find themselves feeling responsible for
championing the client’s right to confidentiality in the face of the organi-
zation’s rules and regulations, in some situations, this is neither legal nor
ethical. For example, in the military, confidentiality is guided by federal
statutes, Department of Defense regulations, and the specific service (i.e.,
Army, Navy, Air Force) regulations, a point that needs to be considered
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by Col. Wipps (see Case Illustration 6.3). While supporting respect for
the privacy of the individuals, these directives also mandate access to
confidential materials by federal employees on a “need to know” basis
(Neuhauser, 2011).
An ethical practitioner attempts to resolve conflicts between organiza-
tional need and individual need in a way that not only reflects the desire
of the practitioner to be supportive of his or her organization but also
upholds the professional code of ethics. Thus, when confronted by the
desire to protect the care seeker’s privacy while abiding by the rules and reg-
ulations of the organization in which one is employed, the use of advanced
warning on the limits of confidentiality would be essential as a means of
serving both the organization of employment and the care seeker.
When There Are Multiple Masters
Ethical practitioners will not only know the mission, objectives, and val-
ues of the organizations within which they work, but will also make known
to their employers the nature of their own professional ethical commit-
ments. Beyond this, it appears that an ethical practitioner will also share with
his or her clients the obligations of fidelity and conditions of employment
and how these may flavor the helping relationships and the practitioner’s
decisions. This is especially important when an organization’s disclosure
policy places additional limits on the confidentiality between client and
helper (see Case Illustration 6.2).
Recently, the issue of multiple clients or conflicts between the needs of
an employing organization with those of the client has taken on a new dimen-
sion with the introduction of managed care. Managed care is a term applied
to a widespread set of attempts to contain health care costs. The term has
been used to describe “any type of intervention in the delivery and financing
of health care that is intended to eliminate unnecessary and inappropriate
care and to reduce costs” (Langwell, 1992, p. 22). Under managed care, third-
party payers review requests for the initial delivery of services, determine the
volume of services to be provided, and review any subsequent requests for
service. Given the level of involvement in the professional decision process,
it could be argued in managed care situations the practitioner has in fact two
clients, the primary client being the person seeking assistance and the second-
ary client being the managed care company. The potential for conflict can arise
in that the needs and goals of these two clients may not always be congruent.
Managed care is essentially an economic strategy designed to provide
care of or better quality for less money. While the concept of cost contain-
ment is noble, the reality is that the goals of managed care can be in conflict
Chapter 6. Conflict–●–141
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142–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
with those of the practitioner (Meyers, 1999). Metzl (2012), for example,
argues that managed care’s desire to create a homogenous cost effective
product or template for treatment planning, while perhaps working with
the administration of EKGs to patients with chest pain are not applicable
to the nonhomogenous client base presenting with depression, personality
disorders, or other form of mental health conditions.
Under these conditions, the question that can arise is, at what point
does the cost containment interfere with the client’s needs and the helper’s
ethical practice?
Managed care may challenge the practitioner’s ability to provide ethical
practice. Managed care stresses time-limited interventions, cost-effective treat-
ment, toward preventive rather than remedial processes (Metzl, 2012). Profes-
sional literature raises several concerns about the impact of managed care on
the effectiveness of treatment provided (Roberts & Hurley, 2012). As noted by
these authors (Roberts & Hurley, 2012), managed care could result in clients
receiving undertreatment, in that they may go underdiagnosed, experience
restricted referral, and have insufficient follow-up. Thus, the policies of man-
aged care may conflict with the practitioner, especially when utilization review
decisions are contrary to professional judgment or when short-term or limited
interventions are inadequate forms of treatments. Ethical rules and standards
are often incongruent with the realities of treatment situations. In a managed
care environment with restrictions to the number of sessions allowed, adher-
ing to professional guidelines for risk management and standard of care service
may simply be unrealistic.
In addition to potentially restricting treatment choice, the third party
review can also compromise client privacy. Given these potential areas of
conflict, what is the ethical practitioner to do?
At a minimum, the ethical practitioner needs to inform clients how their
delivery of services may be influenced by managed care policies and restric-
tions. Our professional codes have addressed this concern by directing
clinicians to provide clients information needed to understand the potential
conflict and the limits imposed on practice. For example, APA directs its
members as follows:
When psychologists agree to provide services to a person or entity
at the request of a third party, psychologists attempt to clarify at the
outset of the service the nature of the relationship with all individuals
or organizations involved. This clarification includes the role of the
psychologist (e.g., therapist, consultant, diagnostician, or expert wit-
ness), an identification of who is the client, the probable uses of the
services provided or the information obtained, and the fact that there
may be limits to confidentiality. (APA, 2010, Principle 3.07)
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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A point echoed in the codes of ethics presented by the American Asso-
ciation for Marriage and Family Therapy (AAMFT, 2015, Principle 1.13),
beyond informing clients of the third-party relationship, practitioners are
directed to gain client permission prior to any disclosure to that third party
(e.g., ACA, 2014, B.3.d; AMHCA, 2010, 2.q; NASW, 2008, 1.07.h).
Another concern that can arise when working within a managed system
is that of balancing the requirements of managed care’s cost containment
principle with the ethical concern of providing quality of care, when such
care requires extending services beyond that sanctioned by the managed
care agency. How it is accomplished is truly the dilemma faced by all man-
aged care providers. Do therapists continue pro bono? Do they challenge the
managed care gatekeepers about artificial limits to needed care?
While the limitations to the number of sessions to be paid by insurance
may make good economic and business sense for the insuring body, the
question remains: What happens to the client once these limits are reached?
Should the client continue to need care, the helper is ethically bound not
to abandon him or her. The helper could refer the client needing additional
treatment or provide pro bono services. Both strategies invite complication.
How does one refer if referral sources are limited? How does one provide
pro bono services to so many and survive financially? The answer may lie
in the decisions an ethical practitioner makes before engaging in managed
care service. Haas and Cummings (1995) advise therapists to consider the
question of how to provide service to the client and how to avoid abandon-
ing clients without going bankrupt before one joins a managed care plan.
Understanding the nature of the managed care contract and resolving areas
of professional standards of practice and care with those of economic neces-
sity is a must for the ethical helper (see Exercise 6.3).
Exercise 6.3
Serving Clients in a Managed Care Environment
Directions: Contact two private practitioners who provide clinical
services and are part of a managed care organization. Ask the practi-
tioners each of the following questions:
• What are the limits to the types and/or length of services you can
provide to your managed care clients?
• Are there are any unique limitations to the confidentiality of your
records when working with managed care clients?
(Continued)
Chapter 6. Conflict–●–143
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144–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
● BEYOND PROFESSIONAL STANDARDS:
A PERSONAL MORAL RESPONSE
• What, if any, avenues of appeal do you have regarding the deci-
sions made by the managed care utilization review boards?
• How do you inform your clients of the special conditions regard-
ing type and length of service, utilization review, confidentiality,
and so forth, that may exist by the nature of providing managed
care services?
• Have you turned down any opportunities to join a particular
managed care group because you found it too restrictive?
• Have you been able to change any policies, procedures, or
requirements in the managed care organization of which you are
a part as a way of better servicing your clients?
• As a provider in managed care, what do you find to be the most
challenging factor to your ability to provide ethical, professional
care for your clients?
(Continued)
While it is easy to grasp and comprehend the dilemmas one may face as
the varying demands, needs, and responsibilities of client, profession, and
system of employment converge on a practitioner, positioning oneself to
make the ethical decision may be quite another story. The existence and
potential impact of these forces is not a simple intellectual or academic
issue. It is a real-life dilemma that has the potential to impact the client, the
practitioner, and the therapeutic relationship. Restrictions of modes and
duration of treatment not only have the potential to undermine effective-
ness but also can erode the professional’s personal and professional values.
The limited autonomy on professional decision-making may increase the
stress experienced in practice and contribute to conditions of burnout and
empathy fatigue (See Chapter 14). Confronted with these conditions, the
ethical practitioner may find herself confronted by a conflict between the
institution’s practices and the standards established by her professional
code. Such conflicts will require ethical practitioners to clarify and resolve
these conflicts in a way that maximizes adherence to ethical dictates of
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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their profession. This can be facilitated by establishing a preplan of resolv-
ing potential conflicts between organization and professional ethics and
values, including adjusting contracts and contract demands so that they are
in line with system goals AND professional standards. When this is not pos-
sible, then it is the contention of these authors that the ethical practitioner
should consider resignation. Exercise 6.4 is provided as a stimulus for your
own development of such a preplan.
Exercise 6.4
Recontracting or Resigning
Directions: Part 1: Below you will find a number of organizational poli-
cies or procedures that a practitioner would need to follow. Identify
those you find objectionable. How would you attempt to rework these
policies/procedures before you would resign your post?
Organizational
Directive (Policies/
Procedures) Rework or Recontract Resign?
All clinical records,
including notes, are
open to inspection
by anyone identified
as an executive
administrator within
the organization.
Attempt to specify the
specific types of data
open for review and tie
each level of data to a
specific administrator
with a “need to know.”
Further, all clients
would be informed
as to the access to
records.
Yes, if not
modified
Allowed only to
utilize a brief therapy
form of service.
Therapy restricted
to eight sessions
maximum.
(Continued)
Chapter 6. Conflict–●–145
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146–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
Organizational
Directive (Policies/
Procedures) Rework or Recontract Resign?
Prior to providing ser-
vice, all intake infor-
mation must be shared
with a review board in
order to achieve per-
mission to continue.
Further, a specific
treatment plan and
progress reports must
be completed after
every four sessions.
As an employee,
you are required
to provide service,
in-house, for all
the clients you see,
regardless of their
needs and your level
of training.
You are required to
acquire a minimum
of 30 continuing
education credits
in your professional
field every 2 years.
Part 2: Ask an individual care provider who is a member of a managed
care program to show you his or her contract and statement of
responsibilities, policies, and procedures governing service delivery.
Review this contract and identify areas that you feel may potentially
compromise your ability to provide ethical practice.
(Continued)
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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CONCLUDING CASE ILLUSTRATION ●
Returning to the scene with which we opened the chapter, we find Ms. Wicks
(Maria’s counselor) expressing her felt conflict among the informal values and
rules of conduct held within the system in which she works, her concern for
her client, and her understanding of her professional code of ethics. As you
read the continuing dialogue, try to identify some of the values and/or under-
lying assumptions existing within that school’s culture and begin to identify
where and how these may conflict with this particular counselor’s under-
standing of her professional code of conduct. The questions in the reflection
section that follows the exchange should help you in this process.
Ms. Wicks: Hi, Tom, it is me again.
Mr. Harolds: Hey, how are you? Did you get that information from the state
association?
Ms. Wicks: Not yet, they are supposed to call me. But, things are getting
more confusing . . .
Mr. Harolds: Really?
Ms. Wicks: Ms. Armstrong, the principal at the school, informed me that it
is understood in the district that we are not to counsel students
regarding sexual issues. She said it is not a formal policy, just
something that “we” all know not to do. So now I’m not sure if
I broke a law, or violated a code of ethics, or may have stepped
over the line in terms of my job definition. I am so confused!
Mr. Harolds: Well, Michelle, this is a very conservative community, and the
truth is that with so many of our students having Latino back-
grounds, we rea1ly don’t want to impose mainstream cultural
values where they don’t belong.
Ms. Wicks: But, Tom, it is not like I’m going to promote a particular position
here. I am just very concerned that she is making some decisions
that could prove harmful and even potentially lethal to her.
Mr. Harolds: It is clear you are concerned about your client, but you need to
understand something. In the past, we attempted to help the
students make what we thought were value decisions. In fact,
in health class we used to have a unit on sexuality and sexually
transmitted diseases. Well, 5 years ago a parent group took the
Chapter 6. Conflict–●–147
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148–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
health teacher, the principal, and the school superintendent
all to court for supposedly “imposing moral values” on their
children. As a result, we removed health from our curriculum,
replaced it with something on career choices, and created a
parent supervisor board for the school that reviews curriculum
decisions. So the superintendent is likely to be extremely sensi-
tive about anything that may be interpreted as promoting a set of
values or beliefs. I guess Ms. Armstrong is simply trying to avoid
pressure from the central office. No sense rocking the boat.
Reflections
1. Assuming that Mr. Harolds’s depiction of the way the system operates
is accurate, what would be the primary value or motive driving deci-
sions around controversial topics?
2. When it comes to decision-making, which of the following would
you suspect takes primacy in the culture of that school: Do what’s
expedient? Avoid conflict at all costs? Be politically correct? Do what
is best for the students?
3. Could you identify an artifact that reflects the operating values and
assumptions within that school?
4. What do you feel Ms. Wicks should do? In relationship to her client?
Future clients? Her principal? Her job definition and contract?
● COOPERATIVE LEARNING EXERCISE
Directions: With a colleague, review each of the following scenarios and
• Identify potential areas of conflict
• Decide if the behavior of the practitioner is ethical
• Identify decision options available for the practitioner
• Discuss possible preplan options that could have been implemented
to reduce the potential of conflict.
Scenario 1: High School Counselor
A high school counselor has been working with a student athlete who
was self-referred, because of his concern about his tendency to attend under-
age drinking parties on the weekends and become intoxicated. The student
expressed genuine concern over these tendencies and appeared willing to
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work with the counselor in order to curtail both the desires and the actions.
He is particularly concerned with changing his behaviors, as the basketball
season has just begun and he is the starting center for the team. There is a
zero-tolerance policy for student athletes engaging in illegal activities, such
as underage drinking. The counselor feels that he should warn the basketball
coach about the student’s tendencies toward attending parties and drinking
on the weekends.
Scenario 2: An Employee Assistance Provider (EAP)
Dr. Livingston is a licensed social worker working in private practice.
Dr. Livingston also provides short-term counseling to employees of a local
manufacturing plant. In this capacity as an employee assistance counselor,
she has agreed to provide short-term (maximum of five visits) counseling to
all employees and offers referral services for those needing more extended
care. Further, her contract calls for her to consult with managers in order to
increase their effectiveness when working with their employees.
In working with Helen, Dr. Livingston discovered that Helen and her
coworkers have been punching in and out for one another and, as a result,
have developed a system where they can cut approximately 8 hours a week
off their actual work while recording and receiving pay for a full 40-hour
week. Helen is a little troubled by this procedure but reports this is what
everybody does. Dr. Livingston feels that she should report this information
to Mr. Hansen, the owner of the company, since it is he with whom she has
a contract.
SUMMARY ●
• Practice decisions made must reflect not only the needs of the client
and characteristics and orientation of the helper but also the unique
characteristics and demands of the context or organization in which
the helping occurs.
• A professional role as well as the expectations of professional behav-
ior is shaped in response to the organization’s expectations and
needs; therefore, these expectations are incorporated as standards
and guides for practice decisions.
• System culture is a pattern of basic assumptions invented, discovered,
or developed by a given group as it learns to cope with its problems of
external adaptation and internal integration. The pattern has worked
well enough to be considered valid and is taught to new members as
Chapter 6. Conflict–●–149
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150–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
the correct way to perceive, think, and feel, in relationship to those
problems.
• Once enculturated within a system, it is easy for the cultural values
to become enacted in the way members prioritize and function—
shaping policies, decision-making, and other operations. As such,
practice decisions may begin to reflect institutional values and
organizational ethics more than they represent “best practice” or
codes of professional conduct.
• Most guidelines, like that of the ACA, indicate that the client is the
primary concern for the ethical helper and the institution secondary.
But it could be argued that accepting a position within an organiza-
tion is a tacit agreement to serve as its agent and to embrace its values
and standards of practice.
• The ethical practitioner needs to be accountable and responsive to
both the system of employment and the individual clients served
within that system.
• Ethical practitioners will share with their clients the obligations of
fidelity, conditions of employment, and how these may flavor the
helping relationships and the practitioners’ decisions. One special
situation in which it is clear there may be more than one client is in
the case of managed care.
• Managed care is essentially an economic strategy designed to provide
care of equal or better quality for less money. The policies of managed
care may conflict with the decisions of an ethical practitioner, espe-
cially when utilization review decisions are contrary to professional
judgment or when short-term or limited interventions are inadequate
forms of treatments.
• Understanding the nature of the managed care contract and resolv-
ing areas of professional standards of practice and care with those of
economic necessity is a must for the ethical helper.
• Acceptance of employment is essentially an agreement with the prin-
ciples and policies of the institution. When conflict exists between the
institution’s practices and the standards established by the code, the
ethical practitioner needs to clarify and resolve conflicts in a way that
maximizes adherences to ethical dictates of his or her profession. This
can be facilitated by establishing a preplan of resolving potential con-
flicts between organization and professional ethics and values, including
adjusting contracts and contract demands so that they are in line with
system goals AND professional standards. When this is not possible,
then it is the contention of these authors that the ethical practitioner
will consider resignation.
Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. SAGE Publications, Incorporated.
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IMPORTANT TERMS ●
artifacts managed care
basic assumptions need to know
client organizational ethics
cultural values preplan
ethical culture of social systems system
limits of confidentiality utilization review
ADDITIONAL RESOURCES ●
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Chapter 6. Conflict–●–151
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152–●–ETHICAL PRACTICE IN THE HUMAN SERVICES
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5320-U3D1
System Culture
System Culture
Chapter 6 of your textbook addresses the concept of multiple levels of
“client” including the individual client and a system of organizations,
referral sources, reporting agencies, and reviewers or billing agencies.
In your initial post to this discussion, describe what is meant by a
“system culture.” What are some of the ethical dilemmas that a provider,
supervisor, or manager might encounter when working with a system in
relation to the needs of an “identified client?” What are some of the
potential ethical dilemmas when working with issues of mandatory
reporting or with managed care or third-party payment agencies? Cite
references from your text or other sources to support your post.
NOTE: Minimum of 350 words and 1 scholarly article
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