Counseling for Effective Decision Making
6

Ethical Issues in Decision-Making Counseling

In books on counseling, ethical matters, if discussed at all, are often relegated to a final chapter, almost as a dutiful afterthought. The importance of ethics in decision-making counseling, however, warrants early treatment.

Ethical issues in counseling abound. Topics such as accountability, confidentiality, fees for service, and so forth could easily be included in our ethical discussion. However, my intention is not to cover every possible issue. Readers interested in pursuing a larger perspective might start with the ethical guidelines published by the American Personnel and Guidance Association and the American Psychological Association (APGA, undated; APA, 1967, 1972). Instead, in this chapter I will discuss two questions that are highly relevant to the conduct of decision-making counseling: Is there always a "right" choice? and What are the ethical limits of counselor input in client decisions?

To answer the first question, I will begin by examining the sandy foundations on which ethical models are constructed. From this groundlevel viewpoint we shall see that ethical laws are often of limited use in dictating the "right" alternative. It will also be apparent that this question is confounded by the fact that the word "right" has multiple meanings. Many decisions have little to do with ethics and the use of this word simply clouds the fact that the judger and the judged may have differing utilities.

My answer to the second question begins with an observation of the relatively unpublicized problem of intrusive counselor utilities that seem to permeate much of what goes on in the name of counseling. Although behaviorists unjustifiably get much of the blame, no school of counseling is free from this potentially insidious phenomenon. After a brief exploration of counselor input in traditional behavioral counseling and the learning mechanisms for that input, I will offer a few guidelines for the conduct of decision-making counseling. Let us now examine these questions in greater detail.

Is There Always a "Right" Choice?

The attempt to achieve something as close as possible to certain knowledge of right and wrong seems to be the aim of all ethical reflection. We might substitute for this right-wrong dichotomy the concepts good-evil, moral-immoral, valuable-valueless, appropriate-inappropriate, and so forth; semantic antics are irrelevant. No one seems to dispute the desirability of obtaining such knowledge, but there is certainly conflict over who has the pipeline to "the way, the truth, and the light."

The passage from a description of human events to a prescription of ethical conduct is risky. It requires a series of often unwarranted assumptions that even the most cursory examination of ethical evolution would reveal as significantly based on a rather unbalanced blending of maladaptive thinking, religious dogmas, and social lubricants. Differences in the proportion of these components seem to account for the myriad ethical beliefs and opinions that surround us today.

Be that as it may, the ethicist (someone who is vocationally preoccupied with moral matters), first assumes that there is a natural law ("right" way of behaving) or ontological system, which can be approximated in terms of an ethical code through the rigorous application of inductive and deductive processes. This is analogous to the thought pattern of the physical or social scientist who presumes that this is not a universe of chance, that organic and inorganic substances operate according to certain laws, and that knowledge of these laws can be had and organized into some sort of reflectively derived superstructure or model.

The ethicist then begins to formulate a series of "self-evident" primary propositions such as "Goodness consists in the satisfaction of desire" (naturalism), or "Man's ultimate goal is happiness" (Thomistic realism). More links are subsequently added to this deductive chain in the form of secondary and tertiary principles. All of this is done within the bounds of logic and reason; Venn diagrams might even be offered as mathematical proof. The process is fascinating, but why is it that we have such contradictory opinion, for example, on ethical solutions to a problem pregnancy? The answer lies with "that whore--Reason" as Voltaire so aptly described it.

A cornerstone of reasoning (and hence of the model-building process) is the syllogism, which in its simplest form consists of a major premise, a minor premise, and a conclusion. It is perfectly possible to have a totally valid (logical) syllogism with a conclusion that is entirely erroneous because the initial premises are never proven but only assumed to be true. Such is the phenomenon that enables the paranoid to be a paragon of logic.

Physical and social scientists overcome this difficulty by subjecting their models to a simple "truth" criterion, namely, "Does it work?" Models are judged "good" or "bad" by their effectiveness in a strictly pragmatic sense. Thus, if we can show that the explosive metal sodium when combined with the deadly gas chlorine yields the harmless and vital substance called table salt, we have an idea that Dalton's atomic model gives us a pretty "good" (workable) insight into the way things really are. Ethicists have no such criteria; what is "good" or "bad" is only the subjective hunch of what seems reasonable, plausible, or nice.

Ethics in Client Decisions

Given the rather arbitrary foundations of ethical models, it would be folly to assume that we can inductively arrive at immutable ethical generalizations ("natural law") governing all kinds of behavior and thus dictating "right" choices. Every moral principle has its exceptions. For example, "Thou shalt not kill," whether chiseled in stone, induced, or assumed to be self-evident, becomes in practice "Thou shalt not kill" except in defense of oneself, in defense of another, in protection of one's property, in times of war, or in cases of capital punishment.

Moral objections to adultery have been dismissed as arbitrary by a number of mental health professionals in favor of "civilized extramarital adventure" (Ellis, 1973). Nevertheless, our legal system, which in theory reflects the will of the majority, considers adultery unequivocally wrong. Are there exceptions to this principle? To a conservative audience, is adultery ever "right"? Consider the decision of Mrs. Bergmeier:

As the Russian armies drove westward to meet the Americans and British at the Elbe, a Soviet patrol picked up a Mrs. Bergmeier foraging food for her three children. Unable even to get word to the children, and without any clear reason for it, she was taken off to a prison camp in the Ukraine. Her husband had been captured in the Bulge and taken to a POW camp in Wales.

When he was returned to Berlin, he spent weeks and weeks rounding up his children; two (Ilse, twelve, and Paul, ten) were found in a detention school run by the Russians, and the oldest, Hans, fifteen, was found hiding in a cellar near the Alexander Platz. Their mother's whereabouts remained a mystery, but they never stopped searching. She more than anything else was needed to reknit them as a family in that dire situation of hunger, chaos and fear.

Meanwhile, in the Ukraine, Mrs. Bergmeier learned through a sympathetic commandant that her husband and family were trying to keep together and find her. But the rules allowed them to release her for only two reasons: (1) illness needing medical facilities beyond the camp's, in which case she would be sent to a Soviet hospital elsewhere, and (2) pregnancy, in which case she would be returned to Germany as a liability.

She turned things over in her mind and finally asked a friendly Volga German camp guard to impregnate her, which he did. Her condition being medically verified, she was sent back to Berlin and to her family. They welcomed her with open arms, even when she told them how she managed it. When the child was born, they loved him more than all the rest, on the view that little Dietrich had done more for them than anybody.

When it was time for him to be christened, they took him to the pastor on a Sunday afternoon. After the ceremony they sent Dietrich home with the children and sat down in the pastor's study to ask him whether they were right to feel as they did about Mrs, Bergmeier and Dietrich. Should they be grateful to the Volga German? Had Mrs. Bergmeier done a good and right thing?*

The foregoing does not mean that ethical generalizations are irrelevant to a client about to make a decision. The collective judgments of moral philosophers and the wisdom of the ages have more than just minor utility. Fletcher (1966) has articulately argued for a situational approach to ethics in which moral principles are considered valid except when their application would reflect a lack of agapé (the New Testament "normative ideal of 'love' " [p. 15]) for our fellow man. Kierkegaard (1954) expressed similar sentiments when he maintained that any break with an ethical universal should be made in "fear and trembling" rather than in the callous arrogance of power, Thus ethical principles are to be taken seriously but not dogmatically.

Essentially, then, ethics is hardly a certain science. Moreover, there is a good deal of debate over what kinds of behavior are to be judged unethical. And finally, even commonly accepted ethical generalizations are subject to exceptions and extenuating circumstances. Thus ethical laws are of limited use in dictating the "right" choice.

Client Choice Problems Outside the Realm of Ethics

Ethical considerations may or may not be present in client decisions. For example, a terminally ill patient debating suicide would undoubtedly undergo a good deal more ethical introspection than an individual contemplating the choice of wardrobe for a cocktail party. Curiously enough, the English language permits us to use the word "right" to describe an alternative in both of these decisions.

Ethical considerations have little or no bearing on many client decisions. Choice of an academic major or professional career, for example, is basically outside the realm of ethics (unless, of course, an unethical profession like "hit man" is a possibility). To speak of a "right" decision in cases such as these is a misnomer; no moral principles are involved. Other utilities such as making money or pursuing interests rather than "rightness or wrongness" are part of the decision.

The use of the term "right" here apparently represents a concept similar to that of a good decision (that is, a decision with a favorable, outcome) discussed in chapter 1. In any event, before such judgments can be made it is important to look at who is doing the judging. For example, Blocher (1974) describes the case of a senior high school girl with a recurring fantasy about setting off on a trip across the country in the company of another girl and implies that this would be a very poor decision. Others might agree, particularly those counselors who feel that students should go right to college. On the other hand, some counselors might argue that the benefits of such a trip would certainly outweigh any slight delay in completing her education. In contrast to such authoritative opinion, has anyone thought to ask the girl (Horan, 1975)? As Herr (1970, p. 3) correctly observes, "The problem is that judgments about whether or not a decision is a 'good' one are typically made not by the chooser but by some external expert. Consequently, such judgments may have no relationship to anything that the decision-maker himself values." Gardner (1965) has succinctly described the dangers of "self-renewal," that is, believing what was good for us must be good for everyone else. In reality who are we to say that a trip is "wrong" and college is "right" for a daydreaming high school senior-or anyone, for that matter?

Whitehead (1938, P. 15) once commented, "The simple-minded use of the notions 'right or wrong' is one of the chief obstacles to the progress of understanding." This remark is particularly pertinent to the conduct of decision-making counseling. Problems of choice permit few if any "right" answers.

What Are the Ethical Limits of Counselor Input in Client Decisions?

My conversion to cognitive-behaviorism came late in my graduate training. I was given a heavy and exclusive dose of orthodox Freudianism in my clinically oriented masters program and during my doctoral work in counseling I became deeply immersed in a sort of Rogerian-Sullivanian existentialism. I have observed that "client manipulation" is not a practice restricted to so-accused "Machiavellian" behaviorists. The issue is every bit as real and, I might add, potentially more insidious, in nonbehavioral approaches to counseling (London, 1967).

Two Personal Vignettes

The first patient assigned to me for a diagnostic workup during my clinical internship at a county mental hospital was a thirty-one-year-old female who might briefly be described as experiencing auditory hallucinations and requiring periodic custodial care for the past decade. The woman's husband had suffered a broken neck and consequent paralysis from the waist down only a few months before her latest admission to the hospital.

My role in her rehabilitation program was to administer a number of projective and psychometric tests and from these data I was supposed to compose what I now believe amounted to an anthropomorphic Freudian fairy tale for the benefit of the attending psychoanalyst, who would probably never read it. In the terms of the prevailing view, "ego" was losing a long-standing battle with "id" and "superego" was trying to prevent my client's recovery. I believe I labeled her a "chronic undifferentiated schizophrenic with paranoid features"; however, such name calling had little to do with understanding her condition.

As luck would have it, this particular patient was brought to the attention of a general staff meeting. Though I was delighted that the attending analyst had in fact read my report, I was totally appalled at his treatment approach. "The basic problem," he began, "is that she's a Catholic. Were she not, she could decide to get a divorce." Then after farming her children out to foster homes, she would be free to frequent the local pubs, where an ample supply of men could be found to fulfill her presently frustrated sexual needs.

In proclaiming that a career of bar hopping was "better" than the job of caring for an invalid husband and children, the analyst revealed a set of ethical values. In cringing at his prescription, I revealed my own. However, the fact that the analyst would in all likelihood covertly attempt to manipulate the client into deciding to abandon her religion and family is much more worthy of comment than our respective differences (Horan, 1974d).

Another rude awakening to the relatively unpublicized problem of intrusive counselor input occurred during a "personal growth group" that I attended early in my career. Group members were predominantly agnostic; there were, however, several active Protestants and Jews. The sole practicing Catholic member volunteered a concern. His wife was an atheist and, having had three children, now wanted to use contraceptives. Though he, too, wanted no more children, he objected to contraceptives on religious grounds. But what was he to do? (The issue of birth control was considerably more troubling to Catholics of a decade ago.)

I watched in utter amazement as Solomon Asch (1952) must have done years before in his conformity-pressure studies. In regard to birth control, the utilities of the group were in complete harmony with those of the wife. After a good deal of anxious squirming, the Catholic member was "led down the road to self-discovery" and found that his "real values" were, after all, similar to those of the group! Recognizing this conversion to the group point of view as such and nothing more, I protested, but apparently not very loudly or at least not convincingly. I have no doubt what the decision would have been had the group been composed of priests and nuns.

Counselor Input in Traditional Behavioral Counseling

Whether we like it or not, human behavior is subject to learning principles that existed long before contemporary behavioral scientists named and described them. Throughout history parents, governments, and religious institutions have attempted to apply these heretofore unnamed principles to influence their charges' behavior. In a sense, then, there is nothing new about the idea of modifying someone's behavior; however, the technology for doing so is rapidly improving.

The application of every counseling theory calls for deliberate counselor-caused changes in client behavior (London, 1967; Skinner, 1971). Few counselors, regardless of their theoretical orientation, would seriously consider their counseling successful if their juvenile delinquent clients continued to steal and be physically assaultive. But the fact that counselors attempt to modify client behavior does not make it ethical to do so without certain constraints. Let us now turn to the issue of counselor input in contemporary behaviorism.

The terms behavior modification, behavior therapy, and behavioral counseling are often used interchangeably. Separate definitions have been suggested but little agreement has resulted (Franzini & Tilker, 1972; Lazarus, 1971). Although the following distinctions may seem arbitrary and only to add to the confusion, they do make it easier to deal with the question of ethics.

Behavior Modification

In behavior modification the client does not have the freedom to terminate the counseling relationship. The client may wish to continue (and would thus simplify the behavior modifier's task); on the other hand, he or she may actively resist. Generally speaking, ethical objections are almost never voiced when behavior modification is applied to specialized populations where there is virtually unanimous social consensus that the troublesome behaviors ought to be changed. For example, some autistic children will literally chew their shoulders to the bone or pummel their heads with their fists until they go blind or deaf unless they are restrained. Few would question the ethics of a counselor attempting to reduce such self-destructive behavior. Likewise, no one would morally object to teaching a retarded individual how to use a toilet.

On the other hand, when there is not virtually unanimous social consensus on the undesirability of a particular behavior (that is, when its maladaptiveness is not self-evident), behavior modification programs should come under serious ethical scrutiny. For example, a prison behavior modifier might justifiably be asked, "Just what does constitute 'good grooming' and why is it worthy of being reinforced?" (see Emery & Marholin, 1977; Winkler, 1977). The issue is further confounded by the fact that some of what goes on in the name of behavior modification is thoroughly disgusting to professional behavior modifiers. In a recent television program on delinquency, for example, an "expert" confidently described how roping a child to a bed-spread eagle-for a week supposedly modified the child's aggressive behavior. Although other such examples exist (see Cotter, 1967; Horan, 1973f; Krasner, 1971), there are relatively few instances of "credentialed" behavior modifiers involved in unethical programming.

Behavior Therapy and Behavioral Counseling

Behavior therapy and behavioral counseling are essentially synonymous terms. Clients see the counselor on a voluntary basis and are free to terminate the counseling relationship at any time. Although the counselor does help clarify the client's concerns, the choice of counseling goals and their order of priority are entirely up to the client, as is the decision to work toward their attainment. Furthermore, when several behavior-change strategies are equally viable, the counselor will invariably implement the strategy the client prefers.

At first blush, then, it would appear that behavioral counseling is essentially a scientific enterprise outside the domain of ethics. The client makes all the decisions about how, when and even if to proceed and the expert counselor, having been exposed to a good deal of behavioral research, simply distills from the literature the most promising behaviorchange strategies. Then, client willing, the counselor proceeds to help the client work toward his or her goals, not the counselor's.

In practice, however, this ethical neutrality is illusory. The conduct of behavioral counseling is every bit as open to intrusive counselor input as is nonbehavioral counseling. The psychoanalyst favoring bar hopping and family abandonment could just as easily have been a behaviorist subtly pushing the client to this therapist-preferred alternative. The personal growth group could very well have been composed of behaviorists whose line of questioning would lead the Catholic member to decide in favor of birth control. The simple application of a counseling strategy to assist a client in attaining a goal may be as ethically neutral as a laboratory investigation of nuclear fission, but the counselor's input into the client's decision to work toward a particular goal is a matter for close ethical scrutiny, as is a politician's deployment of nuclear weaponry.

Learning Mechanisms for Intrusive Counselor Input

Counselor attention has proved to be a very powerful positive reinforcer. Some of the classic studies have shown that attention in the form of head nods or words like "good" or "uh huh" can cause significant increases in the kinds of client verbalization that follow-plural nouns, hostile words, and statements of opinion, (for example, Greenspoon,1955; Verplanck, 1955). In reviewing thirty-one studies of this sort, Krasner (1958) reported a majority of positive results. This line of research has been applied to more clinically relevant client behaviors occurring outside the counseling interview (Krumboltz & Thoresen, 1969).

Even Carl Rogers (1961), who detests this process, acknowledges that it can occur in the counseling interview. Ironically, Rogers himself-the father of nondirective counseling-makes effective use of verbal positive reinforcement (empathy and warmth) in his own counseling. Truax (1966) conducted a microscopic analysis of a sample of twenty therapy sessions between Rogers and a client. He conclusively showed that throughout the course of therapy (a total of eighty-five sessions) Rogers differentially reinforced those kinds of client statements seen as desirable in client-centered counseling theory.

To illustrate the potential insidiousness of this phenomenon, perhaps another personal digression is in order: In spite of the fact that vocational adjustment is one of the best general indexes of mental health (Lofquist & Dawis, 1969), helping clients resolve educational-vocational choice concerns carries relatively little prestige among many counselors. I have occasionally observed counselors and counseling students essentially ignoring (extinguishing) client discussion of career choice concerns to save time, as they put it, for "more important personal topics." Any verbal hints of other problems in living like sex, loneliness, or depression were heavily reinforced by counselor attention. Many clients initially without such problems discovered they had had them all along, but their vocational concerns were never addressed!

The fact that the counselor serves as a powerful role model is another source of serious ethical contamination in decision-making counseling. Counselors have a good deal of status and prestige in the eyes of their clients (if not their employers). Clients are very likely to adopt the values and imitate the behavior of their counselor. Is a homosexual client likely to choose heterosexuality if he or she knows that the counselor is leading a contented gay life-style? Is divorce a more probable alternative if the marriage counselor is divorced? Conversely, we might expect married or heterosexual counselors to exert a similar modeling influence on the decision-making behavior of their clients. (See Krumboltz and Varenhorst, 1965, for further illustration and discussion.)

Ethical Guidelines for Counselor Input in Client Decisions

All of the foregoing indicates that counselors, knowingly or not, may have the power to shape a client's decision in a particular direction. Unless the counselor is in fact absolutely neutral or uncertain about which alternative promises to be most advantageous to the client, it is unlikely that any client's decision will be totally free of this influence. Ethical counselor conduct, then, would call for giving all viable alternatives in a choice problem a "fair hearing" and deliberately withholding any reinforcement for implementing a particular alternative until after the client makes the decision favoring that alternative. Furthermore, when counselors find themselves strongly believing in or opposing a particular alternative, they are probably ethically obliged to refer the client to another counselor or at the very least to discuss their biases with the client, temper them as such, and foster information gathering on all sides of the question.

Many generalizations, including the foregoing ethical proclamations, have their exceptions. It is not uncommon to find clients giving serious thought to maladaptive alternatives. Are counselors obliged to provide a mantle of rationality for clearly crazy options? Probably not. But first of all counselors should be aware that immediately to dismiss such alternatives as preposterous may jeopardize the counseling relationship. (cf. Heubusch & Horan, 1977). The client may terminate prematurely. If the alternative is obviously disadvantageous, this will in all likelihood become apparent as decision-making counseling progresses.

Even if the "craziness" of a particular option is not readily apparent to the client, it would not necessarily be unethical for the counselor deliberately to steer the client away from a maladaptive course of action. In fact one might argue that a counselor would be remiss in not attempting to dissuade a client from pursuing an obviously unethical alternative such as physical assault on another person. However, counselors should not take this highly situational prerogative lightly; direct influence in a client decision ought to be the exception rather than the rule.

In forming guidelines for counselor input, we might recall that in behavior modification little cause for ethical concern exists if there is virtually unanimous informed social consensus on the inappropriateness of a particular target behavior. For example, no one would question the ethics of a mental health professional attempting to eliminate an autistic child's selfmutilating activity. We might cautiously extend this ethical guideline to the conduct of decision-making counseling as well. Counselors may actively discourage certain alternatives and possibly even promote others, to the extent that a hypothetical everyman would not object. Whether this everyman should be the counseling profession or the public at large is a matter for debate. Taking a cue from other professions, I am inclined to opt for the former, being fully aware of the dangers of elitism and in either case the pitfalls inherent in establishing concepts like adaptiveness or insanity by consensual validation. On the other hand, the collective judgments of an informed peer group are certainly more meaningful than the potentially capricious opinions of any one member. Thus counselors who find themselves subtly promoting alternatives that would not be endorsed by the counseling profession at large, and doing so in the guise of impartial decision making, may well be behaving unethically.

On other occasions a client may ask a counselor for direct advice. Should the counselor refuse to provide it? Probably yes. In the first place, decision-making counseling ought to equip the client with a framework for making future decisions as well as with a resolution of the present choice conflict. I am reminded of the old aphorism: Feeding a hungry man will bring him back each night; teaching him to fish will make him self-sufficient. Second, any advice would be dispensed from the counselor's perception of what is reinforcing rather than from the client's vantage point. Finally, counselors who offer advice are likely to be held accountable in case of an unfavorable outcome. This liability might be worth the risk if counselors in fact could make better decisions than the clients themselves; however, no data exists to support such a contention.

On the other hand, if the client fully accepts the responsibility for making the decision but sincerely wonders what the counselor would do if confronted with a similar choice problem, it would seem rather unfair to deny the client access to this information. This sort of counselor self-disclosure might be occasionally permissible, but the counselor's choice of alternatives should be treated as simply a piece of information, not as the best possible course of action.

Summary

There are two ethical questions pertinent to the conduct of decision-making counseling. To answer the first question, "Is there always a 'right' choice?", we must first examine how ethical laws are formulated. Ethics is not a certain science; there is unresolvable debate about what kinds of behavior are to be judged unethical. And even commonly accepted ethical generalizations are subject to exceptions and extenuating circumstances. Thus, ethical laws are of limited use in dictating the "right" choice. Moreover, many client decisions do not involve ethical matters at all; use of the word "right" may confuse the simple fact of differences between client and "expert" utilities.

In considering the second question, "What are the ethical limits of counselor input in client decisions?", we must be aware of the pervasive problem of intrusive counselor utilities in all schools of counseling. Differential attention and modeling factors are possible learning mechanisms for intrusive counselor input.

Ethical guidelines for counselor behavior in decision-making counseling include considering all viable alternatives, withholding reinforcement for implementing an alternative until the client has freely selected one, possibly referring a client to another counselor if the counselor strongly opposes or endorses one of several adaptive alternatives (due to idiosyncratic utilities), intervening only when an alternative is obviously unethical or maladaptive, and treating counselor preference (if at all) as incidental information rather than as the appropriate course of action.

This discussion of ethical issue-, in decision-making counseling closes the first part of the book. Part 11 builds on the foundations of part 1 in reviewing dynamic, rational, and behavioral approaches to decision-making counseling as well as pertinent problem-solving literature.


*From Situation ethics, by Joseph Fletcher. Copyright MCMLXVI, W. L. Jenkins. Used by permission of The Westminster Press.
Counseling for Effective Decision Making - Copyright © 1977 John J. Horan, All rights reserved.
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